clinical epilepsy case studies american epilepsy society

ClinicalEpilepsyCaseStudiesAmericanEpilepsySocietyCCase-Slide*MedicalStudentCasesCase1:5year-oldfemalewithepisodesof“BlankingOut”CCase-Slide*AmericanEpilepsySociety2004CaseStudy1A5y/ofemaleisbroughttoyourofficebecauseofepisodic“blankingout”whichbegan1monthago.Thepatienthasepisodesinwhichsheabruptlystopsallactivityforabout10seconds,followedbyarapidreturntofullconsciousness.Thepatient’seyesareopenduringtheepisodesandsheremainsmotionlesswithoccasional“fumbling”handmovements.CCase-Slide*AmericanEpilepsySociety2004CaseStudy1AftertheepisodethepatientresumeswhateveractivityshewaspreviouslyengagedwithnoawarenessthatanythinghasoccurredShehas30episodesperdayNoconvulsionsCCase-Slide*AmericanEpilepsySociety2004CaseStudy1Pastmedical,physicalanddevelopmentalhistoriesareunremarkable.Nohistoryofpreviousorcurrentmedications;NoallergiesFamilyhistoryispertinentforherfatherhavingsimilarepisodesasachild.CCase-Slide*AmericanEpilepsySociety2004CaseStudy1Generalphysicalandneurologicalexaminationisnormal.Hyperventilationinyourofficereplicatestheepisodes.CCase-Slide*CCase-Slide*CaseStudy1EEGforCaseStudy1CaseStudy1Whatadditionalstudiesdoyouperform,ifany?Whatisthediagnosis?Howdoyouinitiatemedication?Ifso,Which?Wouldyoucounselthefamilyregardingprognosis?CCase-Slide*AmericanEpilepsySociety2004MedicalStudentCasesCase2:“Nervous”Disorder?CCase-Slide*AmericanEpilepsySociety2004CaseStudy225year-oldright-handedmarketingexecutiveforamajorcreditcardcompany,begannoticingepisodesoflosingtrackofconversationsandhavingdifficultywithfindingwords.Theseepisodeslasted2-3minutes.Attimes,thespellsseemedtobebroughtonbyaparticularmemoryfromherpast.Nooneatherjobnoticedanythingabnormal.CCase-Slide*AmericanEpilepsySociety2004CaseStudy2Patienthadnosignificantpastmedicalhistory,andtooknomedicinesexceptforthebirthcontrolpill.Shewasinpsychotherapyforfeelingsofdepressionandanxiety,butwasnottakingmedicationsformoodoranxietydisorderHertherapistnotesthatshehasbeenundersignificantstressfromthebreakupwithherboyfriend.CCase-Slide*AmericanEpilepsySociety2004CaseStudy2Whatisyourdifferentialdiagnosisatthispoint?CCase-Slide*AmericanEpilepsySociety2004CaseStudy2Acarefulmedicalhistoryrevealedthatshehadonefebrileseizureatagethree;nofamilymembershadepilepsy.Thepsychiatristprescribedabenzodiazepinesleepingpilltobeusedasneeded,andscheduledherforanelectroencephalogram(EEG).CCase-Slide*AmericanEpilepsySociety2004CaseStudy2PriortotheEEG,thepatienthadanepisodewhileonacrosscountrybusinesstrip,inwhichsheawokeonthefloornearthebathroomofherhotelroom.Shehadasevereheadacheandnotedsomebloodinhermouth,alongwithaverysoretongue.Shecalledthehotelphysicianandwastakentothelocalemergencyroom.CCase-Slide*AmericanEpilepsySociety2004CaseStudy2Whatisyourdifferentialdiagnosisnow?Howwouldyouclassifyherevent?HowwouldyouevaluatethepatientintheERifyousawherafterthisepisode?CCase-Slide*AmericanEpilepsySociety2004CaseStudy2IntheER,adiagnosisofnocturnalconvulsionwasmade.Aheadcomputerizedtomographic(CT)scanwasnormal.LaboratorytestsincludingaCBC,chemistriesandtoxicologyscreenwerenormal.CCase-Slide*AmericanEpilepsySociety2004CaseStudy2Shewasgivenfosphenytoin1000mgPEintravenouslyandobserved.Shewasdischargedhomeonphenytoin300mgperdayandreferredtoaneurologist.Whatwouldthecontinuedevaluationandtreatmentconsistof?CCase-Slide*AmericanEpilepsySociety2004CaseStudy2Neurologisttookacompleteneurologicandmedicalhistoryandfoundpatienthadanuncomplicatedfebrileseizureasatoddler,butnootherseizures.Therewasnofamilyhistoryofepilepsyinherimmediatefamilymembers.Medicalhistoryisotherwisebenignandshehasnomedicationallergies.Shehadregularmenstrualperiodssinceage13andhasneverbeenpregnant,althoughshewantstohavechildren.Generalandneurologicexaminationwasnormal.CCase-Slide*AmericanEpilepsySociety2004CaseStudy2EEGshowedrightanteriortemporalspikeandwavedischarges.AnMRIofthebrainwasnormal.Complaintofpersistentsedationledtochangefromphenytointolamotrigine,atadosestartingat50mgBIDincreasingby50mg/dayeverytwoweekstoreachatargetdoseof300mg/day.CCase-Slide*AmericanEpilepsySociety2004CaseStudy2Sideeffectswereexplainedtothepatient.Shewasalsostartedonfolicacid1mgperdayandwasadvisedtotakeamultivitamindaily.CCase-Slide*AmericanEpilepsySociety2004CaseStudy2Whatarethemostreasonablechoicesofantiseizuretreatmentforthispatient?Wasanappropriatechoicemade?Whatconsiderationsmustbemadesincesheisawomanofchild-bearingpotential?CCase-Slide*AmericanEpilepsySociety2004CaseStudy2Arethereconsiderationsregardingtheoralcontraceptivepill?Whatisthereasonfortheextrafolicacidandmultivitamin?Whatadviceshouldbegivenregardinglifestyle(sleephabits,alcoholintake)anddriving?CCase-Slide*AmericanEpilepsySociety2004MedicalStudentCasesCase3:70yomanwithhisfirstseizureCCase-Slide*AmericanEpilepsySociety2004CaseStudy370y/omalepresentstotheERwithahistoryofasingleseizure.Hiswifewasawakenedat5:30ambyherhusbandmakinganoddgurglingnoisewithhisheaddeviatedtotheleftandleftarmtonicallystiffened.ThiswasfollowedbygeneralizedbodyjerkingPatientwasunresponsiveEventlasted2minuteswith10minutesuntilfullrecoveryCCase-Slide*AmericanEpilepsySociety2004CaseStudy3IntheER,initiallythepatientisweakerinthelefthandthantherightsideandisfullyresponsiveandhiswifefeelsthathehasreturnedtobaseline.PMH:Non-insulindependentdiabetesFamilyhistory:NegativeforseizuresSocialhistory:Nosmokingoralcoholuse.Neurologicalexamination:NormalCCase-Slide*AmericanEpilepsySociety2004CaseStudy3Currentmedications:Glyburide5mg/dayVitalsigns:BP200/130,HR75(regular)RR14,Temp100.1CCase-Slide*AmericanEpilepsySociety2004CaseStudy3Sodium141meq/LPotassium4.2meq/LChloride99meq/LBicarbonate27meq/LBUN8mg/dLCr0.7mg/dLGlucose60mg/dLCCase-Slide*Hematocrit44%Hemoglobin15.4g/dLWBC12,000/80%NeutrophilsPlatelets180,000AmericanEpilepsySociety2004CaseStudy3Urineanalysis:15WBC/HPF,nitritepositiveABG:pH7.3,pCO2-36,pO2-86,O2saturation93%CTscan:normalEEG:minimalbitemporalslowingCCase-Slide*AmericanEpilepsySociety2004CaseStudy3CTScanCCase-Slide*AmericanEpilepsySociety2004CaseStudy3Whatwork-upisneededafterasingleseizure?Whatarethecausesofseizures,includingwhatconditionslowertheseizurethreshold?Wouldyoutreatthispatientornot?Ifyouchoosetostartamedication,whichdrugwouldyouchooseandwhy?Whatarethepredictorsofseizurerecurrence?CCase-Slide*AmericanEpilepsySociety2004MedicalStudentCasesCase4:A62yomalewithContinuousSeizuresCCase-Slide*AmericanEpilepsySociety2004CaseStudy4A62y/omalewithoutsignificantprevioushistoryofseizurespresentstotheERfollowingonegeneralizedtonic-clonicseizure.Initialassessmentafterthefirstseizurerevealedpoorlyreactivepupils,nopapilledemaorretinalhemorrhagesandasuppleneck.CCase-Slide*AmericanEpilepsySociety2004CaseStudy4Oculocephalicreflexisintact.Respirationsarerapidat22/minandregular,heartrateis105withatemperatureof101.Asyouareleavingtheroom,thepatienthadanotherseizure.CCase-Slide*AmericanEpilepsySociety2004CaseStudy4Whatshouldtheinitialmanagementbe?Whatinitialinvestigationsshouldbeperformedinthissetting?Whatistheappropriatemanagementwithcontinuedseizuresifinitialtherapydoesnotterminatetheseizures?CCase-Slide*AmericanEpilepsySociety2004CaseStudy4Laboratorystudyresults:CBCWBC-13.1HGB11Plt200,000CCase-Slide*Creatinine-1.0Mg1.0Na-132K-4.5Ca-9.0Glucose-90AmericanEpilepsySociety2004CaseStudy4Whatareindicationsforlumbarpunctureinthiscase?CSFcolor-clearCellcounttube#1–500RBC/35WBC-100%NeutrophilsTube#3-100RBC/11WBCProtein65Glucose60CCase-Slide*AmericanEpilepsySociety2004CaseStudy4Urinalysis-(+)ketonesNoWhiteBloodCellsorbacteriaToxscreen:negativeforalcoholpositiveforbenzodiazepinesCCase-Slide*AmericanEpilepsySociety2004CaseStudy4CCase-Slide*YouobtainanMRIofthebrainwiththefollowingimagesAmericanEpilepsySociety2004CCase-Slide*CaseStudy4AmericanEpilepsySociety2004CaseStudy4Whichoftheabovestudieshelpstoexplainthecurrentseizures?Wouldyouaskforotherstudies?WhataretheCSFfindingsduringrepeatedconvulsions?CCase-Slide*AmericanEpilepsySociety2004CaseStudy4DefineStatusEpilepticus.Describethesystemicmanifestationsofstatusepilepticus.Whatcausesstatusepilepticus?WhatistheroleofEEGinstatusepilepticusmanagement?CCase-Slide*AmericanEpilepsySociety2004MedicalStudentCasesCase5:51yearoldfemalewithfrequentseizuresCCase-Slide*AmericanEpilepsySociety2004CaseStudy5SeizureHistory:Herbirthwasunremarkableexceptthatshewasbornwithsyndactylyrequiringsurgicalcorrection.Earlydevelopmentalmilestonesweremetatappropriateages.Shehadherfirstconvulsiveepisodeatage2inthesettingofafebrileillness.CCase-Slide*AmericanEpilepsySociety2004CaseStudy5Howwouldyouevaluateandtreatapatientwithafebrileseizure?Whatclinicalfeaturesareimportantinguidingyourevaluation?CCase-Slide*AmericanEpilepsySociety2004CaseStudy5Shebegantodevelopanewtypeofepisodeinthethirdgrade.Theattacksconsistedofherseeingapinkelephantthatwassittingonvariousobjectsandwavingtoher.Thepatienthassubsequentlyfoundaceramicmodelofanelephantthatwasthesameastheelephantthatshesawduringherseizures.CCase-Slide*AmericanEpilepsySociety2004CaseStudy5Howarehersymptomsdifferentfrommostpatientswithschizophrenia?CCase-Slide*AmericanEpilepsySociety2004CaseStudy5Shewasnotdiagnosedwithseizuresuntiltheageof15.Initially,theseizureswerecontrolledwithmedicine.Afterafewyears,however,theattacksre-occurreddespitetreatmentwithanticonvulsants.CCase-Slide*AmericanEpilepsySociety2004CaseStudy5Atage20,theseizureschangedincharactertothecurrentpattern.Theseizuresbeginwithanauraof“achillingsensationstartingatthelowerbackwithascensiontotheupperbackoverthecourseof10-20seconds”.CCase-Slide*AmericanEpilepsySociety2004CaseStudy5Observersthennoteabehavioralarrest.Shetendstoclenchherteethandbreathheavily,suchthatherbreathingsounds“almostasifshewerelaughing”.Sheisunabletofullyrespondtopeoplefor5-10minutes.Typically,sheexperiences4-5seizurespermonth.CCase-Slide*AmericanEpilepsySociety2004CaseStudy5ShehashadseveralEEGsinthepast;themostrecentavailablereportisfromsevenyearsago,whichrevealedmild,diffuseslowingofbackgroundelementswithnoabnormalitiesnotedduringthreeminutesofhyperventilationandphoticstimulation.ShehadanMRI13yearsagowithnoreportedabnormalities.CCase-Slide*AmericanEpilepsySociety2004CaseStudy5Shehastriedseveraldifferentmedications,butiscurrentlymaintainedoncarbamazepineandlamotrigine.Hercarbamazepinedoseis700mg/dayandLamotrigine125mg/daywithBIDdosing.Shefeelsexcessivelytiredonhigherdoses.Shehasbeenoncarbamazepine32yearsandonlamotrigineforfouryears.Shestatesthatshehashadsomesuccesswiththelamotrigine.CCase-Slide*AmericanEpilepsySociety2004CaseStudy5Inthepast,shehasbeenunsuccessfullytriedonphenobarbital,primidone,valproate,gabapentin,phenytoinandethosuximide.Shehadmarkedweightgainwhiletakingvalproate.Shehatedhavingseizuresinpublicandshe“feltlikeaprisonerinmyownhome”.Uponhearingofseizuresurgery,sherequestedareferralforevaluation.CCase-Slide*AmericanEpilepsySociety2004CaseStudy5Whenareseizures“medicallyrefractory”?WhenshouldyouconsideraninpatientvideoEEGevaluation?Whatmightyoulearnfromsuchanevaluation?CCase-Slide*AmericanEpilepsySociety2004CaseStudy5PastMedicalHistory:1)Migraineheadaches(withthelastoneoccurringfouryearsago)2)status-posthysterectomywithremovalofoneovary25yearsago3)historyofsyndactylyatbirthwithsurgicalcorrections;4)partialthyroidectomy32yearsagoduringpregnancy.CCase-Slide*AmericanEpilepsySociety2004CaseStudy5SocialHistory:Shecurrentlyliveswithhermother.Sheworksasasalesclerk.Shecompletedtwelveyearsofschoolandfinishedonesemesterofcollege.ShehasnotdrivenacarafterbeingreportedtotheDMVbyherdoctor23yearsago.CCase-Slide*AmericanEpilepsySociety2004CaseStudy5Shetellsyouthatshestillhasherdriver’slicense.1)Whatareyourlegalandethicalobligationsasaphysician?2)Whataresomeoftheemploymentissuesexperiencedbypeoplewithepilepsy?CCase-Slide*AmericanEpilepsySociety2004CaseStudy5FamilyHistory:Shehasacousinwithahistoryof”grandmal”seizureswhodiedatage12.Habits:Shedoesnotuseofalcohol,tobacco,orillicitdrugs.Medications:Carbamazepine600/400mg/dayBID,Lamotrigine50/75mg/dayBID,Conjugatedestrogens1.25mgPOqd,thyroxine100mcgPOqd,andsumatriptanPRN.NeurologicExamination:NormalCCase-Slide*AmericanEpilepsySociety2004CaseStudy5ImpressionPossibleMesialTemporalLobeEpilepsyAurasofforcedrecallandrisingautonomicexperienceComplexPartialSeizureSeizuresrefractorytomultipleantiepilepticmedicationsRecommendationEpilepsySurgeryEvaluationCCase-Slide*AmericanEpilepsySociety2004CaseStudy5Thepatientunderwentvideo-EEGmonitoring.CCase-Slide*AmericanEpilepsySociety2004CaseStudy5During5daysofvideoEEG,shehad3typicalCPS.Herseizuresbeganwithhertypicalaurafollowedbylipsmackingandlefthandautomatisms.RighthandhadtonicpostureShehadabriefpost-ictalaphasiaCCase-Slide*AmericanEpilepsySociety2004CaseStudy5CCase-Slide*EEGonsetsconsistedofarapidbuildupofrhythmicthetafrequencyactivityoverthelefttemporalregion(Arrows)AmericanEpilepsySociety2004CCase-Slide*CaseStudy5MRIrevealsanatrophicL.HippocampusAmericanEpilepsySociety2004CaseStudy5Pre-surgicalEvaluation:NeuropsychologicalTestingPerformanceandVerbalIQnormalWada(Intracarotidamobarbital)testLanguageonLeftsideonlyNomemorydifferencewithleftandrightinjectionsCCase-Slide*AmericanEpilepsySociety2004CaseStudy5Pre-surgicalEvaluation:ConclusionsShehascomplexpartialseizuresrefractorytoanticonvulsanttreatmentClinicalandEEGfeaturesarecompatiblewithseizureoriginfromtheleft,language-dominanttemporallobeMRIsuggestsmesialtemporalsclerosisistheunderlyingpathologyShehasanexcellentchanceforaseizure-freeoutcomewithaleftanteriortemporalloberesectionCCase-Slide*AmericanEpilepsySociety2004CaseStudy5SurgerySurgeryunderlocalanesthesiaLanguagemapdeterminedbyelectricalstimulationLanguageareas(greenarrow)andepileptogenictissue(whitearrow)labeledonnextslideCCase-Slide*AmericanEpilepsySociety2004CCase-Slide*CaseStudy5MRIshowinglanguageareasAmericanEpilepsySociety2004CCase-Slide*CaseStudy5SurgeryAnteriortemporalloberesected(arrow)AmygdalaandhippocampusalsoresectedAmericanEpilepsySociety2004CaseStudy5Follow-upImmediatelyfollowingsurgeryshehadmilddysnomiaAtthreemonthspost-op,cognitivetestingconfirmednochangefrompre-opShehashadnoseizuresfortwoyears.Shedeclinesatrialoffofanticonvulsantsforfearofrecurrentseizures.Shedrivestoherappointmentinanewcar.Shewrites,“I’mnowhavingalifeIneverknewwaspossible”CCase-Slide*AmericanEpilepsySociety2004