Abstract The myogenic response is the key autoregulatory mechanism setting cerebral blood flow and its mechanistic foundation is intimately tied to depolarization and the voltage gating of L-type Ca 2+ channels (Ca V 1.2). While critical, this study argues for an additional mechanism, that of pressure itself enhancing Ca V 1.2 activity via cooperative gating and perimembrane trafficking of channel’s subunits. These novel insights were pursued at the cell level using patch-clamp electrophysiology and advanced microscopy, and then functionally in pressurized arteries through measures of tone and intracellular [Ca 2+ ] i . Key findings were confirmed in mutant mice with disrupted functional coupling and translated into arteries procured from human brain tissue. From cerebral blood flow simulations of semi-realistic microvascular networks, we predict that loss of this alternative mechanism leads to maldistribution of brain blood flow and potentially a diminishment of cognitive function. This study reveals previously unrecognized pressure-sensitive Ca V 1.2 regulatory mechanism that advances understanding of cerebral blood flow. Significance Blood pressure sets base arterial constriction - a response critical for blood flow control in brain. This response is tied to Ca V 1.2 channels and their presumptive and exclusive activation by voltage, reasoning now under great scrutiny. We establish herein with advance methods, a second mode of Ca V 1.2 pressure regulation, that of enhanced functional cooperativity among neighboring channels. This novel mechano-response is tied to PKCα and its ability to set channel phosphorylation and Ca V 1.2 trafficking. Ca V 1.2 pressure regulation was observed in human tissues and its disruption (mutant mice) impaired myogenic tone in the presence of preserved voltage control. Cerebral microvascular modeling highlights that losing this mechanism destabilizes blood flow distribution in brain, the knock-on effect being comprised cognitive function.

More than 15 million patients worldwide suffer from drug-resistant epilepsy (DRE). Surgical removal of the seizure onset zone (SOZ)-the brain region(s) from where seizures arise-is the best available treatment for these patients, with post-surgical outcomes depending on the successful identification and resection of the SOZ. Most commonly, SOZ mapping localizes ictal activity occurring spontaneously or evoked by cortical stimulation (CS) during pre-surgical evaluation of patients with epilepsy using stereoelectroencephalography (SEEG). Mapping events such as interictal epileptiform discharges (IEDs), paroxysmal hypersynchronic electrical discharges that often occur outside ictal discharges or during CS, have been less used for SOZ localization. We test the hypothesis that IEDs triggered by CS via SEEG investigation can contribute to the mapping of the SOZ. We evaluated the impact of CS on IEDs in patients investigated with SEEG on epilepsy surgery. We recorded intracranial signals from 30 DRE patients (seizure-free post-surgery). Bipolar and high-frequency (50 Hz) CS were performed with a pulse width of 300 µs and current spanning of 1-8 mA. IEDs were automatically detected pre- and post-stimulation, and their normalized absolute changes were quantified within and outside the SOZ (identified by ictal discharges). We found that the IED rates significantly increased post-stimulation compared with pre-stimulation within the SOZ, while no significant change was observed outside the SOZ (linear mixed-effect model, P-value < 0.001, and AUC = 98% for SOZ and 71% for non-SOZ). This effect was present regardless of whether the stimulation was applied to the SOZ or non-SOZ regions, indicating a broader effect of stimulation on the SOZ. Our results offer a quantitative tool for identifying epileptogenic areas in patients with DRE, enhancing the mapping and localization of the SOZ and potentially improving surgical outcomes.

Effects of deep brain stimulation (DBS) depend on millimetric accuracy and are commonly studied across populations by registering patient scans to a stereotactic space. Multiple factors contribute to estimates of electrode position, but the millimetric contributions of these factors remain poorly quantified. We previously validated 32 anatomical fiducials (AFIDs) to measure AFID registration error (AFRE), which can capture focal misregistration not observed using volume-based methods. To this end, we used the AFIDs framework to examine the effects of misregistration on electrode position in stereotactic space, leveraging a retrospective series of patients who underwent subthalamic nucleus (STN) DBS. Raters independently localized DBS electrodes and AFIDs on patient scans, which were non-linearly registered to a common stereotactic (MNI) space. AFIDs provided intuitive measures of registration accuracy, with AFREs ranging from 1.49 mm to 6.85 mm across brain regions. Subcortical AFIDs in proximity to the DBS target (STN) had AFREs that spatially covaried, suggesting consistent spatial patterns of misregistration to stereotactic space. These identified spatial patterns account for 28% of the variance in electrode position along the axis of maximum variance, corresponding to a median of 0.64 mm (range of 0.05 to 2.05 mm). The AFIDs framework provides millimetric estimates of registration accuracy in DBS, while allowing the uncoupling of registration-related factors from other sources of variance in electrode position. Furthermore, they can be employed for estimating registration-related variance in population studies, for quality control, and to provide a basis for comparison as well as optimization of registration parameters and software.

OBJECTIVE:The aim of this study was to retrospectively compare robot-assisted and manual frame-based stereoelectroencephalography (SEEG) with respect to timing, complications, and outcomes in a high-volume epilepsy surgery center. METHODS:All patients with drug-resistant epilepsy who underwent SEEG from 2000 to 2020 were collected for a retrospective-and from 2017 onward, prospective-database. RESULTS:A total of 192 SEEG procedures consisted of 88 robot-assisted and 104 manual frame-based cases. Both groups were of similar age, gender distribution, and duration of epilepsy. A mean of 10.9 electrodes were implanted for the robot-assisted group versus 9.3 electrodes in the manual frame-based group (p < 0.01) with a mean implantation time per electrode of 8.2 ± 3.4 versus 16.1 ± 7.7 minutes, respectively (p < 0.01). Complications were low in both groups; intracranial hemorrhage was observed in 6.8% and 5.8%, respectively. CONCLUSIONS:Using a stereotactic robot for SEEG electrode insertion can significantly decrease operative time.

OBJECTIVE:This study was undertaken to determine whether bilateral independent or unclear (BI/U) scalp electroencephalographic (EEG) ictal onset patterns may predict the diagnostic yield of stereo-electroencephalography (SEEG) and inform surgical decision-making in patients with focal drug-resistant epilepsy. METHODS:We conducted a retrospective cohort study of consecutive patients with focal drug-resistant epilepsy and BI/U ictal onset on scalp EEG who underwent SEEG evaluation at our center between January 2012 and December 2024. All patients had undergone noninvasive and invasive presurgical assessments. Surgical outcomes were determined using the Engel classification following at least 1 year of postoperative follow-up. A blinded decision validation substudy was also performed, where the team made decisions regarding SEEG and surgical interventions when patients found to have a single SEEG seizure onset zone (SOZ) were presented. Responses were stratified to inform the added diagnostic value of SEEG. RESULTS:Of 255 SEEG cases screened, 84 patients (33%) had BI/U ictal onset on scalp EEG. The cohort was 56% female, with a median seizure onset age of 12 years (interquartile range = 6-20); 65.5% had temporal lobe epilepsy (TLE). A single SOZ was identified in 14.3% of cases (TLE: 14.5%, extratemporal: 13.8%). These patients had shorter SEEG recording durations (mean = 11 vs. 15.79 days in those with multifocal SEEG SOZs, p = .009). Curative focal resections were performed in 12% (n = 10), with long-term Engel I outcomes achieved in one patient of the entire cohort (1.2%). Palliative resections occurred in 26% (n = 22), with Engel I outcomes in 7% (n = 6). In 50% of the blinded cases, the epilepsy surgery team reported that they would not have recommended SEEG based on phase I data. SIGNIFICANCE:In patients with BI/U ictal onset on scalp EEG, the likelihood of identifying a single SEEG SOZ, and subsequently achieving seizure freedom, is low. Scalp EEG ictal onset patterns may aid in triaging candidates for invasive evaluation, informing patients regarding presumed SEEG outcome, and avoiding unnecessary surgical procedures.

Scalp electroencephalography (EEG) may reveal bilateral independent or unclear (BI/U) ictal onset patterns in patients with focal drugresistant epilepsy, presenting a challenge to surgical decision making. The utility of stereoelectroencephalography (SEEG) in this subgroup, particularly the probability of delineating a single seizure onset zone (SOZ) that would permit curative resection, remains poorly understood. This study examined whether BI/U scalp EEG findings could predict SEEG outcomes in this population. We conducted a retrospective cohort study of consecutive patients with focal drugresistant epilepsy and BI/U ictal onset on scalp EEG who underwent SEEG evaluation at the London Health Sciences Centre (Ontario, Canada) between January 2012 and December 2024. All patients had undergone noninvasive and invasive presurgical assessments. Surgical outcomes were determined using the Engel classification following at least one year of postoperative followup. A blinded decision validation substudy was also performed. Blinded to actual outcomes, the team made decisions regarding SEEG and surgical interventions when patients found to have a single SEEG SOZ were presented. Responses were stratified to inform the added diagnostic value of SEEG. Of 255 SEEG cases screened, 84 patients (33%) met inclusion criteria. The cohort was 56% female, with a median seizure onset age of 12 years (IQR 6[ndash]20); 65.5% had temporal lobe epilepsy (TLE). A single SOZ was identified in 14.3% of cases (TLE: 14.5%, extratemporal: 13.8%). Patients with a single SEEG SOZ were found to have shorter recording durations (mean of 11 vs 15.79 days in those with multifocal SEEG SOZs; p=0.009). Curative focal resections were performed in 12% (n=10), with longterm Engel I outcomes achieved in one patient (1.2%). Palliative resections occurred in 26% (n=22), with Engel I outcomes in 7% (n=6). In 50% of the blinded cases, the epilepsy surgery team reported that they would not have recommended SEEG based on phase I data. These findings suggest that patients with BI/U scalp EEG SOZs may be associated with a low likelihood of identifying a single SEEG SOZ and curative outcome. Using BI/U scalp EEG ictal onset as a predictor in preoperative decisionmaking will assist in refining SEEG candidate selection in this large subgroup. ### Competing Interest Statement J. G. B holds the Jack Cowin Endowed Chair in Epilepsy Research at Western University. G.P. receives Xenon X TOLE2/3 and X ACKT clinical trials and Elsevier Neuroimage Editorial Honoraria. Revenues from the above activities are allocated to a research account. GP is also funded by AMOSO (Academic Medical Organization of Southwestern Ontario) Opportunities Fund, Western Strategic Support for CIHR Success Seed program, NSERC Discovery Grant, NSERC RTI Grant, Western CNS Internal Competition Grant, Lawson Internal Research Grant Fund, CNS Department Starting Grant. All other authors confirm no competing interests for this research. ### Funding Statement No funding was received towards this work specifically. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Western University Health Science Research Ethics Board (127171 108606) in London, Ontario, Canada gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

Background: Ventriculoatrial (VA) shunts are used to manage hydrocephalus and idiopathic intracranial hypertension when peritoneal drainage of cerebrospinal fluid is not feasible. The technique of distal catheter placement during VA shunt insertion is controversial, especially between fluoroscopy-guided and transesophageal echocardiography (TEE)-guided techniques. Methods: We retrospectively reviewed our utilization of 2-dimensional (2D) ultrasound-guided internal jugular vein catheterization combined with 3-dimensional (3D) TEE-guided distal VA shunt placement and compared it to the conventional fluoroscopy-guided technique. Results: Ten patients underwent 18 VA shunt insertion procedures between November 2012 and October 2022. The patients had a mean (SD) age of 50 (19) years, body mass index of 35 (14) m/kg², and minimal comorbidities. All had previously undergone failed ventriculoperitoneal shunt procedures. The use of 2D ultrasound to guide internal jugular vein catheterization and 3D TEE to guide distal catheter placement resulted in 22-minute shorter surgical times compared with the fluoroscopy-guided technique (91 minutes vs. 113 minutes, respectively). No complications were noted with either technique. Conclusions: The combined use of 2D ultrasound and 3D TEE allowed for faster procedure times and more precise distal catheter confirmation, contributing to a more streamlined surgical procedure. This small case series underscores the feasibility, efficiency, and safety of anesthesiologist-delivered combined 2D ultrasound and 3D TEE during VA shunt insertion. The use of 3D TEE allows repeated confirmation of distal catheter position and has potential to improve patient safety during rare but complex VA shunt insertion procedures.

Stereoelectroencephalography-guided radiofrequency thermocoagulation (SEEG-guided RF-TC) is a treatment option for focal drug-resistant epilepsy. In previous studies, this technique has shown seizure reduction by ≥50% in 50% of patients at 1 year. However, the relationship between the location of the ablation within the epileptogenic network and clinical outcomes remains poorly understood. Seizure outcomes were analyzed for patients who underwent SEEG-guided RF-TC and across subgroups depending on the location of the ablation within the epileptogenic network, defined as SEEG sites involved in seizure generation and spread. Eighteen patients who had SEEG-guided RF-TC were included. SEEG-guided seizure-onset zone ablation (SEEG-guided SOZA) was performed in 12 patients, and SEEG-guided partial seizure-onset zone ablation (SEEG-guided P-SOZA) in 6 patients. The early spread was ablated in three SEEG-guided SOZA patients. Five patients had ablation of a lesion. The seizure freedom rate in the cohort ranged between 22% and 50%, and the responder rate between 67% and 85%. SEEG-guided SOZA demonstrated superior results for both outcomes compared to SEEG-guided P-SOZA at 6 months (seizure freedom p = .294, responder rate p = .014). Adding the early spread ablation to SEEG-guided SOZA did not increase seizure freedom rates but exhibited comparable effectiveness regarding responder rates, indicating a potential network disruption.

OBJECTIVE:To investigate the effects of vagus nerve stimulation (VNS) on the seizure frequency in patients with drug-resistant epilepsy (DRE) and bilateral temporal lobe epilepsy (bi-TLE). Additionally, we aimed to determine the safety of VNS and its side effects. METHODS:Our retrospective study included 17 patients with bi-TLE who underwent VNS-device implantation at our center from 1997 to 2019. The main outcome was a reduction in seizure frequency. Bitemporal cases were confirmed using scalp electroencephalography (EEG) or invasive electroencephalography (iEEG). RESULTS:The median age at seizure onset was 18 years. Bi-TLE was confirmed by scalp EEG in 47 % and by iEEG in 53 % of the patients. The median follow-up period was 36 months. The median seizure frequency per month before and after VNS was 9.5 (IQR = 4.3-35.3) and 2 (IQR = 0.8-4.2), respectively. Compared to baseline, 70.5 % of the patients achieved ≥ 50 % reduction in seizure frequency, whereas 35.3 % experienced either no or minimal reduction in seizure frequency. The response rate (>50 % reduction in seizure frequency) was 87.5 % in patients who underwent scalp EEG and 55.5 % in those who underwent iEEG. For VNS treatment, the median follow-up was at 36 months (IQR = 17-46.5). Adverse effects were observed in 59 % of the patients, including cough and hoarseness. DISCUSSION:Therapeutic choices are limited in cases of drug-resistant bi-TLE. Our study on VNS-device implantation in bi-TLE suggests a positive outcome.

PURPOSE:Drug-resistant epilepsy (DRE) affects one-third of patients with focal epilepsy. A large portion of patients are not candidates for epilepsy surgery, thus alternative options, such as vagus nerve stimulation (VNS), are proposed. Our objective is to study the effect of vagus nerve stimulation on lesional versus non-lesional epilepsies. METHODS:This is a retrospective cohort study in a single center in London, Ontario, which includes patients with DRE implanted with VNS, implanted between 1997-2018 and the date of analysis is December 2023. PARTICIPANTS:Patients implanted with VNS were classified by lesional (VNS-L) and non-lesional (VNS-NL) based on their MRI head findings. We further subdivided the VNS groups into patients with VNS alone versus those who also had additional epilepsy surgeries. RESULTS:A total of 29 patients were enrolled in the VNS-L, compared to 29 in the VNS-NL. The median age of the patients in the study was 31.8 years, 29.31 % were men (N = 17). 41.4 % (n = 12) of the patients were VNS responders (≥50 % seizure reduction) in the VNS-L group compared to 62.0 % (n = 18) in the VNS-NL group (p = 0.03). When other epilepsy surgeries were combined with VNS in the VNS-L group, the median rate of seizure reduction was greater (72.4 (IQR 97.17-45.88) than the VNS-NL group 53.9 (IQR 92.22-27.92); p = 0.27). CONCLUSIONS:VNS is a therapeutic option for patients with lesional epilepsy, with slightly inferior results compared to patients with non-lesional epilepsy. Patients implanted with VNS showed higher seizure reduction rates if they had previous epilepsy surgeries. This study demonstrates that VNS in lesional epilepsies can be an effective treatment.

A 46-year-old man described 6 months of progressive blurry vision, transient visual obscurations, and pulsatile tinnitus, without constitutional symptoms. He had visual acuity of 20/20 in the right eye and 20/40 in the left eye, enlarged blind spots, bilateral papilledema, and a scalp lump. Examination was otherwise normal, including cranial nerves. CT of the head revealed subtle thickening of the scalp (Figure 1). Lumbar puncture showed protein of 43.8 mg/dL, 0 nucleated cells, and increased opening pressure (38 cmH2O).

Peri-ictal water drinking (PIWD) is the act of drinking water during an electroclinical seizure or up to two-minutes postictally [ [1] Tanno Y. Matsudaira T. Usui N. et al. Periictal water drinking revisited: occurrence and lateralizing value in surgically confirmed patients with focal epilepsy. Epilepsia Open. 2023; 8: 173-182https://doi.org/10.1002/epi4.12690 Google Scholar , [2] Huang S. Al-Abri H. Sachdeva A. Alkhachroum A.M. Shatzman S. Lüders H. Recurrent focal seizures as a feature of status epilepticus presenting as a peri-ictal water drinking. Epilepsy Behav Case Rep. 2018; 10 (Published 2018 Oct 9): 129-132https://doi.org/10.1016/j.ebcr.2018.09.004 Google Scholar ]. PIWD is uncommon, although it has been reported in both children and adults with epilepsy, particularly with temporal lobe epilepsy (TLE). The current literature on PIWD consists solely of cases recorded with scalp-EEG [ [2] Huang S. Al-Abri H. Sachdeva A. Alkhachroum A.M. Shatzman S. Lüders H. Recurrent focal seizures as a feature of status epilepticus presenting as a peri-ictal water drinking. Epilepsy Behav Case Rep. 2018; 10 (Published 2018 Oct 9): 129-132https://doi.org/10.1016/j.ebcr.2018.09.004 Google Scholar ]. PIWD has been associated with a localizing and lateralizing value, over the non-dominant temporal lobe. In this case, an evaluation using stereoelectroencephalography (SEEG) recordings was utilized to gain a deeper understanding of the epileptogenic zone (EZ) and pattern of seizure spread. We present a case of non-lesional, drug-resistant epilepsy (DRE) with PIWD assessed with SEEG.

Background: Studies of deep brain stimulation (DBS) require accurate electrode localization and image registration. We used anatomical fiducials to investigate localization and registration errors in patients who underwent subthalamic nucleus (STN) DBS for Parkinson’s disease (PD). Methods: We conducted a retrospective analysis of patients who underwent bilateral STN DBS for PD. Pre and post operative MRI scans were non-linearly normalized to a standard template (MNI152NLin2009bAsym). Four raters localized DBS electrodes (Lead-DBS), the anterior commissure (AC) and posterior commissure (PC). Errors between rater localizations were calculated (fiducial localization error; FLE). We transformed AC and PC coordinates from template to patient space to calculate the fiducial registration error (FRE)Results: Ninety-nine patients were analyzed, with a median FLE of 0.76mm, 0.74mm, 0.71mm and 0.66mm for the right electrode, left electrode, AC and PC respectively (no significant difference, Wilcoxon sign rank). The median FRE was 1.59mm for AC and 1.21mm for PC, significantly higher than FLE at those coordinates (Wilcoxon sign rank, p<0.001). Conclusions: Raters can accurately localize DBS electrodes, AC and PC from clinical images with sub-millimetric accuracy. Higher FREs at AC and PC suggested registration errors may contribute more than localization errors to electrode uncertainty in a common space.

Objective: In the presurgical evaluation of patients with drug-resistant epilepsy (DRE), occasionally, patients do not experience spontaneous typical seizures (STS) during a stereo-electroencephalography (SEEG) study, which limits its effectiveness. We sought to identify risk factors for patients who did not have STS during SEEG and to analyze the clinical outcomes for this particular set of patients.Methods: We conducted a retrospective analysis of all patients with DRE who underwent depth electrode implantation and SEEG recordings between January 2013 and December 2018.Results: SEEG was performed in 155 cases during this period. 11 (7.2%) did not experience any clinical seizures (non-STS group), while 143 experienced at least one patient-typical seizure during admission (STS group). No significant differences were found between STS and non-STS groups in terms of patient demographics, lesional/non-lesional epilepsy ratio, pre-SEEG seizure frequency, number of ASMs used, electrographic seizures or postoperative seizure outcome in those who underwent resective surgery. Statistically significant differences were found in the average number of electrodes implanted (7.0 in the non-STS group vs. 10.2 in STS), days in Epilepsy Monitoring Unit (21.8 vs. 12.8 days) and the number of cases that underwent resective surgery following SEEG (27.3% vs. 60.8%), respectively. The three non-STS patients (30%) who underwent surgery, all had their typical seizures triggered during ECS studies. Three cases were found to have psychogenic non-epileptic seizures. None of the patients in the non-STS group were offered neurostimulation devices. Five of the non-STS patients experienced transient seizure improvement following SEEG.Significance: We were unable to identify any factors that predicted lack of seizures during SEEG recordings. Resective surgery was only offered in cases where ECS studies replicated patient-typical seizures. Larger datasets are required to be able to identify factors that predict which patients will fail to develop seizures during SEEG.

New-onset refractory status epilepticus (NORSE) is associated with high mortality, therapy-resistant epilepsy (TRE), and poor cognitive and functional outcomes. Some patients develop multifocal TRE, for whom surgery with a curative intention, is not an option. In these patients, vagus nerve stimulation (VNS) is performed as a palliative treatment. We report the long-term outcomes regarding seizure frequency, functional and cognitive outcome, and effectiveness of VNS in two patients with TRE as a consequence of NORSE. In the first patient with cryptogenic NORSE, VNS implantation occurred during the acute stage, probably contributing to the cessation of her status epilepticus. However, in the long-term follow-up, the patient persisted with daily multifocal seizures. In the second patient, VNS implantation was delayed to manage his epilepsy when the NORSE, ultimately due to autoimmune encephalitis, had resolved. During long-term follow-up, no reduction in seizure frequency was achieved. This evidence supporting the use of VNS in patients with TRE after NORSE warrants further investigation.

Chronic pain is a common and debilitating medical condition, affecting almost 20% of the population in North America. Spinal cord stimulators (SCS) have been shown to be an effective and affordable treatment for medically refractory chronic pain caused by numerous conditions. Unfortunately, up to 25% of implanted spinal cord stimulators require revision surgery, and an unknown number of patients may request complete removal of the system. The aim of this study is to perform a retrospective analysis of all patients who have undergone an implantation and subsequent explantation of the spinal cord stimulation system looking for any consistent trends that may predict future outcomes.

Purpose: The presence of verbal auditory hallucinations is often associated with psychotic disorders and rarely is considered as an ictal phenomena. The aim of this paper is to describe the anatomical structures involved in the genesis of this ictal symptom during epileptic seizures and direct cortical stimulation using stereo encephalography (SEEG).Method: The case is of a 31-year-old right-handed female, bilateral speech representation, schizophrenia and with drug-resistant epilepsy and focal aware sensory seizures characterized by ictal verbal auditory hallucinations. She was implanted with depth electrodes, and she was monitored using SEEG recordings. Results: She had focal aware sensory seizures characterized by verbal auditory hallucinations, with the following features: hearing numerous voices (both male and/or female), talking at the same time (not able to distinguish how many). The voices were inside her head, consisted of negative content, and lasted up to two minutes. Some of her focal aware sensory seizures evolved to focal motor seizures and rarely progressed to bilateral tonic clonic seizures. Her neurological examination, her brain MRI and her interictal SPECT were unremarkable. Her PET scan identified mild hypo metabolism over the right temporal and right frontal lobes. Her neuropsychological evaluation showed language laterality undetermined but her functional MRI showed bilateral language representation. On her video-EEG, three seizures were captured with a right posterior temporal onset. A subsequent SEEG showed thirteen typical seizures originating from the posterior temporal neocortical region. The cortical stimulation of the right posterior temporo-parietal neocortical region and right amygdala triggered her typical phenomena, which was multiple voices, inside her head, speaking in the second person, negative content, unable to identify gender, in English, and no side lateralization.Conclusion: Verbal auditory hallucinations should be analyzed carefully because they can be part of the seizure presentation. Our case supports the localization of these hallucinations in the right posterior neocortical temporal regions.

Older epilepsy patients are a fragile group with higher risk of comorbidities and at times, less tolerant to antiseizure medications(ASM). Many of these patients are medically resistant(MR) to ASM and other treatments are required. There is a lack of understanding regarding how improvement of seizures could have an improvement on their quality of life. The goal of this study is to analyze the rates of quality of life(QOL) and how they relate to seizure frequency in MR elderly patients who undergo VNS implantation.