Epilepsy Cases

1
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

2
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

3
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

4
Case 1 (cont)

• General physical and neurological examination is
  normal.
• What else do you want to do?

• Hyperventilation in your office replicates the
  episodes.

5
(No Transcript)
6
Case 1 (conclusion)

• What is the diagnosis?
• How would you treat the patient?
• How would you counsel the family regarding
  prognosis?

7
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.

8
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.

9
Case 2 (cont)

• What is your differential diagnosis at this
  point?

10
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

11
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?

12
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.

13
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

14
(No Transcript)
15
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?

16
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

17
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.

18
Case 4 (cont)

• What should the initial management be?
• What initial investigations should be performed
  in this setting?

19
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?

20
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

21
(No Transcript)
22
(No Transcript)
23
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)?

24
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

25
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

26
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?

27
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
  re-occurred despite treatment with
  anticonvulsants

28
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
• Observers then note a behavioral arrest.
• She clenches her teeth and breaths heavily
  almost as if she were laughing.
• She is unable to respond for 5-10 minutes.
• 4-5 seizures per month.

29
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

30
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?

31
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

32
(No Transcript)
33
(No Transcript)
34
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

35
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.

36
End