Self-Assessment and CME

Patient Management
Problem
Daniel Friedman, MD, MSc

The following Patient Management Problem was chosen to reinforce the subject
matter presented in the issue. It emphasizes decisions facing the practicing
physician. As you read through the case you will be asked to complete
12 questions regarding history, examination, diagnostic evaluation, therapy,
and management. For each item, select the single best response.
To obtain CME credits for this activity, subscribers must complete this
Patient Management Problem online at www.aan.com/continuum/cme. A
tally sheet is provided with this issue to allow the option of marking
answers before entering them online. A faxable scorecard is available only
upon request to subscribers who do not have computer access or to
nonsubscribers who have purchased single back issues (send an email
to ContinuumCME@aan.com).
Upon completion of the Patient Management Problem, participants may
earn up to 2 AMA PRA Category 1 CreditsTM. Participants have up to 3
years from the date of publication to earn CME credits. No CME will be
awarded for this issue after February 28, 2019.

Learning Objectives
Upon completion of this activity, the participant will be able to:
& Manage the evaluation of a first unprovoked seizure
& Understand the factors that influence the risk of seizure recurrence
& Manage antiepileptic drugs in women with epilepsy prior to conception
and during pregnancy
& Recognize and evaluate drug-resistant epilepsy

Address correspondence to
Dr Daniel Friedman, NYU
Langone Medical Center,
223 East 34th Street, NYU
Comprehensive Epilepsy
Center, New York, NY 10016,
Daniel.Friedman@nyumc.org.
Relationship Disclosure:
Dr Friedman serves on the
physician advisory board
of the Epilepsy Foundation,
on the editorial board of
Epilepsy.com, and as a
consultant for Cyberonics, Inc.
Dr Friedman has received
personal compensation for
speaking engagements
from the American College
of Veterinary Internal
Medicine and paid travel
accommodations/meeting
expenses from Alexza
Pharmaceuticals. Dr Friedman
receives royalties from
Oxford University Press and
research support from the the
Centers for Disease Control
and Prevention, the Epilepsy
Foundation, the National
Institute of Neurological
Disorders and Stroke, and
UCB, Inc.
Unlabeled Use of
Products/Investigational
Use Disclosure:
Dr Friedman reports
no disclosure.
* 2016 American Academy
of Neurology.

Case
A 24-year-old right-handed woman with a past medical history significant
only for migraine presents for medical attention after experiencing a
witnessed convulsion while at work. Coworkers report that she was sitting
in a business meeting when her eyes rolled back and her arms stiffened.
She groaned loudly as she fell to the floor. The convulsion lasted about
1 minute and was followed by 10 minutes of confusion. Emergency
medical services was called, and she was taken to the local emergency
department, where the patient is noted to have a normal physical and
neurologic examination other than a lateral tongue laceration and a lack
of recall for the events of the afternoon.

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329

Patient Management Problem

b 1. Which of the following investigations is most likely to reveal an underlying

cause for her seizure?
A. basic metabolic panel
B . brain imaging (head CT or MRI)
C. complete blood count
D. lumbar puncture
E . urine toxicology
Admission to the hospital is recommended, but the patient declines this. She
is discharged from the hospital with close follow-up arranged and presents
for a neurologic consultation several days later. During the neurologic
history, she reveals that for the past 2 years she has experienced
paroxysmal episodes in which the voices of the people around her
suddenly grow louder, yet she has difficulty making out the words they
are saying. At times, this feeling grows so intense that she feels she has to
stop what she is doing. These episodes last 20 to 40 seconds. She has
experienced five of these episodes, including one on the day of her
convulsion. She states that she sustained a mild head injury while playing
field hockey in high school when she collided with another player. She
was confused for about 5 minutes but did not lose consciousness. She also
reports that her brother had a febrile seizure at age 3. A 1.5-tesla MRI
with and without gadolinium appears normal. A routine awake and
asleep EEG reveals mild right temporal slowing but no other abnormalities.

b 2. Which of the following clinical features in this patient is most suggestive that
she is at high risk for seizure recurrence?
A. a concussion without loss of consciousness while playing field hockey in
high school
B . family history of febrile seizure
C. her age
D. her history of paroxysmal episodes over the past 2 years
E . right temporal slowing on EEG
Treatment with levetiracetam is recommended. The patient is counseled
about teratogenic risks of antiepileptic drugs.

b 3. As part of the discussion of the risks and benefits of levetiracetam, the patient
should be specifically informed about which of the following adverse effects?
A. anorexia and weight loss
B . mood and personality changes
C. pancreatitis
D. renal stones
E . visual field defects

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February 2016

The patient is started on levetiracetam and titrated to an initial dose of

500 mg 2 times a day. She is also prescribed folic acid 2 mg daily.

b 4. What is the approximate likelihood that this medication will completely

prevent recurrent seizures?
A. 5%
B . 15%
C. 25%
D. 50%
E . 80%
Despite the levetiracetam, the patient continues to have focal seizures
about once per month, at times with brief loss of awareness. The dose of
levetiracetam is increased gradually to 3000 mg/d without significant
improvement in her seizures, and she reports that she is often tired
during the day. After a discussion with her on a follow-up visit, she is
cross-tapered to lamotrigine over the next 2 months.

b 5. Having failed to achieve seizure freedom with levetiracetam, what is the

approximate likelihood that the second medication will fully control
her seizures?
A. 1%
B . 11%
C. 33%
D. 66%
E . 88%
On lamotrigine monotherapy, the patients seizure frequency and fatigue
improve. She still continues to have a focal seizure approximately every 3
months. She recently married, and she and her husband are interested in
starting a family. She continues to take folic acid 2 mg daily.

b 6. How should this patient and her husband be counseled regarding specific
known teratogenic risks of lamotrigine?
A. lamotrigine has been associated with an elevated risk of cleft lip and
palate in one study
B . lamotrigine has been associated with an increased risk of autism in
offspring
C. lamotrigine has been associated with congenital heart defects in offspring
D. lamotrigine has been associated with neural tube defects
E . lamotrigine is not associated with any congenital malformations or
neurodevelopmental abnormalities

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Patient Management Problem

b 7. Six months later, the patient returns and states that she is 10 weeks pregnant.
What is the most appropriate course of action regarding her lamotrigine?
A. check serum levels regularly and adjust the dose to maintain stable levels
B . discontinue lamotrigine
C. lower the dose
D. maintain the preconception dose throughout the pregnancy
E . switch to carbamazepine
The patient has an uncomplicated pregnancy. Serum lamotrigine levels are
checked monthly, and her lamotrigine dose is adjusted to maintain her
prepregnancy serum level of 6.0 mg/dL to 7.0 mg/dL. Her total daily dose is
increased by 250% over the course of her pregnancy. She delivers a healthy
baby girl, and her lamotrigine dose is slowly lowered to the prepregnancy
amount over the course of 3 weeks. However, about 6 months later,
her seizure frequency increases to monthly, with more episodes including
a loss of awareness. Her lamotrigine dose is increased without a significant
impact on her seizures. Her most recent level was 8.7 mg/dL (laboratory
reference range 3.0 mg/dL to 12.0 mg/dL), and she reports occasional dizziness.

b 8. What is the next appropriate course of action?

A. increase the dose of lamotrigine
B . initiate therapy with valproate
C. obtain a positron emission tomography (PET) scan of the brain
D. refer for placement of a vagus nerve stimulator
E . refer to an epilepsy monitoring unit for characterization of her seizures
The patient is referred to a comprehensive epilepsy center and admitted
to the epilepsy monitoring unit for characterization of her seizures. During
the 4-day admission, she has four focal seizures characterized by quiet
staring, automatic movements of her right hand, and dystonic posturing
of her left hand that last for 30 to 75 seconds. The EEG shows a 2-Hz to
3-Hz ictal rhythm with onset in the right temporal region. She is amnestic
for three of her seizures but reports an aura of distorted sound for one
of the seizures.

b 9. Which of the following tests would be most useful in determining the

likelihood that she would benefit from epilepsy surgery?
A. ictal single photon emission computed tomography (SPECT)
B . intraarterial amobarbital procedure
C. magnetoencephalography (MEG)
D. neuropsychological testing
E . 3-tesla epilepsy protocol MRI

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A 3-tesla MRI with a dedicated epilepsy protocol reveals a linear band of

increased T2 signal in the white matter of the right temporal lobe and
blurring of the right hippocampal architecture, consistent with a malformation
of cortical development in the right temporal lobe (PMP Figure 1).

3-Tesla MRI with a dedicated epilepsy

protocol reveals a linear band of increased
T2 signal in the white matter of the right
temporal lobe (red arrow) and blurring of the right
hippocampal architecture (yellow arrow), consistent with
a malformation of cortical development in the right
temporal lobe.

PMP FIGURE 1

b 10. What should this patient be told in regard to epilepsy surgery?

A. epilepsy surgery can decrease her life expectancy
B . epilepsy surgery can improve her quality of life
C. epilepsy surgery is not a reasonable treatment option
D. she is at risk for left inferior quadrantanopia if she has surgery
E . she should try another medication prior to considering epilepsy surgery
b 11. What is the approximate likelihood that the patient will have long-term
(5-year) freedom from disabling seizures following epilepsy surgery?
A. 10%
B . 25%
C. 30%
D. 65%
E . 90%

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Patient Management Problem

The patient undergoes a right temporal lobectomy and is seizure free

following surgery for the next 2 years. On a follow-up visit 2 years after
surgery, she is interested in coming off her antiseizure medications.

b 12. What is the most accurate statement about seizure recurrence with
tapering medications following successful epilepsy surgery?
A . antiseizure medications should never be stopped entirely following surgery
B . her short duration of epilepsy prior to resection makes recurrence after
tapering more likely
C . lamotrigine use is associated with a lower risk of postoperative seizure
recurrence after tapering
D . a majority of patients who have seizure recurrence after stopping antiseizure
medication will be able to regain control once they restart medications
E . patients who have temporal lobe resections are more likely to have
seizure recurrence
An EEG demonstrates no residual epileptiform activity. The patient decides
to taper off lamotrigine after discussing the risks and benefits with her
epileptologist. Two years later, she experiences a brief episode of auditory
distortion similar to her prior simple partial seizures. She is restarted on
lamotrigine at a lower dose than she was previously taking and does not
have any further episodes.

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February 2016