Monthly Case

A 49-year old female patient suffered a first clear generalized tonic-clonic seizure out of wakefulness in the early afternoon. She and a witness did not remember any clinical signs or symptoms that point to partial onset. The relevant question is: what is the risk for occurrence of another unprovoked seizure?

In the emergency room, a brain CT scan was performed which was normal. For sufficient sensitivity, a cerebral MRI scan – following a specific epilepsy protocol with temporal angulation – is required. This was normal as well. Routine EEG and sleep EEG following sleep deprivation were also normal.

In this constellation, there are no hints for an enduring alteration of the brain which increases the probability for another epileptic seizure. Following the most recent definition of epilepsy, the risk for another unprovoked seizure within the next 10 years has to be more than 60 %, thus equalling that after two unprovoked seizures (Fisher et al. 2014 Epilepsia).

We explained to the patient that she has a mildly increased risk for seizure recurrence but that this risk is not that high that by definition she already suffers from epilepsy.

In this regard, there is no indication for antiepileptic drug treatment. The patient is not allowed to drive a car up to 3.5 t on her own for the next 6 months.

If cMRI or EEG would have demonstrated pathological findings, the patient would have an increased risk for seizure recurrence and thus epilepsy.

This case demonstrates the significant relevance to assess recurrence risk after a first unprovoked epileptic seizure.

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