aes epilepsy cases

7/29/2019 AES Epilepsy Cases

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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 anythinghas occurred

She has 30 episodes per day

No convulsionsFather 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.



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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 nervous…um…

25 year-old right-handed marketing executive for

a major credit card company, began noticing

episodes of losing track of conversations andhaving 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 takingmedications for mood or anxiety disorder

Her therapist notes that she has been under

significant stress from the breakup with her

boyfriend.



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Case 2 (cont)

What is your differential diagnosis at this

point?



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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 oddgurgling noise. Px's head was deviated to the leftand his left arm was stiffened.

After a few moments he had generalized body jerking.

Patient was unresponsiveEvent 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" peripheralarteries



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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 decreasedLOC

ABC’s intact

Initial assessment after the first seizure revealedpoorly 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 – normalCa, Mg, Phos,Albumin – normal

PTT/INR – normalLiver 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)

What’s the cause of the seizures (if any)?

Are there any other studies you’d 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 doesn’t 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 birthMilestones 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 thisworry 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 withmedicine.

After a few years, however, the attacks re-

occurred despite treatment with

anticonvulsants…



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Case 5 (cont)

At age 20, the seizures changed in character to thecurrent 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.



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Case 5 (cont)

In the past, she has been unsuccessfully

tried on phenobarbital, primidone,

valproate, gabapentin, phenytoin andethosuximide.

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 driver’s

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

medicationsRecommendation: 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 rightinjections



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Case 5 (conclusion)

Immediately following surgery she had milddysnomia, 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, “I’m now having a life I never knew was possible.”



End

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