Monthly Case

A just 18-year-old male patient has epilepsy with likely tonic clonic generalized seizure out of sleep for the last 2 years. The patient does not remember seizure onset, third party observations are not available. At some mornings, the patient remarked strong muscle ache and lateral tongue bites. This constellation does not allow to make another diagnosis than tonic clonic generalized seizures. Until now, the patient had been in out-patient treatment at another center. Brain MRI and routine EEG were normal. In summary, this patient suffers from unclassified epilepsy, seizure onset in sleep may point to focal epilepsy. According to the patient, so far he had not been recommended taking an antiepileptic drug, the rationale behind this remained unclear.

We informed the patient that – after five unprovoked epileptic seizures – he has a high risk (> 80%) for occurrence of further seizures. We further informed him that sleep-bound generalized tonic clonic seizures in particular bear the risk of sudden unexpected death in epilepsy (SUDEP). Eventually, we were able to convince the patient to take an antiepileptic drug. We initiated treatment with levetiracetam at a dose of 500 mg two times daily. At least for the next 6 months, the patient was seizure-free.

In summary, after two unprovoked epileptic seizures, the risk for a third seizure within the next 10 years is more than 60%. According to the current criteria of the International League Against Epilepsy, two unprovoked seizures – due to the high recurrence risk – define epilepsy, generally antiepileptic drug treatment is recommended.

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