Breaking the Cycle: GAD65 Autoimmune Epilepsy with Multidien Seizure Pattern in a Woman Misdiagnosed with Catamenial Seizures
Pooja Bhandari1, Hannah Austin1, Ahmad Mahadeen1
1Neurology, University of Mississippi Medical Center
Objective:

We present a rare case of drug-resistant temporal lobe epilepsy associated with glutamic acid decarboxylase (GAD) antibodies with a multidien seizure pattern initially classified as catamenial epilepsy.


Background:

Cyclical seizure patterns are a recognized feature of epilepsy in some patients. Most neurologists are familiar with circadian cycles and catamenial cycles in women. Multidien cycles (seizure patterns that recur every 7-30 days) are less commonly identified, but these can overlap with menstrual related rhythms.


Design/Methods:
N/A
Results:

A 46-year-old woman started having focal seizures with and without preserved consciousness in her 30s. Later, she started having bilateral tonic-clonic seizures that increased cyclically, peaking around her menses, raising suspicion for catamenial epilepsy. Multiple antiseizure medication trials were unsuccessful, and she underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy at age 36. Despite this, there was no improvement in seizure frequency or severity, and her quality of life continued to decline. MRI showed asymmetric right amygdala enlargement and hippocampal asymmetry. Further evaluation revealed elevated serum (444 nmol/L) and CSF (1.04) GAD65 antibody levels.

IVIG therapy provided minimal benefit. She was later started on 6-monthly rituximab infusions. Video-EEG monitoring showed independent bilateral temporal sharp waves mostly on the right and right temporal ictal onset pattern with focal seizures. Due to the underlying pathology, invasive evaluation was deferred and she underwent bilateral hippocampal responsive neurostimulator (RNS) implantation. With the combination of rituximab, clobazam, and cenobamate, she achieved over 12 months free of bilateral tonic-clonic seizures, a significant decrease in focal seizures, and improved quality of life.


Conclusions:

Cyclical seizures in women with epilepsy should not always be presumed to be catamenial as this may incorrectly lead to harmful interventions. A multimodal approach to treatment of GAD65 TLE can result in improvement in seizures and quality of life.


10.1212/WNL.0000000000217213
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