Post on 03-Apr-2018
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 1/36
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
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 2/36
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
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 3/36
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
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 4/36
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.
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 5/36
5
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 6/36
6
Case 1 (conclusion)
What is the diagnosis?
How would you treat the patient?
How would you counsel the family
regarding prognosis?
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 7/36
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.
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 8/36
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 takingmedications for mood or anxiety disorder
Her therapist notes that she has been under
significant stress from the breakup with her
boyfriend.
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 9/36
9
Case 2 (cont)
What is your differential diagnosis at this
point?
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 10/36
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
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 11/36
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?
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 12/36
12
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.
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 13/36
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" peripheralarteries
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 14/36
14
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 15/36
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?
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 16/36
16
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
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 17/36
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.
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 18/36
18
Case 4 (cont)
What should the initial management be?
What initial investigations should be
performed in this setting?
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 19/36
19
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?
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 20/36
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
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 21/36
21
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 22/36
22
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 23/36
23
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)?
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 24/36
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 doesn’t stop minutes…
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 25/36
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 birthMilestones were met at appropriate ages
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 26/36
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 thisworry well-founded?
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 27/36
27
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…
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 28/36
28
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.
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 29/36
29
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”
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 30/36
30
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?
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 31/36
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
medicationsRecommendation: epilepsy Surgery
Evaluation
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 32/36
32
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 33/36
33
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 34/36
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 rightinjections
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 35/36
35
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.”
7/29/2019 AES Epilepsy Cases
http://slidepdf.com/reader/full/aes-epilepsy-cases 36/36
End