Monthly Case

A 37-year-old male subject is denied by a casualty insurance to become an insurant due to the argument that he would suffer from epilepsy. Practically, the patient had bilateral tonic clonic seizures at age of 21 and 23 years out of wakefulness, he does not remember a focal onset. One of the seizures manifested at late morning, the other at early evening. There were no triggers such as sleep deprivation, fever or intake of potentially proconvulsant compounds. Family history for epilepsy was unremarkable, there were no hints for other seizure types. Routine and sleep deprivation EEGs were normal as was brain MRI. After the second seizure, the proper diagnosis of epilepsy was made; as there were no hints for focal or generalised epilepsy, it was allocated to be unclassified. Due to significantly increased risk for seizure relapse, antiepileptic drug treatment with levetiracetam was initiated, the maximal daily dose of 1,500 mg was well tolerated. Following the explicit will of the patient, after 2 years of treatment levetiracetam was stopped. Routine EEG at 6 months after withdrawal was still normal.

The question is for how long after the last seizure and for how long after withdrawal of the antiepileptic drug epilepsy formally still persists – for ever? In a position paper from 2014 (Fisher et al. in Epilepsia), the International League Against Epilepsy has cleary defined when epilepsy begins and when it is resolved. A patient has epilepsy after two unprovoked epileptic seizures – as in the current case – or already after one unprovoked seizure, if EEG or MRI findings indicate a significantly increased risk for seizure relapse, i.e. a recurrence risk of more than 60% within the next 10 years. In an individual patient, epilepsy is resolved, if the last seizure manifested at least 10 years ago and if the patient did not take an antiepileptic drug for at least the terminal 5 years.

The current patient has not experienced any epileptic seizures for 14 years, and he has not taken antiepileptic drugs for 12 years. He does not suffer from epilepsy any more. Pragmatically, the patient does not have any restriction in regard to driving, this includes trucks and buses. Thus, the insurance company cannot argue that their refusal is due the fact that the patient (still) has epilepsy. If antecedent epilepsy which is resolved for several years effectively means an exclusion criterium for a casualty insurance statement, needs legal clarification.

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