Awake resection of temporal encephalocele associated with drug-resistant epilepsy: illustrative case.

backgroundThe association between temporal encephaloceles (TEs) and drug-resistant epilepsy (DRE) is well recognized, yet the literature regarding therapeutic management remains scarce and largely retrospective. Reported strategies vary from conservative approaches to extensive resection of encephaloceles including the adjacent epileptogenic zone (EZ). Surprisingly, although the EZ may be localized within or adjacent to eloquent areas, surgeries under awake conditions have not been described. One plausible explanation is the potential risk of intraoperative pain during surgical manipulation in the area of the richly innervated basal dura. OBSERVATIONS: The authors present a case of a 23-year-old right-handed male with a left-sided TE associated with incapacitating DRE lasting 8 years. Preoperative evaluation, including 18F-fluorodeoxyglucose positron emission tomography, suggested a large EZ within the dominant temporal lobe. An awake resection of the encephalocele and the EZ was performed; electrocorticography was utilized to tailor the resection extent. Speech and language functions were tested during the entire procedure. Surgical manipulation during encephalocele resection did not cause any discomfort. No postoperative neurological deficit was observed; the long-term seizure outcome is Engel class II. The patient returned to work. LESSONS: In selected cases in which the EZ adjacent to TEs involves eloquent areas, awake resection may be safely performed. https://thejns.org/doi/10.3171/CASE26699.