• Varun M Bhave, Joshua D Bernstock, Julia M Carlson, Ari D Kappel, Erickson F Torio, Jason A Chen, Walid Ibn Essayed, Kara L Gawelek, Daniel F DiToro, Saef Izzy, and G Rees Cosgrove.
• Harvard Medical School, Boston, Massachusetts, USA.
• Neurosurgery. 2023 May 1; 92 (5): 915933915-933.

BackgroundHerpes simplex virus (HSV) is a common cause of viral encephalitis and can result in refractory seizures. Although HSV encephalitis (HSVE) is treated primarily with acyclovir, surgery can play a role in medically intractable cases.ObjectiveTo systematically review cases describing surgery for the treatment of severe HSVE. We also present an illustrative case of anterior temporal lobectomy (ATL) for refractory status epilepticus in a patient with unilateral HSVE. This case demonstrates one clinical context in which surgery can be a useful adjunct.MethodsWe performed a systematic review using PubMed and Google Scholar, including case reports and series describing surgical interventions for HSVE. Clinical data were extracted from 54 publications that incorporated 67 patient cases.ResultsSurgical decompression occurred at a wide range of times after the onset of illness, although most patients were operated on 4 or more days after HSVE symptoms began. Numerous reports indicated that decompressive craniectomy, temporal lobectomy, and hematoma removal could treat intractably elevated intracranial pressure because of HSVE with favorable long-term outcomes. We describe an additional case in which a 52-year-old woman with HSVE developed refractory right temporal lobe seizures. After ATL, the seizures resolved with significant clinical improvement.ConclusionSurgical treatment can be a useful adjunct for treatment of HSVE. There is substantial variability in the timing of surgical decompression in patients with HSVE, which can be necessary up to approximately 3 weeks after illness onset. ATL should be considered for refractory status epilepticus in HSVE with a unilateral seizure focus.Copyright © Congress of Neurological Surgeons 2023. All rights reserved.

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