A 25-year-old woman has focal impaired awareness seizures and one secondarily generalised tonic-clonic seizure. MRI shows a left mesial temporal sclerosis. She is started on levetiracetam but continues to have 2–3 seizures per month despite optimal dosing. This pattern is best described as:

• A Pseudoseizures (functional neurological disorder)
• B Inadequate drug dosing; increase levetiracetam to maximum dose first
• C Juvenile myoclonic epilepsy; switch to valproate
• D Drug-resistant (refractory) epilepsy; referral to epilepsy surgery centre is indicated ✓

Explanation

Drug-resistant epilepsy is defined by the ILAE as failure of adequate trials of two tolerated and appropriately chosen antiseizure medications to achieve sustained seizure freedom. This patient has mesial temporal lobe epilepsy (MTLE) — the most surgically remediable epilepsy syndrome. Anterior temporal lobectomy achieves seizure freedom in 60–70% of MTLE patients with hippocampal sclerosis. Continued medication trials after two failures have diminishing returns, and early surgical referral is recommended to prevent cognitive and psychosocial consequences of ongoing seizures.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.