A 45-year-old woman presents with recurrent focal seizures with impaired awareness featuring oroalimentary automatisms and postictal confusion. EEG shows left temporal sharp waves. MRI reveals left mesial temporal sclerosis. She has failed carbamazepine and lamotrigine. The next best step is
- A Add levetiracetam as combination therapy
- B Start vagus nerve stimulation
- C Refer for epilepsy surgery evaluation ✓
- D Trial of immunotherapy
Correct answer: C. Refer for epilepsy surgery evaluation
Explanation
For drug-resistant mesial temporal lobe epilepsy with hippocampal sclerosis, epilepsy surgery (anterior temporal lobectomy with amygdalohippocampectomy) is the treatment of choice and offers seizure freedom in 60-80 percent of cases. Referral for surgical evaluation is indicated after failure of two appropriately chosen antiepileptic drugs. VNS is palliative and reserved for non-surgical candidates. Immunotherapy is not indicated.
Reference: Bailey and Love's Short Practice of Surgery / ILAE guidelines
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.