The patient is a 53-year-old woman with a history of seizures beginning at the age of 5 years. The seizures occurred several times daily when she was a young child. Witnesses described a sudden blank stare, sometimes accompanied by humming or picking at her clothes. Occasionally she walked around during the episodes but she never fell down. Urinary incontinence occurred with some of the seizures up until the age of 12. Although she never had a warning or an aura, she usually knew when she had a seizure because she recalled a sensation 'as if daydreaming'. She specifically described this as not merely a loss of time but as a definite feeling. She has had only four generalized tonic-clonic seizures in her life, each proceeded by an odd feeling of 'going down a tunnel.'
Precipitating factors included the premenstrual state and 'stress'. As a car passenger, she noted that sunlight flickering through the trees made her feel as if she were going to have a seizure.
Previous treatments had included phenobarbital, ethosuximide, phenytoin, primidone and acetazolamide. She had a previous EEG that was abnormal, but she reported that her doctors couldn't decide whether she had 'petit mal' or 'frontal' seizures. When I first saw her, she was 42 years old and was taking carbamazepine 1400 mg/day. She was having up to 20 seizures each day, and she stated that she had never gone more than 3 days in her life without seizures. Despite this, she had 13 years of education, was married with children and had a supervisory job.
General and neurological examinations were normal. The patient appeared to be of above-average intelligence. An EEG demonstrated hyperventilation-induced three-per-second spike-wave discharges with a generalized distribution and a bifrontal voltage maximum. One of these discharges lasted 14 seconds and was
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