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NEUROSAE 2018 ANNUAL MEETING EDITION (VOLUME 10, ISSUE 3)
QUESTION 41 OF 100
A right-handed, 28-year-old woman presents with refractory epilepsy. Her seizures are characterized by unresponsiveness with minimal mouth and hand movements, but secondary generalizations are rare. Therapeutic doses of carbamazepine have not been effective in preventing seizure activity, and she now takes levetiracetam 1,500 mg twice daily. An MRI scan of the brain is shown. Which of the following is the most appropriate management?
A. Increase levetiracetam to 2,000 mg twice daily.
B. Add phenytoin 300 mg every night.
C. Add valproate 500 mg twice daily.
D. Referral for insertion of a vagus nerve stimulator.
E. Referral for left temporal lobectomy. **
** = Your answer
Despite trials with two appropriately selected antiepileptic drugs (AEDs), the patient has refractory epilepsy. Her MRI scan is consistent with mesial temporal sclerosis. Data suggest the likelihood of seizure freedom on medical therapy alone decreases after failure of two AEDs. A randomized trial demonstrated the superiority of surgical therapy in medically refractory mesial temporal lobe epilepsy.
* Engel J Jr, McDermott MP, Wiebe S, et al. Early surgical therapy for drug-resistant temporal lobe epilepsy: a randomized trial. JAMA. 2012 Mar 7;307(9):922-930.
* Kwan P, Brodie MJ. Early identification of refractory epilepsy. N Engl J Med. 2000 Feb 3;342(5):314-319.