Resective Surgery for Double Epileptic Foci Overlapping Anterior and Posterior Language Areas: A Case of Epilepsy With Tuberous Sclerosis Complex

Abstract

Tuberous sclerosis complex is a genetic systematic disorder characterized by hamartomas in multiple organs. Cortical tubers, the hamartomas in the cerebrum, cause multifocal refractory seizures. In certain cases, epileptic foci potentially involve language areas, and hence, extra- and intraoperative cortical mapping can help identify anterior and posterior areas, thus avoiding postsurgical language impairment. We report on a 21-year-old female with tuberous sclerosis complex experiencing refractory partial seizures due to two epileptic foci in the left hemisphere overlapping anterior and posterior language areas. To completely evaluate both language areas, we performed stepwise resections beginning from the anterior to the posterior epileptic focus. Although the patient presented with expressive aphasia following anterior resection, it was possible to conduct language tests during every resection. Postoperatively, she presented with expressive aphasia, comprehension deficits, left-right disorientations, and arithmetic deficits. The language dysfunctions almost disappeared at 5 weeks after the surgery and were completely resolved at 6 months after surgery. At postoperative 9 months, she was free from seizures.

An update on tests used for intraoperative monitoring of cognition during awake craniotomy

“… Language + Motor Verbal tasks + Motor movements Motor Opening + closing hand Flexion + tension foot Complex movement such as screwing a nut Visuospatial Line bisection task Object naming in opposite quadrants Social cognition Emotion recognition task Executive function Go/No-go task Working Memory Memorize stimuli, then distraction: is this stimuli the same as previous or not? Calculation Calculation [ 178 ] Language Picture naming Nonverbal semantic association test ( PPTT ) Social cognition Reading the Mind in the Eyes Test [ 179 ] Language Counting Object picture-naming task ( DO80 ) Semantic association task Language + Motor Counting/ DO80 + Contralateral movement [ 180 ] Language Number counting Picture naming task Verbal semantic association task (PPTT) Motor Upper limb movements Visuospatial Line bisection task [ 181 ] Language Counting Picture naming [ 182 ] Language Counting Motor Finger grasping Sticking out tongue Moving the fingers [ 183 ] Language Naming items Motor Finger tapping task [ 184 ] Language Picture naming Word reading Spontaneous speech [ 185 ] Language Free conversation Picture naming Responsive naming [ 186 ] ...…”