Summer 2009

Case Study: Neurosurgery Relieves Lifetime of Seizures

Josephy Sullivan, M.D.

Nine-year-old Aarika Rodriguez had been suffering seizures since infancy, regularly emerging from sleep trembling and disoriented. Yet in her short life, she had failed with seven different medications, either because they were ineffective or because of severe side effects. In February 2008, her central California neurologists referred Rodriguez to UCSF Benioff Children's Hospital Joseph Sullivan, M.D., pediatric epileptologist.

"The single-type seizure and a single, subtle abnormality on her MRI made her a surgical candidate," says Sullivan, who over the following months conducted a series of tests to map the seizure activity against critical brain functions.

He began with a video EEG that indicated the seizures occurred in the left frontal lobe — the same locale as the lesion that had been revealed on the MRI. The next step was magnetoencephalography (MEG), which showed spikes that also appeared close to the MRI abnormality. "But we were unable to map speech with the MEG, and speech was a concern," says Sullivan.

Kurtis Auguste, M.D.

Next up was a functional MRI, but that too failed to disclose speech location. And when they tried a Wada procedure, the young girl could not tolerate it. That left Sullivan and pediatric neurosurgeon Kurtis Auguste, M.D., with one option: invasive strip and grid monitoring. In July 2008, Auguste performed a craniotomy, opening the dura and laying down a subdural grid that contained 64 electrodes in an 8x8 pattern.

The grid effectively revealed the speech centers as well as a more precise location for seizure activity. "Speech was a short distance away from the seizures, and we were convinced resection would not run the risk of causing speech problems," says Auguste.

Using intraoperative neuronavigation — where the surgeon works from computer images that provide four different, adjustable views of the targeted area — Auguste resected the lesion as well as other electrically active tissue. "The neuronavigation was invaluable because it allows us to be much more precise," he says.

Rodriguez emerged from the procedure with pristine speech and, as of April 2009, is back in school. She has remained seizure-free in the months since her surgery. Except for a January 2009 follow-up with Sullivan and Auguste, and one scheduled for 2010, she has returned to the care of her referring neurologists, who will maintain her medication for a year postoperatively. If she remains seizure-free, Sullivan and her home neurologists will discuss titrating her off her medications.

"Aarika's case is a strong illustration of the advantages of a center that has, among other things, an epileptologist, who can expertly evaluate when it is time to move from medications to surgery; the ability to perform any necessary procedure (temporal lobectomy, lesional frontal lobe, nonlesional frontal lobe, corpus callosotomy, multiple subpial transection, hemispherectomy); and access to the most up-to-date equipment and collaborative expertise, including pediatric craniofacial plastic surgeons to help address cosmetic concerns with neurosurgery," says Auguste.

For more information, contact Joseph Sullivan, M.D., at (415) 353–8440 or Kurtis Auguste, M.D. at (415) 353–2348.

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