Epilepsy Cases

Adapted from the American Epilepsy Society This presentation has been modified. Among other things, it now uses metric units. Revise March 29, 2006

Case 1 - Blanking out

5 y.o. female Blanking out at school x1 month Episodes in which she abruptly stops all activity for about 10 seconds, followed by a rapid return to full consciousness Eyes are open during the episodes and she remains motionless with occasional fumbling hand movements
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Case 1 (cont)
After the episode the patient resumes whatever activity she was previously engaged with no awareness that anything has occurred She has 30 episodes per day No convulsions Father had similar episodes as a child
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Case 1 (cont)
General physical and neurological examination is normal.
What else do you want to do?

Hyperventilation in your office replicates the episodes.

Case 1 (conclusion)
What is the diagnosis? How would you treat the patient? How would you counsel the family regarding prognosis?

Case 2 - Just nervousum

25 year-old right-handed marketing executive for a major credit card company, began noticing episodes of losing track of conversations and having difficulty with finding words. These episodes lasted 2-3 minutes. At times, the spells seemed to be brought on by a particular memory from her past. No one at her job noticed anything abnormal.
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Case 2 (cont)
Patient is on the oral birth control pill. She was in psychotherapy for feelings of depression and anxiety, but was not taking medications for mood or anxiety disorder Her therapist notes that she has been under significant stress from the breakup with her boyfriend.

Case 2 (cont)
What is your differential diagnosis at this point?

Case 2 (cont)
One febrile seizure at age three No family history EEG arranged, however

Prior to the EEG, the patient had an episode while on a trip, in which she awoke on the floor of her hotel room. Severe headache Blood in her mouth Very sore tongue

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Case 2 (conclusion)
What is your differential diagnosis now? How would you classify her event? How would you evaluate the patient in the ER if you saw her after this episode? What treatment would you start, if any? Are there any special concerns?

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Case 3 - First time for everyone

70 y.o. male presents to the ER His wife was awakened at 0530 by an odd gurgling noise. Px's head was deviated to the left and his left arm was stiffened. After a few moments he had generalized body jerking. Patient was unresponsive Event lasted 2 minutes but stopped spontaneously. His wife said he seemed drowsy and confused.
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Case 3 (cont)
There was no history of prior seizure In fact, the patient was "relatively healthy"
Random BG 12.2 BP 170/96 Several runs of a.fib noted on telemetry Florid carotid bruits and "rock hard" peripheral arteries

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Case 3 (conclusions)
What work-up is needed after a single seizure? What are the causes of seizures, including what conditions lower the seizure threshold? Would you treat this patient or not? If you choose to start a medication, which drug would you choose and why? What are the predictors of seizure recurrence?

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Case 4: And on and on

62 y.o. man Previously well Witnessed GTC seizure ER with decreased LOC ABCs intact Initial assessment after the first seizure revealed poorly reactive pupils, no papilledema or retinal hemorrhages and a supple neck
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Case 4 (cont)
Brainstem reflexes were intact Reflexes were brisk but symmetric, plantar flexor response bilaterally
As you are leaving the room, the patient has another seizure.

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Case 4 (cont)
What should the initial management be?
What initial investigations should be performed in this setting?

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Case 4 (cont)
Lytes normal CBC normal Renal normal Ca, Mg, Phos, Albumin normal
PTT/INR normal Liver enzymes normal

CK 472
What else do you need? An LP! Why?

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Case 4 (cont)
CSF color clear Cell count tube

Tube 1: 500 RBC/ 35 WBC Tube 3: 100 RBC/ 11 WBC

Protein 0.33 Glucose 3.3

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Case 4 (cont)
Whats the cause of the seizures (if any)?
Are there any other studies youd like to perform?

What is the acute management of the etiology (not the seizures)?

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Case 4 (conclusion)
What is your acute management of the seizures? Assuming

the second one did not recur the second one stopped spontaneously the second one stops, but he seizes again in 20 minutes the second one doesnt stop minutes

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Case 5: A difficult case

32 y.o. female with multiple seizures Seizure History
Febrile convulsion x 1 at age 2 Seeing pink elephants which would wave at her while sitting on various objects at age 8

Syndactyly surgical correction at birth Milestones were met at appropriate ages

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Case 5 (cont)
Was the febrile convulsion important?
If so, how would you investigate it? Does she need to go on treatment?

What do you make of the elephant?

Her mother worries about schizophrenia, is this worry well-founded?

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Case 5 (cont)
She finally given a diagnosis of epilepsy at 15 y.o.
Initially, the seizures were controlled with medicine. After a few years, however, the attacks reoccurred despite treatment with anticonvulsants

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Case 5 (cont)
At age 20, the seizures changed in character to the current pattern.

The seizures begin with an aura of a chilling sensation starting at the lower back Over 10-20 seconds, this feeling goes up into the small of her back She clenches her teeth and breaths heavily almost as if she were laughing. She is unable to respond for 5-10 minutes.
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Observers then note a behavioral arrest.

4-5 seizures per month.

Case 5 (cont)
In the past, she has been unsuccessfully tried on phenobarbital, primidone, valproate, gabapentin, phenytoin and ethosuximide. She had marked weight gain while taking valproate. She hated having seizures in public and she felt like a prisoner in my own home
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Case 5 (cont)
She tells you that she still has her drivers license.
What are your legal and ethical obligations as a physician? What are some of the employment issues experienced by people with epilepsy?

Any other concerns?

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Case 5 (interlude)
Possible Mesial Temporal Lobe Epilepsy
Auras of forced recall and rising autonomic experience Complex Partial Seizure

Seizures refractory to multiple antiepileptic medications Recommendation: epilepsy Surgery Evaluation

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Case 5 (cont)
Pre-surgical Evaluation: Neuropsychological Testing

Performance and Verbal IQ normal

Wada (intracarotid amobarbital) test

Language on Left side only No memory difference with left and right injections

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Case 5 (conclusion)
Immediately following surgery she had mild dysnomia, at three months post-op, cognitive testing confirmed no change from pre-op She has had no seizures for two years. She drives to her appointment in a new car. She writes, Im now having a life I never knew was possible.
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End