Volume 77, Number 7
Pharmacoresistant epilepsy:
From pathogenesis to current and emerging therapies
A 32-year-old right-handed woman has had seizures starting at the age of 12 years. She recalls that while in middle school she began to have sporadic episodes, which consisted of a rising feeling in her stomach that felt like butterflies and lasted for 1 to 2 minutes.
She did not have any spells of unresponsiveness until her early 20s, when she was noted to have staring episodes while smacking her lips, and then to be briefly confused and disoriented. She had her first “grand mal” seizure 5 years ago, and five antiepileptic medications have failed since then. Currently, she reports two to 10 seizures per month, which tend to cluster around her menses.
She had two prolonged febrile seizures at the age of 2 years, which occurred at two separate times during an ear infection. She also has a history of comorbid depression that started in early adulthood. She is currently taking two appropriate antiepileptic medications along with an antidepressant (a selective serotonin reuptake inhibitor). Otherwise, her past medical history is unremarkable, and there is no family history of epilepsy or other neurologic disorder. Three months ago she was involved in a motor vehicle accident, and her driver’s license was suspended. She has not been able to return to work since then.
During video-electroencephalographic (EEG) evaluation, the patient experienced several of her typical seizures. The 10-second EEG tracing and corresponding capture of simultaneous video recording (Figure 1) (note the glazed facial appearance associated with unresponsiveness, confirmed by the examiner at her bedside; the puckering of the lips; and the dystonic posturing of the right hand in this instance) were obtained during one of her seizures. The results of the patient’s magnetic resonance imaging (MRI)─three consecutive coronal cuts, fluid-attenuated inversion recovery sequence─are included in the lower panel.
1. Based on this information, the most likely diagnosis is:
- Generalized epilepsy, well controlled
- Psychogenic nonepileptic seizure (PNES), or “pseudoseizure”
- Focal epilepsy, medically intractable
- Hypoglycemia
- Febrile seizures, uncontrolled
