LS’s presentation is consistent with a focal-onset seizure that evolved into a bilateral tonic-clonic seizure. One notable risk factor contributing to her current condition is her history of febrile convulsions in childhood. Although febrile seizures are generally benign, complex febrile seizures (particularly those that are prolonged, focal, or recur within 24 hours) have been associated with an increased risk of developing temporal lobe epilepsy later in life (Berg et al., 2017). Given that her febrile seizure occurred following pneumonia and included convulsions at age 10, which is later than typical febrile seizures. This could indicate a more significant underlying predisposition to epilepsy.

Since LS’s basic metabolic workup is unremarkable, the next step involves neuroimaging and electroencephalography (EEG) to evaluate structural and electrical brain abnormalities. A magnetic resonance imaging (MRI) scan is especially critical in cases like this, where a focal seizure origin is suspected. MRI can help identify mesial temporal sclerosis, cortical dysplasia, or other structural causes of epilepsy that could guide both prognosis and treatment (Krumholz & Wiebe, 2021). Additionally, prolonged or ambulatory EEG monitoring might be useful if there is uncertainty about the diagnosis or if events recur.

The presence of epileptiform discharges over the right temporal region on EEG strongly supports a diagnosis of focal epilepsy, specifically temporal lobe epilepsy. Given this evidence and the unprovoked nature of her seizure, initiating antiseizure medications is recommended to reduce the risk of recurrence. First-line treatments for focal-onset seizures in adults include lamotrigine (Lamictal), levetiracetam (Keppra), and oxcarbazepine (Trileptal). Levetiracetam is often favored for its favorable side effect profile and ease of titration (National Institute for Health and Care Excellence [NICE], 2022). The decision to start anti seizure medication also considers the patient’s quality of life, safety (e.g., driving), and psychosocial implications of another seizure.

In short, LS’s history, EEG findings, and seizure presentation justify starting anti seizure therapy, with further imaging (preferably an MRI) essential to clarify the underlying etiology.

References

Berg, A. T., Coryell, J., Saneto, R. P., Grinspan, Z. M., Alexander, J. J., & Pathak, S. (2017). Early-life epilepsies and the emerging role of genetic testing. JAMA Pediatrics, 171(9), 863–871. https://doi.org/10.1001/jamapediatrics.2017.1743

Krumholz, A., & Wiebe, S. (2021). Diagnosis and management of epilepsy in adults: A review. JAMA, 325(21), 2218–2228. https://doi.org/10.1001/jama.2021.4914

National Institute for Health and Care Excellence (NICE). (2022). Epilepsies: Diagnosis and management. https://www.nice.org.uk/guidance/ng217