Monthly Case

A 31-year-old female patient has suffered the last 15 years from tonic clonic generalized seizures occurring once yearly. She does not remember if these fits are preceded by subjective or objective behavioral changes that would indicate that these seizures have partial onset. Beyond the Grand Mal, the patient has smaller seizures with some impairment of consciousness since childhood. However, she is unable to further describe this seizure type. Frequency is four to five times per month.

Routine EEG repeatedly shows generalized spike-wave-complexes at 3/s, while reading the patient stumbles indicating a behavioral correlate of the EEG discharges. During long-term-Video-EEG recording, the patient has two semiologically different seizures. On the one hand, a typical tonic clonic generalized seizure without obvious partial onset occurs; EEG shows 3/s spike-wave-complexes at seizure onset. On the other hand, the patient suffers one of the smaller seizures with some loss of contact. This is accompanied by a seizure pattern characterized by rhythmic theta activity confined to left temporal structures. Cranial 3 Tesla MRI (FLAIR sequence) shows a hyperintensive lesion in left temporo-basal structures that probably corresponds to a benign tumor.

In the constellation delineated above, we assume that this patient suffers from both partial and generalized epilepsy. The latter manifests only in Grand Mal, the slight cognitive impairments during generalized EEG discharges are not perceived by the patient. The small seizures, that could have been absence seizures as well, are clinical manifestation of the left temporal seizure pattern. These seizures are slight automotor (= complex partial) seizures and indicate partial epilepsy caused by the left temporal lesion.

On presentation in the Epilepsy-Center, the patient was treated with high dose valproic acid. We added levetiracetam. If automotor seizures continue with this antiepileptic treatment regimen, epilepsy surgery – despite coexisting idiopathic genealized epilepsy – may be discussed perspectively.

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