Monthly Case

A 43-year-old female patient has experienced for 8 years short episodes of 5-10 sec duration with some feeling of pressure in her stomach, this is followed by a rather unspecific sensation affecting the whole body, eventually she feels some tightness of her whole body for another 20 sec. It was not entirely clear, if she is fully conscious during these episodes. Frequency of these episodes is 2-3 / month. At admission to our clinic, the patient was treated with 400 mg zonisamide daily. The patient herself had the perception that her episodes are dissociative seizures. Brain MRI showed hippocampal sclerosis on the left.

To diagnose these episodes correctly, we performed video-EEG-monitoring for 48 h. As it was unclear, if the nature of these episodes was epileptic or dissociative, we withdrew the antiepileptic medication with zonisamide. During video-EEG-monitoring, one habitual episode manifested. The semiological course was as reported previously by the patient. The EEG technician entered the room during the phase with body tightness. At this time point, the patient was completely conscious and reactive. During the feeling of stomach pressure, the EEG demonstrated an ictal seizure pattern with rhythmic theta activity at 6-7 / s. This finding allowed allocating the stomach pressure to an epigastric aura, i.e. a simple partial seizure. We strongly assume that the late behavioral changes with tightness of the whole body are not part of the epileptic seizures, but rather represent a postictal reaction to the aura and the associated discomfort.

After advising the patient on the correct diagnosis, she wanted to remain untreated after prior withdrawal of zonisamide. She expressed that she rather stands the epileptic auras than taking an antiepileptic drugs regularly. We explained to the patient that the hippocampus sclerosis indicates an increased risk for seizure occurrence. Furthermore, we would not be able to exclude that the auras evolve to complex partial seizures with impaired consciousness or even a secondary generalized tonic clonic seizure. The patient decided to take that risk.

As for more than 1 year the patient has only suffered epileptic seizures without impairment of consciousness, she is allowed to drive a car on her own from 3 months after withdrawal of zonisamide.

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