Monthly Case

A 25-year-old male patient suffers for 8 years from focal epilepsy characterized by epigastric auras (sensation ascending from the stomach to the throat) and automotor seizures (impaired consciousness with oral automatisms). Frequency of the latter seizure type is 4-5 per month. 1.5 T cranial MRI is normal. Current antiepileptic drug treatment consists of 3,000 mg levetiracetam and 500 mg zonisamide. Previously, the patient was treated with lamotrigine which had to be withdrawn at a dose of 50 mg due to exanthema. In summary, the patient suffers from pharmacoresistant focal epilepsy.

The next management step would be comprehensive evaluation for resective epilepsy surgery aiming at removal of the epileptogenic focus. This evaluation comprises long-term video-EEG-monitoring to record the patient’s habitual epileptic seizures. Furthermore, the patient is applied high-field cranial MRI at 3 T, the additional yield for detection of epileptogenic lesions is 10 to 15%. Also, the patient undergoes extensive neuropsychological testing in order to detect and quantify frontal or temporal lobe deficits. Additional diagnostic tests are performed in dependence on the first findings.

We explained to the patient in detail that after failure of two antiepiletic drugs in high doses sustained seizure freedom with administration of further antiepileptic drugs is highly unlikely. We further explained him the chances and risks of resective surgery, in general the majority of patients clearly benefits from this operation.

However, the patient couldn’t imagine any kind of operation on his brain and thus declined the highly recommended presurgical assessment. As this experience is quite common to us, we systematically assessed for a 6-month-period, how many patients refuse presurgical monitoring and what are the main reasons for refusal. Every second patient with intractable focal epilepsy was recommended presurgical assessment by us, in the other patients seizure frequency and severity was too low. However, 75% of patients who were recommended video-EEG-monitoring – as the current patient – declined that offer. The main reason was some diffuse fear of brain surgery. This survey indicates that eligible patients timely need intensive education on the benefits and potential harms of epilepsy surgery.

In the current patient, at every outpatient visit we will address the topic of surgical treatment of his epilepsy.

Cases of the months before