A Dilemma: Electrographic Seizure Activity in the Absence of Clinically Perceptible Seizures and the Ethical Challenges of Medical Decision-Making.

A 37-year-old male with refractory left temporal epilepsy was admitted to the epilepsy monitoring unit to examine correlates of observable clinical seizure activity, those captured by responsive neurostimulation system (RNS) and continuous video electroencephalogram (cvEEG). The patient was diagnosed at age three, was on three anti-epileptic drugs, with an RNS implant since 2020 and was admitted to the epilepsy monitoring unit. The patient reported no seizures since 2019. cvEEG and RNS data were collected, and a comprehensive neuropsychological evaluation was conducted. cvEEG revealed brief electrographic activity originating from the left and right anterior temporal regions, occurring mainly on the left side. The activity was characterized ictally by prominent anterior temporal sharp waves, with a left-sided predominance. RNS data showed similar results but recorded electrographic activity in excess of cvEEG. Although clinical and electrographic manifestations tend to be stereotyped for seizures, there were no behavioral observations of clinical seizures during these recorded electrographic seizures on RNS data. The patient also reported no seizures. Neuropsychological results showed impairment across multiple cognitive domains. This case report highlights the need for a more detailed approach to determining allowable electrographic activity since these thresholds directly impact restrictions on patients with epilepsy. Highly sensitive measurement tools may better detect seizures, but in isolation, they cannot fully convey a complete picture of the patient's status without other data and clinical indicators. Data from emerging technology must be weighed in conjunction with clinical symptoms to optimize patient safety, quality of life, and outcomes.