The patient provided written informed consent giving permission to submit this data, which was collected as part of routine clinical care, for publication. A 42-year-old right-handed male with drug-resistant epilepsy was referred for surgical evaluation. He had a single febrile seizure at one year of age, a single focal to bilateral generalized tonic-clonic (FBTC) seizure associated with a tonsillectomy at age 4, and recurrent seizures beginning at age 20. Seizure types included focal aware events every other week, focal with impaired awareness events twice per year, and GTC events twice per year. Anti-epileptic drugs (AEDs) were phenytoin and divalproex prior to surgery, phenytoin and gabapentin at the 6-month post-surgical evaluation, and phenytoin at 22-year follow-up. He underwent left ATL at age 42 and subsequently had three seizures: one focal impaired awareness seizure 2 months post-operatively, one FBTC seizure 14 years post-operatively, and one FBTC seizure following a traumatic brain injury 22 years post-operatively.
There were no birth complications, and developmental milestones were met on time. Additional medical history is significant for melanoma. Psychiatric history is significant for generalized anxiety disorder and depressive disorder, unspecified. Medications at the time of his post-TBI evaluation included escitalopram, duloxetine, and phenytoin. Academically, he was an excellent student who earned bachelor's and master's degrees in business and engineering. He works full-time in a managerial role. He is married and has two children.
Video electroencephalogram showed a left temporal seizure focus. Magnetic resonance imaging (MRI) of the brain indicated left mesial temporal sclerosis. Functional MRI revealed left hemisphere language dominance using a semantic decision task. Neurological exam was normal. Neuropsychological test results obtained approximately 4 months prior to surgery were largely average to above average except for weaknesses in picture naming, facial discrimination, and bimanual fine motor speed and dexterity (see Table 1).
The patient underwent left ATL and returned for post-surgical neuropsychological evaluation approximately 8 months later. He had a single focal seizure with impaired awareness approximately 2 months following surgery (Engel Class IIB). Neuropsychological test results indicated improvement in facial discrimination and declines on measures of verbal and perceptual intellectual skills, wordlist learning and memory, and picture naming (see Table 1). Of note, these test findings indicate a dissociation between change in story learning and recall (no decline) and list learning and recall (significant decline) following left ATL. The list learning task, which contains semantically unrelated words, likely requires more effortful strategies to learn and recall items compared to a story memory task that contains contextually related information. This finding is consistent with previous literature that has shown semantically unrelated list learning and recall tasks are most sensitive to left temporal pathology and/or resection.
At age 64, the patient sustained a moderate traumatic brain injury (TBI). He fell down a flight of stairs and briefly lost consciousness. Duration of post-traumatic amnesia was approximately two days. His initial Glasgow Coma Scale score was 11 but declined to 3 when he had a FBTC seizure. Acute CT of the head showed intraparenchymal hemorrhagic contusions in the left temporal lobe and bilateral anterior-inferior frontal lobes, scattered subarachnoid hemorrhage and small subdural hematomas with a small amount of intraventricular hemorrhage, and remote postsurgical changes with a large region of cystic encephalomalacia and subadjacent gliosis involving the anterior-inferior left temporal lobe. MRI of the brain showed bifrontal hemorrhagic contusions, a contusion within the right anterior temporal lobe, and scattered subarachnoid, intraventricular, and parenchymal based blood products (Fig. 1). He was admitted to the hospital for approximately one week and then transferred to inpatient rehabilitation for approximately one week, where routine physical therapy, occupational therapy, and speech therapy services were initiated, and then discharged to his home.
Approximately 2 months post-TBI, he was referred for an evaluation in a multidisciplinary Traumatic Brain Injury Clinic staffed by providers from physical medicine and rehabilitation and neuropsychology to characterize his recovery following TBI and determine his readiness to return to work. At that time, he reported being nearly at his pre-injury baseline and was hoping to return to work soon. Brief neuropsychological testing revealed significant verbal memory impairment and milder weaknesses in auditory attention and verbal fluency (see Table 1), although the clinical significance of these finding was not entirely clear, given his history of left ATL. Given the nature of his job, which was associated with potential risk to the well-being of his community if errors were made, he was not cleared to return to work, and an additional month of recovery time followed by more comprehensive neuropsychological evaluation was recommended.
Neuropsychological test results approximately 22 years following left ATL and 3 months following moderate TBI demonstrated excellent recovery and remarkable stability (i.e., no standard score changes greater than one standard deviation) relative to his 8-month post-ATL cognitive test scores (see Table 1 and Fig. 2). Although weaknesses were observed on measures of wordlist learning and memory and picture naming, these scores were unchanged compared to his 8-month post-ATL evaluation. Therefore, he was released to return to work part-time with oversight, with a plan to gradually increase his hours and responsibilities as tolerated. He subsequently successfully returned to work full-time and reportedly resumed his previous workload without difficulty.