Case Study

A 15 year old right-handed female experienced a febrile convulsion prior to a nocturnal "grand mal" seizure at 12 years. Subsequent seizures were manifest as a déjà vu prior to a stare, impaired responsiveness, lip smacking, left hand posturing, right hand fidgeting with post-ictal confusion. Lamotrigine (LTG) therapy resulted in monthly "petit mal" seizures prior to conversion to carbamazepine (CBZ). Seizures worsened despite high doses. She was converted to levetiracetam and became seizure free for 6 months. MRI demonstrated right mesial temporal sclerosis, and EEG was normal.

CC_1.jpg

When do you consider epilepsy drug resistant?

MRI is superior to CT in detecting patients with focal seizures. In addition, in patients with epilepsy, the initial EEG is often normal. Mesial temporal sclerosis is a strong predictor of drug resistant focal seizures. Drug resistance is the failure of adequate trials of two tolerated, appropriately chosen and used AED drug schedules1. Febrile seizures in patients with drug-resistant epilepsy are a common risk factor for temporal lobe epilepsy. The AED choices in this case were favorable for a female of child-bearing potential, though after 2 drug failures the risk for relapse is high despite an initial success2. Right temporal lobectomy resulted in prolonged seizure freedom.

References

  1. Kwan P, Arzimanoglou, Berg AT, et al. Definition of drug resistant epilepsy: Consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies. Epilepsia 2010;51(6):1069-1077.
  2. Berg AT, Levy SR, Testa FM, D'Souza R. Remission of epilepsy after 2 drug failures in children: a prospective study. Ann Neurol 2009;65:510-519.
Authored By: 
William O. Tatum DO
I<
Authored Date: 
10/2010