Monthly Case

No antiepileptics despite seizures | 4-2014

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A 28-year old patient suffers from epilepsy with Grand Mal for 5 years. Seizures manifest while awake, but without any further binding to the sleep-wake-cycle. Even purposeful asking did not give hints for focal onset of seizure semiology. Routine and sleep-deprivation EEG were normal as was cerebral MRI. We allocated the condition to unclassified epilepsy, as we did not find evidence for partial or generalized epilepsy. 20% of all epilepsies are unclassified, in some cases the further course of the condition allows to make the syndromatic diagnosis of partial or generalized epilepsy.

The current patient reported 4-5 five Grand Mal annually. Despite this rather high frequency of severe epileptic seizures, the patient declined – from onset of his epilepsy – taking of antiepileptic drugs. He indicated a generally dismissive attitude towards chronically taking medication.

We explained to that patient that the main problem in epilepsy is that seizures generally manifest very sudden and often without any warning. In Grand Mal, uncontrolled falls may result in substantial injuries. We further had to explain him that patients may die during or shortly after a Grand Mal. This sudden unexpected death in epilepsy patients (SUDEP) is likely caused by seizure-related cardial arrhythmias. The most efficient measure to prevent SUDEP is prevention of Grand Mal. Despite our explanations, the patient further declined to take antiepileptic drugs.

Non-adherence towards physicians’ recommendations presents a great challenge, in particular in pharmacotherapy of chronic diseases. In the current case, the patient at least communicated his non-adherence; commonly, the doctor does not know about the irregular or absent taking of antiepileptic drugs.

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