Question:
A 19-year-old man presents with intractable generalized tonic-clonic (GTC) seizures, which worsen with sleep deprivation. He also reports morning twitching and jerks while taking carbamazepine. Additionally, he experienced muscle twitching during his EEG when exposed to flashing lights.
a. What are the expected EEG findings?
Choose the correct option:
A. Generalized 4- to 6-Hertz (Hz) polyspike and wave discharges with a photoconvulsive response
B. Generalized 3-Hz spike and wave discharges
C. Generalized 2.0-Hz spike and wave discharges
D. Left temporal focal epileptiform discharges
b. What is the next step in treatment?
Choose the correct option:
A. Add phenytoin.
B. Change carbamazepine to oxcarbazepine.
C. Change from carbamazepine to levetiracetam.
D. Continue carbamazepine and add levetiracetam.
The correct answer and explanation is:
iturn0image0The patient’s presentation suggests Juvenile Myoclonic Epilepsy (JME), characterized by myoclonic jerks, generalized tonic-clonic seizures (GTCs), and sensitivity to photic stimulation. JME typically manifests between ages 12 and 18 and accounts for approximately 5–10% of all epilepsy cases. citeturn0search16
a. Expected EEG Findings
The hallmark EEG pattern in JME is:
- Option A: Generalized 4- to 6-Hertz (Hz) polyspike and wave discharges with a photoconvulsive response.
These discharges are often elicited by photic stimulation, consistent with the patient’s muscle twitching during EEG exposure to flashing lights. citeturn0search16
b. Next Step in Treatment
Carbamazepine is generally ineffective for absence or myoclonic seizures and may exacerbate generalized genetic epilepsies like JME. citeturn0search20 Therefore, the appropriate treatment modification is:
- Option C: Change from carbamazepine to levetiracetam.
Levetiracetam is effective in managing myoclonic and generalized tonic-clonic seizures and is considered a suitable alternative, especially for women of childbearing age due to valproic acid’s teratogenic risks. citeturn0search16
Detailed Explanation
JME is an idiopathic generalized epilepsy syndrome with a strong genetic component. Patients typically experience myoclonic jerks, especially upon awakening, which can progress to GTCs. EEG findings of generalized 4- to 6-Hz polyspike and wave discharges are characteristic. Photic stimulation during EEG can provoke these discharges, aligning with the patient’s photic sensitivity. citeturn0search16
Carbamazepine is not recommended for JME as it may worsen seizure control. Valproic acid is highly effective but poses teratogenic risks, making it less suitable for women of reproductive potential. Levetiracetam offers a favorable safety profile and efficacy in treating myoclonic and generalized seizures, making it an appropriate choice for this patient. citeturn0search16
Proper diagnosis and treatment adjustments are crucial in managing JME to prevent seizure exacerbation and improve patient outcomes.