Monthly Case

A 22-year old male patient suffers a first tonic-clonic generalized epileptic seizure. The seizure occurs from wakefulness at midday. Focal onset of this seizure is not reported. In the night before the seizure, sleep duration was shorter than usual. Other clinical seizure forms so far had not occurred. In routine EEG, generalized spike-wave-discharges at 3 Hz with an amplitude maximum in frontal leads were seen. This constellation indicates that the patient has a significantly increased risk for further unprovoked seizures, this defines epilepsy. Due to seizure semiology, the trigger sleep deprivation, and the interictal EEG findings, we allocated the syndrome to idiopathic generalized epilepsy. We initiated pharmacological treatment with the aim to prevent further seizures (that eventually is a secondary prophylaxis), the substance administrated was valproic acid at 2 x 300 mg daily. We informed the patient that he is banned to drive a car himself for the next 12 months.

The former definition of epilepsy demanded occurrence of at least two unprovoked epileptic seizures. The new revised epilepsy definition provides that patients have epilepsy if after the first unprovoked seizure there is an increased risk for further seizures. A structural MRI lesion or interictal epileptic discharges in the EEG indicate such an increased recurrence risk. Patients then need antiepileptic drug treatment. If neuroimaging and EEG are normal, the first unprovoked seizure is not associated with an increased recurrence risk. This is termed as an isolated unprovoked seizure and does not need treatment, the patient is not allowed to drive a car himself for the next 6 months.

The question “Is one seizure epilepsy?” needs to be answered with yes and no, critical is the extent of seizures recurrence risk.

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