Monthly Case

23-year-old man with a seizure on wakening | 9-2015

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A 23-year-old man had developed epilepsy with three presumably generalized tonic clonic seizures in the last 4 years, there were no hints for focal seizure onset. Even in detailed history taking, there were no clear hints for binding to the time of day or sleep-wake-cycle. Several routine EEGs and a recent head MRI were normal. So far, the patient was not treated with antiepileptic drugs. On the basis of the previous course of the disease, syndromatically we initially assumed unclassified epilepsy. We performed a long-term video-EEG which was normal. In order to increase diagnostic sensitivity, the patient was put on sleep deprivation. On ward round the next morning, we met the patient sleeping. We woke him up, and within minutes he suffered first severe myoclonus of the upper extremities and the trunk which threw the patient on his back. Three minutes later, repetitive myoclonus developed to a generalized tonic clonic seizure accompanied by an accordant EEG seizure pattern. Thus, during rounding we were able to make the diagnosis of idiopathic generalized epilepsy (subsyndrome: juvenile myoclonic epilepsy), we initiated antiepileptic drug treatment with valproic acid.

This case illustrates that – on the one hand – sleep deprivation is a strong trigger in idiopathic generalized epilepsy and that – on the other hand – wakening or awakening displays a predilection for seizure manifestation in this epilepsy syndrome.

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