A 30-year-old man had an uneventful previous history, except for moderate head trauma at the age of 3 years. Four years later, he started to have generalized convulsive seizures with abrupt loss of consciousness and some concomitant absence seizures. Most of the convulsions occurred on awakening; those few that did not occurred at random. There was no family history of epilepsy or febrile convulsions. At this time, the patient's sleep rhythm was irregular. He was awake late in the evenings and got up late in the mornings. According to his mother, he suffered from sleep deprivation. He was active in youth athletics but was somewhat hyperactive and restless. Antiepileptic drug therapy was initially unsuccessful but, at the age of 10, he was seizure-free.
After this, despite frequent discussions and advice, he continued his lifestyle with irregular and apparently inadequate nocturnal sleep. As an adult, he was well motivated to take his medication because of the risk of having his driving licence revoked. He did not use alcohol.
Neurological examination was normal. His IQ was 80. The initial EEG showed massive 3—4 Hz bilateral symmetric spike-and-wave discharges, easily provocable by flicker light and hyperventilation. Eight years later, during a seizure-free period, EEG was normal in the waking state but during sleep there were a few right-sided spikes and spike-and-wave complexes, and flicker light and hyperventilation sensitivity had disappeared. Clinically, the patient's seizures were obviously primarily generalized without any warning, but the assymmetric spike-and-wave complexes on the EEG were interpreted by a neurophysiologist as a sign of a focal origin of the seizures. Not unexpectedly, however, a magnetic resonance imaging (MRI) scan of the brain was normal. A recent repeat MRI scan was also normal.
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