Brain Tumor Res Treat.  2023 Oct;11(4):289-294. 10.14791/btrt.2023.0035.

Awake Surgery for Lesional Epilepsy in Resource-Limited Settings: Case Report and Review of Literature

• Bajwa MH
• Hashmi SA
• Nisar A
• Baqai MW
• Bakhshi SK
• Qadir MA
• Shafiq F
• Enam SA

• KMID: 2547409
• DOI: http://doi.org/10.14791/btrt.2023.0035

Abstract

Epilepsy surgery is a well-established treatment for drug-resistant epilepsy, with awake craniotomy being used in certain cases to remove epileptogenic foci while preserving crucial brain functions. We are presenting the first reported case from Pakistan of a 19-year-old woman who underwent awake epilepsy surgery to treat cortical dysplasia. She had a history of generalized tonic-clonic seizures since her childhood and was referred to our clinic due to an increase in seizure frequency. EEG and MRI identified the epileptogenic focus in the right parieto-temporal region. The patient underwent a neuro-navigation guided awake craniotomy and an excision of the epileptogenic focus in the right parieto-temporal region. The procedure was carried out using a scalp block and dexmedetomidine for conscious sedation, enabling the patient to remain awake throughout the surgery. Intraoperative mapping and electrocorticography were used for complex multidisciplinary care. Post-resection corticography showed no spikes along the resected margins. The patient was discharged without any complications and remained free of symptoms a year after the surgery. Awake epilepsy surgery is a viable option for removing epileptogenic foci while preserving vital cognitive functions. However, it is seldom used in low- and middle-income countries such as Pakistan. The successful outcome of this case underscores the need for greater awareness and availability of epilepsy surgery in resource-limited settings. Cost-effective measures, such as using small subdural strips for intraoperative localization, can be implemented.

Keyword

Drug resistant epilepsy; Neurosurgery; Anesthesia; Resource-limited settings

Figure

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  Fig. 1 Preoperative MRI of the lesion in sagittal (A, B, G, H), axial (C, D, I, J), coronal views (E, F, K, L), with T2-FLAIR and corresponding T1-post contrast sequences. The lesion shows few hyperintense regions on FLAIR imaging with no contrast enhancement. FLAIR, fluid-attenuated inversion recovery.

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  Fig. 2 Intraoperative delineation of lesion margins as determined on electrical corticography: medial margin (A), posterior margin (B), anterior margin (C), and lateral margin (D).

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  Fig. 3 Immediate pre-resection electroencephalography (EEG). A: Anterior margin of the epileptogenic zone EEG. B: Posterior margin of the epileptogenic zone EEG. These depict fast and spike wave patterns.

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  Fig. 4 Intraoperative images. A: Depicts margins of the epileptogenic zone identified by intraoperative electrocorticography, as marked by a black thread. B: Depicts immediate post-resection cavity.

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  Fig. 5 Postoperative EEG of anterior margin (A), posteromedial margin (B), and lateral margin (C), depicting normal waves. EEG, electroencephalography.

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  Fig. 6 Post-operative MRI scan images showing resection of the lesion in T2 sagittal (A and E), T2 axial (B and F), T1 axial post-contrast (C and G), FLAIR axial sequences (D and H). FLAIR, fluid-attenuated inversion recovery.

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