MKSAP Quiz: Epilepsy management
A 35-year-old man is evaluated for a 3-year history of epilepsy. Seizures typically occur twice monthly. Treatment with oxcarbazepine and lamotrigine, although initially reducing seizure frequency, has been largely ineffective. What is the most appropriate next step in management?
A 35-year-old man is evaluated for a 3-year history of epilepsy. Seizures typically occur twice monthly, last 2 minutes, and are characterized by staring, lip smacking, and confusion; approximately once every 6 months, the patient experiences a whole-body convulsion marked by incontinence and prolonged confusion for several hours. Treatment with oxcarbazepine and lamotrigine, although initially reducing seizure frequency, has been largely ineffective. He no longer drives or works because of the seizures. He also has migraines, which are well controlled by sumatriptan.
On physical examination, vital signs are normal. All other physical examination findings, including those from a neurologic examination, are unremarkable.
Results of routine outpatient electroencephalography (EEG) are normal. An MRI of the brain shows right hippocampal atrophy.
Which of the following is the most appropriate next step in management?
A. Levetiracetam
B. Topiramate
C. Vagus nerve stimulation
D. Video EEG monitoring
MKSAP Answer and Critique
The correct answer is D. Video EEG monitoring. This content is available to MKSAP 18 subscribers as Question 41 in the Neurology section. More information about MKSAP is available online.
This patient is having ongoing focal seizures with altered awareness (formerly known as complex partial seizures) because of temporal lobe epilepsy despite taking two antiepileptic drugs and should be referred to an epilepsy center for monitoring by video electroencephalography (EEG). Because his epilepsy is medically intractable, he may be a candidate for epilepsy surgery. Video EEG is the first step in determining candidacy for surgery by confirming that the seizures seen on video EEG match the location of abnormal findings on MRI. Temporal lobectomy leads to seizure freedom in 60% to 70% of patients with temporal lobe epilepsy not helped by medication and is the best option for treating this patient.
Although levetiracetam and topiramate are reasonable options for treating this seizure type, and topiramate has the added benefit of migraine prophylaxis, the chance of seizure freedom from an additional drug is only approximately 5% to 10%. Additionally, this patient's migraines are already well controlled, so a prophylactic agent is not required.
Use of a vagus nerve stimulator is a palliative measure, is unlikely to result in freedom from seizures, and should be offered only if resection is not an option.
Key Point
- Video electroencephalography is first step in determining candidacy for epilepsy surgery in patients with medically intractable epilepsy.