What is the treatment for a calcified hematoma causing seizures in the left high frontal region?

Treatment of Calcified Hematoma Causing Seizures in Left High Frontal Region

For patients with calcified hematoma causing seizures in the left high frontal region, surgical removal of the seizure focus is recommended when seizures are refractory to medical management.

Medical Management

First-Line Antiepileptic Drug Therapy

• Levetiracetam or lamotrigine are preferred first-line antiepileptic drugs due to their efficacy and overall good tolerability profile 1
• Valproate (30 mg/kg IV loading dose) may be considered as an alternative, particularly if psychiatric side effects occur with levetiracetam 2, 3
• Avoid enzyme-inducing anticonvulsants like phenytoin, phenobarbital, and carbamazepine due to their side-effect profiles and drug interactions with steroids and other medications 1

Duration of Antiepileptic Therapy

• Patients with calcified lesions and seizures should receive antiepileptic drugs for seizure control 1
• If seizures are well-controlled, consider tapering and discontinuing antiepileptic drugs after 6 months of seizure freedom, but only if there are no risk factors for recurrent seizures 1
• Risk factors for seizure recurrence include residual lesions, breakthrough seizures, or history of multiple seizures 1

Imaging Follow-up

• Brain MRI should be performed in patients with seizures and calcified parenchymal lesions 1
• Follow-up MRI should be repeated at least every 6 months until resolution of any associated cystic components 1

Surgical Management

Indications for Surgical Intervention

• Surgical removal should be considered in patients with refractory epilepsy despite optimal medical management 1
• Calcified hematomas in the frontal region causing medically refractory seizures are good candidates for surgical resection 4, 5

Surgical Approach

• Complete surgical removal of the calcified hematoma is recommended when technically feasible 4, 5
• Preoperative mapping of the seizure focus may be necessary, particularly for lesions near eloquent cortex in the frontal region 1

Perioperative Management

• Corticosteroids are recommended in the perioperative period to decrease brain edema 1
• Continue antiepileptic drugs throughout the perioperative period to prevent breakthrough seizures 1

Special Considerations

Differential Diagnosis

• Consider other calcified lesions in the differential diagnosis, including calcified neurocysticercosis, haemangioma calcificans, and calcified empyema 4, 5
• Haemangioma calcificans can present as a calcified nodule near the brain causing seizures and may require surgical intervention 5

Monitoring

• Regular follow-up with EEG may help detect subclinical seizures and guide antiepileptic drug management 1
• Monitor serum drug levels to ensure therapeutic range and evaluate for toxicity, especially with valproate 2

Pitfalls to Avoid

• Do not use phenytoin in patients with intracranial hemorrhage due to associated excess morbidity and mortality 2
• Be aware that levetiracetam can cause delirium and behavioral abnormalities, which may complicate management 3
• Do not routinely use corticosteroids in patients with isolated calcified parenchymal lesions and perilesional edema unless there are specific indications 1