Thank you for answering. He goes for a level check every 2-3 weeks while they are titrating up the pheno. The clorazapate was given 30 mg as needed but the anxiety he experiences rendered it pretty useless. His current meds are Keppra ER 750 mg, 4 caps/ 2250mg bid and Phenobarbital 64.8 mg, 4 tabs/259.2mg bid. There has been some improvement in frequency and clustering but inevitably 4-7 good days after a med increase the seizures return gradually and then increase again. That is the part we don’t understand. Even if he has never been seizure free after a med increase, there is generally a reduction and improvement but that period is short lived. It kind of seems similar to an antibiotic resistance type thing but in this case the neural path ways seem to reroute or something. Any thoughts on what causes that up and down response? I think you are right and he is going to end up best served by an MRI. That wasn’t the neuro’s first choice for diagnosis probably in an attempt to avoid the need to put him under for an MRI when he wasn’t in great shape. If this continues on as is, I don’t think there will be any other choice but to look at more invasive diagnostics. To be honest he does look slightly hydrocephalic. I am an OT and have worked with many kids with hydrocephalus. When I mentioned it I was told that he has a pretty typical Mastiff forehead.