Patient R is a woman, 38 years of age, with a history of seizures since birth. She is otherwise in good health. Her current diagnosis is temporal lobe epilepsy. Patient R experiences focal seizures ("complex partial" and focal seizures that evolve bilaterally). She states that she is aware that a seizure is going to occur because she has a very brief "strange sensation." This sensation is her aura. After the aura, the patient cannot recall any other events until the postictal period. During the postictal time, Patient R is fatigued and confused and often experiences headaches.

Witnesses have noticed a typical pattern to Patient R's seizures. First, she becomes very quiet and blank. She will not communicate or respond to other individuals. She experiences vocalizations and yells in a very loud voice, "Jesus, help me." During the vocalizations, Patient R will experience automatisms that include pulling at her clothing. Usually, the seizure ends after approximately 60 seconds, and she regains consciousness within several minutes. At other times, the seizure will evolve, and she will experience tonic posturing followed by clonic movements. The tonic-clonic phase is quite severe and may last several minutes. The postictal period after the evolved seizure is prolonged and may last for several hours. Patient R experiences disorientation, confusion, and somnolence. She has experienced status epilepticus twice in the past.

At times, Patient R's seizures occur almost every day. However, some days will be seizure-free, and she may have several days at a time with no seizure events. Unfortunately, this does not occur consistently. Most days she will experience at least one seizure, and often she has several during the same day.

She has been on a number of AEDs in the past, including phenytoin, phenobarbital, valproic acid, and experimental medications. Her current medications include carbamazepine and topiramate, with lorazepam as needed. She also takes an over-the-counter multivitamin and, occasionally, acetaminophen for headache. Her sister has been instructed on administering lorazepam when Patient R is experiencing several consecutive seizures that occur over a 15-minute period or after her second bilaterally evolved focal seizure for the day. Her sister administers the lorazepam approximately once every two weeks. However, Patient R's seizures are quite variable with no known pattern. One week, she may not require any lorazepam; the next week, she may require it several times.

Patient R is very compliant with her medications. She uses a pillbox and can correctly describe her daily medications and doses. She has used a seizure calendar method of tracking her seizures for years. Each day she records the number of seizures she has and describes them. Patient R has no family history of epilepsy, and she has not had any surgical treatments.

During Patient R's physical examination, her physician discovers that the patient has difficulty with coordination. There are deficits in cognitive processes, such as calculation and abstract thinking. The exam is otherwise unremarkable.

Patient R has a twin sister who is neurologically normal. The twin sister provides a large amount of social and emotional support and is always present to accompany the patient at her visits. Patient R is a very independent woman who lives in an assisted living center and wears a protective helmet. She has completed the 5th grade. She does not use nicotine products, drink alcohol, or use illicit substances. She has experienced difficult situations in the past related to a divorce and loss of her only child.

The patient has been involved in the trial of several new experimental AEDs with varying success. The latest study she participated in had a positive effect on her seizure frequency. Unfortunately, the pharmaceutical company discontinued the medication from the study. As a result, other alternatives were sought. Her current healthcare providers evaluated Patient R and placed her in the epilepsy monitoring unit for simultaneous EEG/video monitoring.

In the epilepsy monitoring unit, Patient R's AEDs are slowly withdrawn. She begins to experience her typical events, including vocalizations. During these events, a large amount of motor activity is exhibited and EEG readings are difficult to ascertain. The medical team suspects a diagnosis of pseudoseizures. The patient completes the neuropsychologic testing, and the evaluation continues for several days. The patient experiences a focal seizure that evolves to a bilateral convulsive seizure, and the EEG readings clearly reveal epileptogenic changes. Sphenoidal electrodes are placed to obtain localizing information. Patient R continues to have a large number of seizures and requires frequent administration of intravenous benzodiazepines to maintain seizure control.

After more than a week of monitoring, a seizure focus is determined. Unfortunately, multiple focal areas exist in the bilateral temporal and frontal lobes, eliminating the surgical option. The patient is restarted on her AEDs and stabilized, and alternative treatments are discussed. The patient and healthcare team agree that a vagus nerve stimulator would be a positive option. Alterations in the medication regimen are discussed. The patient and sister are offered the option to attempt dosing with felbamate with close monitoring. Patient R does not want to attempt felbamate and opts for slowly removing the topiramate and attempting a trial with lamotrigine while awaiting the vagus nerve stimulator placement. This medication is somewhat helpful, but the vagus nerve stimulator provides substantial relief.