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.
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.
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