Nikesh Ardeshna, MD
Dr. Ardeshna is the Medical Director of Adult Epilepsy Services at Royal Oak Hospital, Beaumont Health System, in Royal Oak, Michigan.
The patient is a 26-year-old female with a history of epilepsy since the age of 12. The patient’s seizures are characterized by an unusual taste in her mouth, followed by numbness on the right side of her body, followed at times by progression to a generalized tonic-clonic seizure (secondary generalization). The patient also has a history of depression and anxiety. Over the last few months, the patient complains of worsening memory loss and slower thinking and processing. An MRI of the brain shows left mesial temporal sclerosis. The patient is currently on topiramate, levetiracetam, and lacosamide. She has tried five other anti-epileptic drugs (AEDs) in the past. Currently, the patient is not seizure free. The longest the patient has been seizure free is two weeks.
What would be the best possible strategy for managing this patient?
A. Switch AED
B. Increase AED dosing
C. Add another AED
D. Evaluate for epilepsy surgery
The correct answer is D—evaluate for epilepsy surgery. The patient has drug-resistant epilepsy, defined as the failure of two first-line AEDs. Studies have shown that in this type of patient, additional AEDs or changing AEDs has a very small chance of achieving seizure freedom. Studies have shown that epilepsy surgery, in patients with lesional drug-resistant epilepsy, has the highest chance of providing seizure freedom and improvement in quality of life.
The memory loss and cognitive slowing noticed by the patient could be due to:
A. Side effects of AEDs
B. Effects of many years of seizures
C. The patient’s imagination
D. Both A and B
The correct answer is D—both A and B. Memory loss and cognitive slowing can be side effects of AEDs; this is more likely to be seen in patients on polytherapy. Memory loss and cognitive slowing are among the symptoms that can be seen with long-term poorly controlled epilepsy.
Comorbidities seen frequently in epilepsy patients include:
A. Memory loss
B. Personality change
E. All of the above
The correct answer is E—all of the above. Comorbidities are seen in epilepsy patients, particularly those with uncontrolled seizures over many years. Comprehensive epilepsy care involves treating not only seizures, but also the above-mentioned comorbidities, as these can have a significant effect on a patient’s quality of life.