Wicket spikes misinterpreted as focal abnormalities in idiopathic generalized epilepsy with prescription of carbamazepine leading to paradoxical aggravation

• Published in: Neurophysiologie clinique 2009-08, Vol.39 (3), p.139-142
• Main Authors: Crespel, A, Velizarova, R, Genton, P, Coubes, P, Gélisse, P
• Format: Article
• Language: English
• Subjects: Aggravation; Anticonvulsants - administration & dosage; Anticonvulsants - adverse effects; Anticonvulsants - therapeutic use; Benzodiazepines - administration & dosage; Benzodiazepines - therapeutic use; Biological and medical sciences; Carbamazepine; Carbamazepine - administration & dosage; Carbamazepine - adverse effects; Carbamazepine - therapeutic use; Carbamazépine; Clonazepam - administration & dosage; Clonazepam - therapeutic use; Diagnostic Errors; Drug Therapy, Combination; Electroencephalography; Epilepsy, Temporal Lobe - diagnosis; Epilepsy, Tonic-Clonic - chemically induced; Epilepsy, Tonic-Clonic - diagnosis; Epilepsy, Tonic-Clonic - drug therapy; Female; Fructose - administration & dosage; Fructose - analogs & derivatives; Fructose - therapeutic use; Headache. Facial pains. Syncopes. Epilepsia. Intracranial hypertension. Brain oedema. Cerebral palsy; Humans; Idiopathic generalized epilepsy; Isoxazoles - administration & dosage; Isoxazoles - therapeutic use; Medical sciences; Middle Aged; Nervous system (semeiology, syndromes); Neurology; Pointes en palissade; REM sleep; Remission Induction; Sleep Stages - physiology; Sommeil paradoxal; Temporal Lobe - physiopathology; Theta Rhythm; Valproic Acid - administration & dosage; Valproic Acid - therapeutic use; Wicket spikes; Épilepsie généralisée idiopathique
• ISSN: 0987-7053; 1769-7131
• DOI: 10.1016/j.neucli.2009.02.004

Summary Wicket spikes (WS) are a normal variant EEG pattern that sometimes can be mistaken for epileptiform activity. We present a patient with WS and idiopathic generalized epilepsy who had been wrongly diagnosed with focal epilepsy, which leads to the prescription of carbamazepine with severe aggravation of generalized tonic–clonic seizures. She was referred for presurgical assessment of refractory focal epilepsy but long-term video-EEG showed sharp theta waves over the temporal regions during awakening, with a typical aspect of WS during drowsiness, nREM sleep stages I–II, and rapid eye movements (REM) sleep. There were a few generalized spike-waves during sleep but interictal changes were increased in frequency at awakening with bursts of fast-generalized spike-waves. Carbamazepine was progressively withdrawn and the patient was progressively switched to zonisamide. The patient no longer complained of generalized tonic–clonic seizures. At one year follow-up, this patient receives zonisamide with valproate. She has remained seizure-free.