Left temporal encephalomalacia due to herpes

Case #81: MRI brain 5/8/95: Left temporal encephalomalacia secondary to herpes encephalitis, 1998.

CC: Episodic head turning to the left and aphasia.

 

Hx: This 30 y/o RHF initially presented in 1988(age 28; 2 years prior to this exam) with severe headache, delirium and fever. She then developed a right hemiplegia. She was treated with unknown medications and recovered, but was left with residual aphasia, and right hemiplegia. She was fairly stable until 9/9O when she began experiencing episodic headaches and right homonymous hemianopsia. An EEG revealed a left temporal seizure tendency and she was placed on Dilantin(DPH); and then DPH and CBZ. The CBZ was later discontinued and she remained on DPH only.

In 9/92, she began experiencing episodic head turning to the left, cessation of speech, and covering her groin with both hands for periods of up to 30 seconds. The episodes were following by period of fatigue. Phenobarbital was then added to DPH, but was discontinued shortly thereafter for behavioral change. Depakote was then added to DPH, but she subsequently experienced weight gain and tremors. At the time of presentation she was having 2-4 episodes per day on DPH 300 bid and VPA 750 tid (DPH level 23.2 , VPA level 88.8).

 

PMH: as above.

FHx/SHx: lives with parents. No Tobacco, ETOH, illicit drugs.

 

EXAM: Vital signs were unremarkable.

MS: numerous semantic paraphasic errors of speech, word finding deficit, and circumlocution of thought process.

CN: unremarkable.

Motor: full strength throughout.

Sensory: No deficits appreciated.

Coord: ND

Gait: normal.

Station: not mentioned.

 

Course: The patient underwent Video/EEG monitoring but failed to have a spell. Her seizures proved intractable to standard FDA approved AEDs. She underwent FDG-PET scanning on 5/12/95 and this revealed severe hypometabolism involving a large portion of the left hemisphere, especially in the inferior portion of the left frontal lobe and a small area in the high frontal lobe. She underwent intracranial EEG monitoring on 5/31/95 and this appeared to reveal a left temporal focus. Extracranial EEG monitoring had previously shown frequent interictal focal slowing and epileptiform discharges from the left temporal region, though during one non-videotaped seizure there was 6--12-seconds of 8-10Hz spike/spike-wave activity followed by 120-180seconds of rhythmic delta activity from the left posterior quadrant. Neuropsychological assessment prior to surgery was notable for severe Wernicke's aphasia, agraphia and severely impaired reading and aural comprehension, and less severe memory deficits. She underwent left frontal corticectomy on 6/7/95 without subsequent seizure control. She then entered an open-label vigabatrin trial in addition to the DPH and CBZ she was placed on post operatively. At last follow-up, 2/27/97, she appeared to have no improvement in seizure frequency (41 seizures during 2/97) despite CBZ, DPH, and vigabatrin. There was no change in her Neuropsychologic evaluation in 1997 when compared to previous evaluations.

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