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A 35-year-old known epileptic presents with continuous tonic-clonic seizure activity lasting > 30 minutes unresponsive to IV lorazepam 4mg and IV levetiracetam 3g. He is now intubated. What is the next step — IV phenytoin, valproate, or lacosamide? At what point do we declare refractory SE and initiate anesthetic agents (propofol/midazolam/ketamine)? What does EEG monitoring add in this setting?

35M with no prior seizure history presents with a witnessed generalized tonic-clonic seizure lasting 2 minutes at work. Post-ictal confusion for 20 minutes. No family history of epilepsy. Brain MRI (1.5T) is normal. EEG done 48 hours later is normal. No prior head trauma, meningitis, or substance abuse. ANA, glucose, electrolytes all normal. Per ILAE 2017 guidelines, does a single unprovoked seizure with normal MRI and EEG warrant starting AED? What is the 2-year recurrence risk? If AED is needed, which is preferred in a young male?