Abstracts

Rationale: Epilepsy and Multiple Sclerosis (MS) are common neurological disorders. The prevalence of seizures in MS is slightly greater than in the population as a whole (2-4%), however in the vast majority of these inviduals seizures coexist with symptoms and signs with both temporal and spatial resolution. Epilepsy in isolation remains an uncommon presentation of demyelinating disease, of uncertain epidemiology. We hightlight two cases of anti-epileptic drug resistant epilepsy (DRE) which necessitated varying strategies of indiviudalised care. Methods: Case series review. Results: Case 1This 32 year old young lady who presented with first seizure during her second pregnancy at age 27 at 33 weeks gestation. Characteristic seizure semiology comprised of acute confusion, with staring unresponsiveness, and subsequent bilateral tonic clonic convulsion with rightward head turning at the onset of generalisation. Initial MRI demonstrated three non-enhancing white matter lesions juxtacortical and peri-callosal suggestive of demyelinating disease. Subsequent MRI showed the occurrence of new characteristic white mater lesions. CSF was positive for oligoclonal bands. No family history of seizures nor MS was revealed. No alternate aetilogy for seizure was identified. Seizures proved to be drug resistant and disabling. Video EEG demonstrated left anterior temporal seizures. PET scan revealed regional left temporal hypometabolism. In 2016, at age 31 our patient underwent left anterior temporal lobectomy, with modified hippocampal resection. Despite a cluster of postoperative focal and bilateral tonic clonic seizure seizures, she now remains seizure free > 9 months (Engel Class 1a). Neuropathology confirmed demyelination. Case 2This 33 year-old you lady presented following her first seizure at age 21 year. She was treated with AED therapy and remained 8 years seizure free until birth of second child, when there was the re-emergence of seizures with a stereotyped events of drug resistant déjà vu with subsequent altered awareness. She has never had a bilateral tonic clonic convulsion. Initial MRI showed bilateral subcortical white matter abnormalities in the temporal poles. These progressed radiologically, with characteristic juxta-cortical and callosal lesions in the genu of the corpus callosum. CSF was positive for oligoclonal bands. There is a negative family history of epilepsy, however our patient has a sister with MS on disease modifying therapy. Drug resistant and disabling seizures persist. Continuous video EEG demonstrated bilateral independent anterior temporal seizures. Despite imaging evolution, she has never had a 'characteristic' MS symptom. Following lengthy discussion (off label ) Natalizumab was introduced by monthly infusion. Repeat imaging after six months of treatment reveals no new white matter lesions, however DRE persists. Conclusions: Drug resistant epilepsy as a manifestation of Multiple Sclerosis is an unusual accompaniment of this disease. Seizures as an isolated symptomatic manifestation of demyelination is almost certainly uncommon, but of unclear epidemiology. Complex epilepsy surgical evaluation and MS disease modifying therapies may off a role in the treatment of such patients. Awareness of this unique subset of both disorders highlights the challenges faced by neurologists with ever more complicated therapeutic options. Funding: None