1. Intractable epilepsy due to postnatal MCA stroke Mariam S. Aboian Mayo Medical School

2. J.V. is 34 yr R-h M ✤ Cerebral Palsy due to Right MCA stroke after birth; term delivery ✤ simple and complex partial sz starting at 5 months ✤ Status epilepticus (2) ✤ failed 10 AEDs

3. Exam ✤ Left spastic hemiparesis, able to walk  CN normal  Strength and Tone 5/5 on right side  Strength and Tone 2/5 LUE and 4/5 LLE

4. Sz focus Mapping ✤ Sz semiology - EMU monitoring  right frontal onset - limited flexion of left arm (1)  left leg is tonically extended (2)  turning to the left (2)  beginning of seizure head turns to the left (2)  bicycle type movements (frontal focus)

5. Sz focus Mapping ✤ Scalp EEG - EMU monitoring  interictal theta slowing over R hemisphere  2 interpretable seizures  3-4 Hz ictal epileptiform discharges is either generalized w/ R>L or right-sided

6. Sz focus Mapping - PET ✤ Hypometabolism in  R orbital frontal region,  R anterior and superior temporal lobe  R occipital pole  R basal ganglia and thalamus

7. Pre-op MRI Hypo-intense non-enhancing R frontoparietal and temporal lobe, R thalamus, ant limb of R internal capsule, R caudate nucleus, R cerebral peduncle, R pons and medulla

8. Operative Set-up

9. Dysplastic Brain with cystic changes

10. Intra-op Motor Mapping Functional MRI: negative

11. Step 1: Temporal Lobectomy

12. Step 2: Frontal Lobectomy

14. Step 3: Occipital Lobectomy

15. Step 4: Hippocampus dissection

16. Step 5: Closure

17. Postnatal stroke and epilepsy ✤ 1:4,000 of term infants w/ stroke (deVeber et al, 2000) ✤ neuronal apoptosis is prevalent in postnatal synaptogenesis period (Vexler and Yenari, 2009) ✤ deVries et al, Neuropediatrics, 1997  7 w/ main branch involvement: hemiplegia (7/7), epilepsy (2/7) ✤ McClelland and Maxwell, Ann Neurol, 2007  9 adults (>18 yrs) w/ hemiplegia and unilat visual field loss; 5 seizure free >30 yr follow up

18. Acknowledgements Dr. A. Eskandar Dr. M. Simon Tara Jennings Sub-Is: Nelson and Akin Residents: Dr. J. Gerrard, Dr. G. Dunn Dr. J. Gale Harvard Medical School and MGH Mayo Medical School