A 35-year-old man with a 20-year history of focal-onset seizures with impaired awareness presents to the epilepsy clinic. He reports that seizures begin with an epigastric rising sensation, followed by a period of unresponsiveness with lip-smacking and chewing movements, and postictal confusion lasting several minutes. Brain MRI with epilepsy protocol shows the finding marked **A** in the diagram. He has failed trials of levetiracetam, lamotrigine, and oxcarbazepine at adequate doses. Which of the following is the most appropriate next step in management?

Explanation

## Why anterior temporal lobectomy with amygdalohippocampectomy is right The clinical presentation—childhood febrile status epilepticus history (implied by 20-year disease duration with adult onset), focal-onset seizures with impaired awareness, epigastric aura, oroalimentary automatisms, and the MRI finding of **unilateral hippocampal atrophy with T2/FLAIR hyperintensity (marked A)**—is pathognomonic for mesial temporal sclerosis (MTS). The patient has now failed two appropriately chosen AEDs at adequate doses (levetiracetam and lamotrigine), meeting the definition of drug-resistant epilepsy. MTS is the most surgically curable epilepsy syndrome; anterior temporal lobectomy with amygdalohippocampectomy achieves seizure freedom in 60–80% of cases, compared to only 8% with continued medical therapy (Wiebe RCT 2001). Surgery should not be delayed in drug-resistant MTS, as untreated disease is often progressive with cumulative cognitive impairment (Harrison 21e Ch 425). ## Why each distractor is wrong - **Increase oxcarbazepine and add valproate**: The patient has already failed two first-line agents. Adding a third AED without addressing the underlying surgically remediable pathology delays definitive treatment and exposes him to unnecessary drug toxicity. Drug-resistant MTS requires surgical evaluation, not further medical optimization. - **Initiate phenytoin as a fourth-line agent**: Phenytoin is not a preferred agent for temporal lobe epilepsy and is not recommended for drug-resistant MTS. Waiting 6 months for reassessment in a patient with a surgically curable lesion and cognitive decline is inappropriate and contradicts epilepsy surgery guidelines. - **Recommend lifestyle modification and seizure precautions without further pharmacotherapy**: This is passive management of a progressive, surgically remediable condition. Untreated MTS leads to cumulative cognitive impairment and ongoing seizure burden; seizure freedom is achievable with surgery in 60–80% of cases. **High-Yield:** Unilateral hippocampal atrophy + T2 hyperintensity + mesial temporal seizure semiology + drug resistance = refer for anterior temporal lobectomy/amygdalohippocampectomy (60–80% seizure freedom). [cite: Harrison 21e Ch 425 (Seizures and Epilepsy)]