EpilepsyEpilepsyEpilepsyEpilepsy

Hyunmi Choi, M.D., M.S.Hyunmi Choi, M.D., M.S.Columbia Comprehensive Epilepsy Columbia Comprehensive Epilepsy

CenterCenterThe Neurological InstituteThe Neurological Institute

SeizureSeizureSeizureSeizureSymptomSymptomSy ptoSy ptoTransient eventTransient eventParoxysmalParoxysmalyyTemporary physiologic dysfunctionTemporary physiologic dysfunctionCaused by selfCaused by self--limited, abnormal, limited, abnormal, hypersynchronous electrical discharge of hypersynchronous electrical discharge of cortical neuronscortical neuronsMay occur only during course of an acute May occur only during course of an acute May occur only during course of an acute May occur only during course of an acute medical or neurologic illness (not medical or neurologic illness (not persisting after resolution of acute illness)persisting after resolution of acute illness)p g )p g )

EpilepsyEpilepsyEpilepsyEpilepsy

Chronic disorderChronic disorderChronic disorderChronic disorderRecurrence of seizureRecurrence of seizureU k d d di t blU k d d di t blUnprovoked and unpredictableUnprovoked and unpredictableDistinct form with own natural Distinct form with own natural history and response to treatmenthistory and response to treatmentSeizure type(s) in a pt Seizure type(s) in a pt yp ( ) pyp ( ) p•• stereotypedstereotyped

EpidemiologyEpidemiologyEpidemiologyEpidemiology

PrevalencePrevalencePrevalencePrevalence•• 11--2% of population2% of population

IncidenceIncidenceIncidenceIncidence•• AgeAge--adjusted annual incidence rate adjusted annual incidence rate

31 t 57 100 000 31 t 57 100 000 31 to 57 per 100,000 31 to 57 per 100,000

Incidence rates highest among Incidence rates highest among hild d ld l hild d ld lyoung children and elderlyyoung children and elderly

EpidemiologyEpidemiologyEpidemiologyEpidemiology

6060--70% achieve control of seizures 70% achieve control of seizures with antiepileptic medicationswith antiepileptic medicationswith antiepileptic medicationswith antiepileptic medications3030--40% refractory to medication40% refractory to medicationMortality Mortality Mortality Mortality •• Risk incurred by underlying diseaseRisk incurred by underlying disease•• Accidental deathsAccidental deaths•• Accidental deathsAccidental deaths•• Sudden unexplained death is 25 times Sudden unexplained death is 25 times

more common in epilepsy pts than in more common in epilepsy pts than in p p y pp p y pgeneral populationgeneral population

ClassificationClassificationClassificationClassification

Developing a rational plan of investigationDeveloping a rational plan of investigationDeveloping a rational plan of investigationDeveloping a rational plan of investigationMaking sound decisions aboutMaking sound decisions about

When and how long to treatWhen and how long to treat•• When and how long to treatWhen and how long to treat•• Choosing appropriate antiepileptic drugChoosing appropriate antiepileptic drug•• Considering surgical treatmentConsidering surgical treatment•• Considering surgical treatmentConsidering surgical treatment

Providing prognosisProviding prognosisInternational League Against Epilepsy International League Against Epilepsy International League Against Epilepsy International League Against Epilepsy (1981 &1987)(1981 &1987)

Simple partial seizure Simple partial seizure (partial onset epilepsy)(partial onset epilepsy)(partial onset epilepsy)(partial onset epilepsy)

Pts interact normally with environment Pts interact normally with environment Pts interact normally with environment Pts interact normally with environment Discharge occurs in limited and Discharge occurs in limited and circumbscribed area of cortexcircumbscribed area of cortexc cu bsc bed a ea o co tec cu bsc bed a ea o co teSymptomSymptom•• Subjective (“Aura”)Subjective (“Aura”)j ( )j ( )

Déjà vu, jamais vu, epigatric rising sensation, fear, Déjà vu, jamais vu, epigatric rising sensation, fear, feeling of unreality or detachment, olfactory hallucinationfeeling of unreality or detachment, olfactory hallucinationUnilateral sensory disturbanceUnilateral sensory disturbanceUnilateral sensory disturbanceUnilateral sensory disturbance

•• Observable manifestationObservable manifestationFocal motor Focal motor “Jacksonian march”“Jacksonian march”

Complex partialComplex partial( )( )(Partial onset epilepsy)(Partial onset epilepsy)

Impaired consciousnessImpaired consciousnessAutomatismAutomatism•• Repetitive, complex, purposeless motor activityRepetitive, complex, purposeless motor activity•• LipLip--smacking repeated swallowing chewing smacking repeated swallowing chewing •• LipLip--smacking, repeated swallowing, chewing, smacking, repeated swallowing, chewing,

picking motions with handspicking motions with handsStaringStaringPostPost--ictally ictally –– pts confused and disoriented for pts confused and disoriented for several minutesseveral minutes7070--80% of complex partial seizures arise from 80% of complex partial seizures arise from 7070 80% of complex partial seizures arise from 80% of complex partial seizures arise from temporal lobestemporal lobesRemainder arise from frontal and occipital lobesRemainder arise from frontal and occipital lobes

Secondarily generalized tonic Secondarily generalized tonic l i il i iclonic seizureclonic seizure

(partial onset epilepsy)(partial onset epilepsy)

ContralateralContralateralH d d i tiH d d i ti•• Head deviationHead deviation

•• Gaze deviationGaze deviation•• Arm elevationArm elevation•• Followed by bilateral extension (tonic)Followed by bilateral extension (tonic)•• Bilateral clonic activity (clonic)Bilateral clonic activity (clonic)•• PostPost--ictal lethargyictal lethargy

Absence seizureAbsence seizure(Generalized epilepsy)(Generalized epilepsy)

Momentary lapses in awarenessMomentary lapses in awarenessMomentary lapses in awarenessMomentary lapses in awarenessMotionless staringMotionless staringArrest of ongoing activityArrest of ongoing activityArrest of ongoing activityArrest of ongoing activityNo warning No warning No postictal periodNo postictal periodNo postictal periodNo postictal periodCharacteristic EEG finding during seizureCharacteristic EEG finding during seizure•• 3 Hz generalized spike wave3 Hz generalized spike wave•• 3 Hz generalized spike wave3 Hz generalized spike wave

Ethosuximide Ethosuximide Seizure can be induced with Seizure can be induced with Seizure can be induced with Seizure can be induced with hyperventilation in officehyperventilation in office

Generalized tonic clonicGeneralized tonic clonic(Generalized epilepsy)(Generalized epilepsy)

Abrupt loss of consciousnessAbrupt loss of consciousnessAbrupt loss of consciousnessAbrupt loss of consciousnessLoud vocalization as air forced across Loud vocalization as air forced across contracted vocal cords (ictal cry)contracted vocal cords (ictal cry)co t acted oca co ds ( cta c y)co t acted oca co ds ( cta c y)Bilateral tonic extension of trunk and Bilateral tonic extension of trunk and limbs (tonic)limbs (tonic)( )( )Synchronous muscle jerking (clonic)Synchronous muscle jerking (clonic)PostPost--ictallyictallyPostPost ictallyictally•• Unarousable, then lethargic and Unarousable, then lethargic and

confusedconfused•• Prefer to sleepPrefer to sleep

Other generalized seizure typesOther generalized seizure typesOther generalized seizure typesOther generalized seizure typesMyoclonic seizureMyoclonic seizure•• Rapid brief muscle jerkRapid brief muscle jerk•• Bilaterally, synchronouslyBilaterally, synchronously•• Asynchronously, unilaterallyAsynchronously, unilaterally•• Myoclonic jerks range from isolated small Myoclonic jerks range from isolated small

movements of face, arm or leg to movements of face, arm or leg to massive bilaterally jerksmassive bilaterally jerks

Atonic seizureAtonic seizure•• Drop attacksDrop attacks•• Sudden loss of muscle tone resulting in Sudden loss of muscle tone resulting in

fallsfalls

Temporal lobe epilepsyTemporal lobe epilepsyTemporal lobe epilepsyTemporal lobe epilepsyAge of onset: 7Age of onset: 7--2020History of febrile seizure as infantHistory of febrile seizure as infantSeizure types:Seizure types:

Si l i l (“A ”)Si l i l (“A ”)•• Simple partial (“Aura”)Simple partial (“Aura”)•• Complex partialComplex partial•• Secondarily generalized tonic clonic Secondarily generalized tonic clonic •• Secondarily generalized tonic clonic Secondarily generalized tonic clonic Characteristic EEG findingCharacteristic EEG finding•• Focal spike waves over temporal lobeFocal spike waves over temporal lobeStructural abnormality on MRIStructural abnormality on MRI•• Mesial temporal lobe sclerosisMesial temporal lobe sclerosisOften refractory to medicationOften refractory to medication

Juvenile Myoclonic EpilepsyJuvenile Myoclonic EpilepsyJuvenile Myoclonic EpilepsyJuvenile Myoclonic EpilepsyIdiopathic generalized epilepsyIdiopathic generalized epilepsyA f t 12A f t 12 2020Age of onset: 12Age of onset: 12--2020Neurologically and intellectually normalNeurologically and intellectually normalSeizure types:Seizure types:Seizure types:Seizure types:•• Generalized tonic clonic seizuresGeneralized tonic clonic seizures•• Myoclonic seizuresMyoclonic seizures

Sensitivity to sleep deprivation and alcoholSensitivity to sleep deprivation and alcoholCharacteristic EEG findingCharacteristic EEG finding•• 44--5 Hz generalized spike wave discharges5 Hz generalized spike wave discharges•• 44 5 Hz generalized spike wave discharges5 Hz generalized spike wave discharges

Valproate, lamotrigine Valproate, lamotrigine Avoid drugs like carbamazepine or phenytoinAvoid drugs like carbamazepine or phenytoinUsually lifelongUsually lifelong

Childhood Absence EpilepsyChildhood Absence EpilepsyChildhood Absence EpilepsyChildhood Absence EpilepsyIdiopathic generalized epilepsyIdiopathic generalized epilepsyd opat c ge e a ed ep epsyd opat c ge e a ed ep epsyAge of onset: 4Age of onset: 4--12 years12 yearsNeurologically and intellectually normalNeurologically and intellectually normalg y yg y yRecurrent absence seizuresRecurrent absence seizuresIf untreated, absence seizures can occur If untreated, absence seizures can occur hundreds of times a dayhundreds of times a dayEEG during absence characteristic 3EEG during absence characteristic 3--Hz Hz generalized spike wavegeneralized spike wavegeneralized spike wavegeneralized spike waveEthosuximide and valproateEthosuximide and valproate60% terminal remission60% terminal remission60% terminal remission60% terminal remission

Identifiable cause of epilepsy as Identifiable cause of epilepsy as f ti ff ti fa function of agea function of age

N t t 3 N t t 3 33 20 20 2020 60 60 O 60 O 60 Neonate to 3 Neonate to 3 yryr

33--20 yr20 yr 2020--60 yr60 yr Over 60 yrOver 60 yr

Prenatal Prenatal Genetic Genetic Brain tumorsBrain tumors Vascular Vascular InjuryInjury predispositipredispositi

onondiseasedisease

Perinatal Perinatal InfectionsInfections TraumaTrauma Brains Brains InjuryInjury tumorstumors

Metabolic Metabolic defectsdefects

TraumaTrauma Vascular Vascular diseasedisease

TraumaTrauma

Congenital Congenital malformationmalformation

Congenital Congenital malformatiomalformationn

InfectionInfection Systemic Systemic metabolic metabolic derangementderangementgg

InfectionInfection Metabolic Metabolic defectdefect

InfectionsInfections

Metabolic causes of acute Metabolic causes of acute (symptomatic) seizure(symptomatic) seizure

Low calciumLow calciumLow calciumLow calciumLow sodiumLow sodiumLow glucoseLow glucoseLiver failureLiver failureRenal failureRenal failureAnoxiaAnoxiaAnoxiaAnoxiaNonketotic hyperglycemic stateNonketotic hyperglycemic state

Medical TreatmentMedical TreatmentMedical TreatmentMedical Treatment

Acute symptomatic seizuresAcute symptomatic seizuresAcute symptomatic seizuresAcute symptomatic seizures•• Childhood febrile seizureChildhood febrile seizure•• Metabolic or toxic encephalopathyMetabolic or toxic encephalopathy•• Metabolic or toxic encephalopathyMetabolic or toxic encephalopathy•• If conditions resolve without permanent If conditions resolve without permanent

brain damage seizures usually selfbrain damage seizures usually self--brain damage, seizures usually selfbrain damage, seizures usually self--limitedlimited

Single unprovoked seizureSingle unprovoked seizureSingle unprovoked seizureSingle unprovoked seizure•• Only 25% later develop epilepsyOnly 25% later develop epilepsy

E ilE ilEpilepsyEpilepsy

OutlineOutlineOutlineOutline

Surgically remediable epilepsiesSurgically remediable epilepsiesSurgically remediable epilepsiesSurgically remediable epilepsiesCriteria for surgical candidacyCriteria for surgical candidacyS i l l tiS i l l tiSurgical evaluationSurgical evaluationGoals of surgeryGoals of surgeryTypes of surgeryTypes of surgerySurgical OutcomesSurgical OutcomesSurgical OutcomesSurgical Outcomes

Mesial temporal lobe epilepsyMesial temporal lobe epilepsyMesial temporal lobe epilepsyMesial temporal lobe epilepsy

Most common and widely recognizedMost common and widely recognizedMost common and widely recognizedMost common and widely recognizedH/o febrile seizures H/o febrile seizures CPS b i i 1CPS b i i 1 tt 2 2 dd d dd dCPS begins in 1CPS begins in 1stst or 2or 2ndnd decadedecadeAnt or midtemporal spike on EEGAnt or midtemporal spike on EEGHippocampal atrophy and inc signal Hippocampal atrophy and inc signal on MRIon MRI<20% undergo spontaneous <20% undergo spontaneous remission of szremission of szremission of szremission of sz

Mesial temporal lobe sclerosisMesial temporal lobe sclerosisMesial temporal lobe sclerosisMesial temporal lobe sclerosis

Lesional neocortical epilepsyLesional neocortical epilepsyLesional neocortical epilepsyLesional neocortical epilepsy

Discrete neocortical lesion Discrete neocortical lesion Discrete neocortical lesion Discrete neocortical lesion Examples: tumor, vascular Examples: tumor, vascular malformation focal cortical dysplasiamalformation focal cortical dysplasiamalformation, focal cortical dysplasiamalformation, focal cortical dysplasiaSurrounding cortex Surrounding cortex ––occult pathology and occult pathology and be epileptogenicbe epileptogenicbe epileptogenicbe epileptogenic

Cavernous AngiomaCavernous AngiomaCavernous AngiomaCavernous Angioma

Cortical dysplasiaCortical dysplasiaCortical dysplasiaCortical dysplasia

Tassi, L et al. Brain 2002Tassi, L et al. Brain 2002

“Nonlesional” neocortical “Nonlesional” neocortical epilepsyepilepsy

Most challengingMost challengingMost challengingMost challengingTemporal vs. extratemporalTemporal vs. extratemporalPh II l ti t il d t Ph II l ti t il d t Phase II evaluation tailored to Phase II evaluation tailored to patientspatientsMicroscopic pathologyMicroscopic pathologyRelationship to eloquent cortexRelationship to eloquent cortexp qp q

Goals of surgeryGoals of surgeryGoals of surgeryGoals of surgery

Identify discrete and localized area of Identify discrete and localized area of Identify discrete and localized area of Identify discrete and localized area of seizure focusseizure focusEstablish lack of vital functionEstablish lack of vital functionEstablish lack of vital functionEstablish lack of vital functionCurativeCurative•• Eradicates seizures and need for medEradicates seizures and need for medEradicates seizures and need for medEradicates seizures and need for med

PalliativePalliative•• Lessens seizure severity and frequencyLessens seizure severity and frequencyy q yy q y

Criteria for surgical candidacyCriteria for surgical candidacyCriteria for surgical candidacyCriteria for surgical candidacy

Medical IntractabilityMedical IntractabilityMedical IntractabilityMedical IntractabilitySurgically remediable syndromeSurgically remediable syndromeContraindicationsContraindicationsContraindicationsContraindications•• Underlying degenerative or metabolic disordersUnderlying degenerative or metabolic disorders•• Primary generalized epilepsy syndromePrimary generalized epilepsy syndromey g p p y yy g p p y y•• Benign epilepsy syndromes with potential for Benign epilepsy syndromes with potential for

spontaneous remissionspontaneous remission•• Medication noncompliance Medication noncompliance •• Medication noncompliance Medication noncompliance •• Interictal psychosisInterictal psychosis•• Severely dysfunction family dynamicsSeverely dysfunction family dynamicsy y y yy y y y

Tests important in preTests important in pre--surgical surgical evaluationevaluation

VideoVideo--EEG, including recording typical EEG, including recording typical seizuresseizuresseizuresseizuresMRIMRINeuropsychological testingNeuropsychological testingWada testWada testPETPETIctal SPECTIctal SPECTIctal SPECTIctal SPECTFunctional MRIFunctional MRIIntracranial EEGIntracranial EEGIntracranial EEGIntracranial EEG

VideoVideo--EEG MonitoringEEG MonitoringVideoVideo EEG MonitoringEEG Monitoring

To record seizures, and interictal To record seizures, and interictal (between seizures) EEG activity(between seizures) EEG activity( ) y( ) y24 hr monitoring, ~7 days. 24 hr monitoring, ~7 days. Withdraw medicationsWithdraw medicationsWithdraw medicationsWithdraw medicationsActivation (HV, photic, sleep Activation (HV, photic, sleep d i ti )d i ti )deprivation)deprivation)

Magnetic Resonance ImagingMagnetic Resonance ImagingMagnetic Resonance ImagingMagnetic Resonance Imaging

Wada testWada testWada testWada test

To identify language and memory To identify language and memory To identify language and memory To identify language and memory function in each hemisphere function in each hemisphere separatelyseparatelyseparatelyseparatelyHelps predict risks of surgeryHelps predict risks of surgery•• memorymemory•• languagelanguage

Helps predict success of surgeryHelps predict success of surgerySame day procedureSame day procedurey py p

Other testOther testOther testOther test

PETPETPETPETSPECTSPECTN h l i l t tN h l i l t tNeuropsychological testNeuropsychological test

Invasive MonitoringInvasive MonitoringInvasive MonitoringInvasive Monitoring

Negative nonNegative non--invasive testsinvasive testsNegative nonNegative non invasive testsinvasive testsA discrete lesion located near region A discrete lesion located near region of seizure onset of seizure onset of seizure onset of seizure onset If nonIf non--lesional, estimate and place lesional, estimate and place i t i l l t d b d ll i t i l l t d b d ll intracranial electrodes based on all intracranial electrodes based on all nonnon--invasive test resultsinvasive test results

Invasive monitoringInvasive monitoringInvasive monitoringInvasive monitoring

EEG electrode EEG electrode placement placement (int ac anial (int ac anial (intracranial (intracranial monitoring) monitoring) Record seizure with Record seizure with video/EEG in Epilepsy video/EEG in Epilepsy Monitoring UnitMonitoring UnitWhen area of seizure When area of seizure When area of seizure When area of seizure onset is not precisely onset is not precisely defined during phase I defined during phase I evaluationevaluationevaluationevaluation

Epilepsy surgeryEpilepsy surgeryEpilepsy surgeryEpilepsy surgery

History of Brain surgery for epilepsyHistory of Brain surgery for epilepsy•• >100 years old>100 years old•• >100 years old>100 years old

The most common operation The most common operation •• resection of the anterior portion of either the resection of the anterior portion of either the resection of the anterior portion of either the resection of the anterior portion of either the

right or left temporal loberight or left temporal lobe

The restThe rest•• resections of portions of the frontal, parietal or resections of portions of the frontal, parietal or

occipital lobes, and section of the anterior twooccipital lobes, and section of the anterior two--thirds of the corpus callosum thirds of the corpus callosum thirds of the corpus callosum thirds of the corpus callosum

Surgical OutcomeSurgical OutcomeSurgical OutcomeSurgical OutcomeDependent on syndrome and Dependent on syndrome and Dependent on syndrome and Dependent on syndrome and concordance of findingsconcordance of findingsAnterior temp resection Anterior temp resection 7070--90% 90% Anterior temp resection Anterior temp resection 7070 90% 90% LesionectomyLesionectomy 75% 75%

l ll l 0%0%NonNon--lesional resectionlesional resection <50% <50% ~5% complication rate in temporal ~5% complication rate in temporal lobectomy, most temporary; ~1% lobectomy, most temporary; ~1% permanent complicationpermanent complication

What options exist for patients withWhat options exist for patients withWhat options exist for patients with What options exist for patients with patients who are not surgical patients who are not surgical

??candidates?candidates?

M lti l i f i tM lti l i f i tMultiple regions of seizure onsetMultiple regions of seizure onsetSeizure starts in a region with Seizure starts in a region with intact functioningintact functioningCannot undergo surgery safely Cannot undergo surgery safely g g y yg g y ybecause of multiple factors such as because of multiple factors such as age, concurrent medical problemsage, concurrent medical problemsg , pg , p

Vagus Nerve Stimulation (VNS)Vagus Nerve Stimulation (VNS)Vagus Nerve Stimulation (VNS)Vagus Nerve Stimulation (VNS)

First done 1988 FDA approved 1997First done 1988 FDA approved 1997First done 1988, FDA approved 1997First done 1988, FDA approved 1997Surgical implantationSurgical implantationP i di dj t t f ti l ti P i di dj t t f ti l ti Periodic adjustments of stimulation Periodic adjustments of stimulation to maximize benefit and minimize to maximize benefit and minimize id ff tid ff tside effectsside effects

Magnet allows selfMagnet allows self--activationactivationBeing studied for depression as wellBeing studied for depression as well

Vagal Nerve StimulatorVagal Nerve StimulatorVagal Nerve StimulatorVagal Nerve Stimulator

Experiemental: Current clinical Experiemental: Current clinical trialstrials

Brain Stimulation with implanted Brain Stimulation with implanted devicedevice•• Responsive NeurostimulatorResponsive Neurostimulator

Detects seizuresDetects seizuresAt seizure focusAt seizure focus

•• Deep brain stimulationDeep brain stimulationppBilateral anterior nuclei of ThalamusBilateral anterior nuclei of Thalamus

Responsive NeurostimulatorResponsive NeurostimulatorResponsive NeurostimulatorResponsive Neurostimulator

Responsive NeurostimulatorResponsive NeurostimulatorResponsive NeurostimulatorResponsive Neurostimulator

Stimulation of the Anterior Nucleus of Stimulation of the Anterior Nucleus of the Thalamus for Epilepsythe Thalamus for Epilepsy

Example: AFExample: AFExample: AFExample: AFPresented age 21, college studentPresented age 21, college student

i t 10i t 10seizure onset age 10seizure onset age 10feeling of “disorientation”, inability to feeling of “disorientation”, inability to speak preservation of consciousness oral speak preservation of consciousness oral speak, preservation of consciousness, oral speak, preservation of consciousness, oral automatisms, presently 4automatisms, presently 4--7/week7/weekfebrile seizure @ 10 mo; normal examfebrile seizure @ 10 mo; normal exam@ ;@ ;EEG rare left sharp waves, MRI normalEEG rare left sharp waves, MRI normalhad failed phenytoin, carbamazepinehad failed phenytoin, carbamazepinep y , pp y , p

Neuropsychological testNeuropsychological testNeuropsychological testNeuropsychological test

FSIQ 101; VIQ 101; PIQ 102FSIQ 101; VIQ 101; PIQ 102FSIQ 101; VIQ 101; PIQ 102FSIQ 101; VIQ 101; PIQ 102mild left dysfunction on specific mild left dysfunction on specific language taskslanguage taskslanguage taskslanguage tasks

WadaWadaWadaWada

left language dominanceleft language dominanceleft language dominanceleft language dominanceleft injection: 7/8 recallleft injection: 7/8 recalli ht i j ti 6/10 lli ht i j ti 6/10 llright injection: 6/10 recallright injection: 6/10 recall

SummarySummarySummarySummary

temporal appearing seizures temporal appearing seizures temporal appearing seizures, temporal appearing seizures, intractableintractableconcordant ictal EEGconcordant ictal EEGconcordant ictal EEGconcordant ictal EEGno MRI abnormalityno MRI abnormalityminimal interictal spikesminimal interictal spikesWada suggestive of left mesial Wada suggestive of left mesial ggggdysfunctiondysfunctionunclear whether mesial or neocorticalunclear whether mesial or neocorticalunclear whether mesial or neocorticalunclear whether mesial or neocortical

FollowFollow--upupFollowFollow upup

standard left temporal lobectomy 1standard left temporal lobectomy 1--standard left temporal lobectomy 1standard left temporal lobectomy 12020--9999no further seizuresno further seizuresno further seizuresno further seizuresmild decline in verbal memory, mild decline in verbal memory, improvement in naming, receptive improvement in naming, receptive improvement in naming, receptive improvement in naming, receptive language, arithmeticlanguage, arithmeticcarbamazepine discontinued 2carbamazepine discontinued 2--9999carbamazepine discontinued 2carbamazepine discontinued 2 9999gabapentin discontinued 2gabapentin discontinued 2--0000working as financial analystworking as financial analystworking as financial analystworking as financial analyst

ConclusionConclusionConclusionConclusion

Epilepsy surgery is an underutilized Epilepsy surgery is an underutilized Epilepsy surgery is an underutilized Epilepsy surgery is an underutilized procedureprocedureSurgically remediable syndrome and Surgically remediable syndrome and Surgically remediable syndrome and Surgically remediable syndrome and medically refractorymedically refractoryN i i l ti h ld N i i l ti h ld Noninvasive evaluation should Noninvasive evaluation should considered early in diseaseconsidered early in disease