Monthly Case

Delayed diagnosis | 5-2013

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A 42-year-old female patient reports at her first visit in our epilepsy outpatient clinic epigastric sensations occurring paroxysmally for more than 5 years. The sensation is stereotyped, duration is 10 to 20 sec, and frequency is up to three times a week. We specifically asked her if this feeling is accompanied or followed by loss of contact or impaired awareness, but this was denied. As the patient spends a lot of time on her own, there was no chance to get some description from third party. In the last years, she did not seek for medical advice as in daily life these epigastric episodes were not relevant for her.

To further clarify the diagnosis, the patient was admitted for longterm video-EEG to the Epilepsy-Center Berlin-Brandenburg. During 72 h-recording, two episodes with typical symptoms occurred. While the patient was tested by the technician, she was unresponsive for 30 to 40 sec before she returned to normal consciousness. After the seizures, the patient did not remember that she had any other behavioural changes beyond the epigastric sensation. Ictal EEG revealed a seizure in the right temporal structures. Cerebral MRI was normal.

We told the patient that we have made the diagnosis of focal epilepsy that seems to have manifested more than 5 years ago. For all that time, the patient realised the epigastric auras but she was amnesic for the automotor seizures. A study has demonstrated that in the awake state more than half of automotor seizures are not remembered by patients. We assume that the patient frequently develops impaired consciousness following the auras, but does not realise seizures due to ictal amnesia.

We started antiepileptic treatment with levetiracetam, a follow-up appointment in our clinic is pending.

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