The Japanese Journal of Psychiatry and Neurology, Vol. 47, No. 2, 1993 267 Video Session Frontal Lobe Epilepsy with Supplementary Motor Seizures Successfully Treated with Cortical Resection following Intracranial EEGKCTV Monitoring and Functional Mapping Takayasu Tottori, M.D., Kazuichi Yagi, M.D., Tadahiro Mihara, M.D., Kazumi Matsuda, M.D., Koichi Baba, M.D., Toshio Hiyoshi, M.D., Yutaka Watanabe, M.D., Yushi Inoue, M.D., Yuko Kubota, M.D. and Masakazu Seino, M.D. National Epilepsy Center, Shizuoka Higashi Hospital, Shizuoka Introduction Three patients who had medically refractory supplementary motor seizures were successfully treated with cortical resection following long-term intracranial EEG/CCTV monitoring with the use of grid and strip electrodes. CT and/or MRI showed lesions in the vicinity of the supplementary motor area (SMA) in all the 3 patients. This study deals with the electroclinical features of SMA seizures, documented by EEG/CCTV, and the Fig. 1: MRI (long SE) shows a well circumscribed lesion just anterior of the primary motor cortex in the vicinity of the supplementary motor area. seizure outcome of the surgery. Subjects and Methods The patients were men, aged 26 to 31, whose epilepsy began at age 8 to 13, with a duration of 12 to 22 years. Their seizures occurred as frequently as 10 to 100 times per day and tended to occur in clusters. Cortical excision was carried out after the epileptogenic focus was localized in the SMA by CCTV/EEG and the anterior edge of the primary motor cortex was identified with functional mapping. Case Report The patient was a 26-year-old man who was healthy until the onset of epilepsy. He had a tonic-clonic convulsion at the age of 13. He then began to have repeated seizures lasting a few seconds characterized by bilateral facial contraction, elevation of the upper extremities and shoulders, rotation of the trunk, and speech arrest with preservation of consciousness. The seizures took place 10 to 30 Fig. 2 : Lateral view of skull XP shows the placement of strip electrodes covering the tumorous lesion, lateral frontal cortex, cingulate gyrus, and supplementary motor area, and of grid electrodes covering the primary motor cortex and the sensory cortex. Selected Papers: Video Session 268 times a day. When these brief seizures occurred in clusters, he exhibited complex gestural automatisms and unilateral tonic posturing with loss of contacts with the environment. CT and MRI showed lesions in the anterior part of the primary motor cortex and in the vicinity of the left SMA (Fig. 1). Interictal scalp-recorded EEGs showed paroxysmal high-amplitude slow waves and sharp waves dominantly in the left frontal region and in the vertex. Ictal scalp-recorded 13 EEGs showed a short burst of bilateral lowamplitude fast wave rhythm accompanying facial contractions. After noninvasive evaluations, we placed intracerebral strip and grid electrodes to cover the lesion site, sensorimotor area, and the SMA (Fig. 2). We documented 82 spontaneously occurring seizures, some in clusters lasting for an hour. Fig. 3 shows one of the seizure discharges of a part of the clustering events. Further, cortical stimulation was conducted to exemplify Fig. 3: Intracranial ictal EEGs show one seizure event of a part of long lasting and clustering seizures. A bilateral facial contraction appeared at arrow 1, coinciding with slow-wave activities followed by a build-up of low-amplitude fast rhythms in the SMA (IH2 4-5, IH3 4-5) that spread to the ipsilateral lateral frontal cortex (FL1 1-2). Low-amplitude fast waves then spread to all leads with an augmenting amplitude. At arrow 2, tonic posturing of the right arm and hand began. At arrow 3, gestural automatisms of scratching the neck with the fingers of the left hand started while tonic posturing was still continuing. The Japanese Journal of Psychiatry and Neurology, Vol. 47, No. 2, 1993 269 the habitual electroclinical seizures as well as to identify the motor representation with functional mapping. The results are summarized in Fig. 4. Cortical resection was then carried out. The lesion was a thrombosed arteriovenous malformation (AVM). There were no postoperative complications except for a transient motor weakness and disability of fluent speech lasting a few weeks. During the 11-month period to date, he has had no seizures. Results and Conclusion Lesions in the 3 patients were found to be a thrombosed AVM, ectopic gray matter, and a cavernous angioma. After the surgery, 2 patients became completely free from seizures, and the other patient had seizures only a few times a month. There were no permanent complications. The follow-up period and outcome are summarized in Table 1. Table 2 shows the seizure manifestations and other ictal symptomatology of the 3 patients. Secondarily generalized tonic-clonic seizures were seen only in one patient. The signal symptoms were a sensation of being electrified in one patient and an indescribable cephalic sensation in another patient. Tonic posturing was symmetrical in one patient and asymmetrical in another. The asymmetrical tonic posturing was predominantly contralaterally to the side of the epileptogenic focus. These seizure symptomatologies were irrelevant to the seizure outcome. In all the 3 Ictal discharge 0Af1er discharge OAVM - Motor 0finger em 0 head Sensory 0 finger 0 forearm @ arm and head 4D abdomen Stimulation biphasic square wave duration 0 3msec frequency 50 Hz inrensiry 3 - 8 mA time I - 3 wc Reuction line Fig. 4 : Sites of AVM, cortical stimulation, and functional mapping, and the responses in case 1. Table 2 : Ictal Symptomatology of the 3 Patients Table 1 : Pathology of the Lesions and Surgery Outcome Case 1 Pathology Neurologicala complications Follow-up period Seizure outcome Case 2 Case 3 Thrombosed Ectopic gray Cavernous AVM matter angiom a None None None 10 M Free 16 M Free 24 M 1/M (sleep) Case 1 Signle symptoms Moaning Speech arrest Bilateral facial contraction Elevation of shoulder Rotation of trunk Tonic posturing Secondary GTC Complex gestural automatisms + : present, ~ : absent. - + + + + + + Case 2 Case 3 + + + + + + + + + + + + + - + - 270 Selected Papers: Video Session patients, the resected area was the SMA in addition to the adjacent area. The extent of the resection was tailored individually according to the electroclinical seizure patterns and the site of the tumorous lesions. We trust that such considerations might bring about a favorable outcome of resection surgery involving the SMA.