Case: 57-year-old Woman with Seizure-like Episodes

by Roy Strowd, MD

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    00:01 In this lecture, we'll talk about partial-onset epilepsy and specifically focus on the treatment for partial-onset epilepsy.

    00:10 Let's start with a case.

    00:12 This is a 57-year-old woman who presents for evaluation of seizure like episodes.

    00:17 The first spell occurred while at home at the table when she developed a severe pain in her right upper quadrant that progressed to a rising sense of nausea, and then her husband saw her slumped over in her chair.

    00:31 This lasted 30 seconds to a minute.

    00:32 And afterwards, she felt "hot on the inside", and was "clammy and disoriented".

    00:38 She had a second spell that was very similar to the first and occurred at a restaurant.

    00:43 During which the patient felt hot, clammy, flushed, developed this rising nausea from the right upper quadrant, followed by slumping over in her chair.

    00:52 By presentation, she had multiple more spells, all beginning with the rising nausea, progressing to lightheadedness, and a near sense of passing out.

    01:02 But did she did not actually pass out.

    01:04 Again, we're seeing that stereotypic nature to these episodes.

    01:09 There's no history of febrile seizures, encephalitis, meningitis, head injury, with or without loss of consciousness, no motor vehicle accidents, no family history of seizure, no staring spells as a child, no reported nocturnal events, and no myoclonus is reported.

    01:25 So what's the diagnosis? Well, as with other seizures, we can walk through the typical features that we evaluate for these patients.

    01:34 What happened before the episode, during the episode, after the episode, and any wildcard features? Prior to the episode for this patient, she describes this rising sense of nausea.

    01:46 It's stereotypic.

    01:47 It happens before every single episode, and is consistent with an aura.

    01:53 That aura here may localize to the medial temporal lobe.

    01:58 The second thing we look at is the event.

    02:00 The description of the event.

    02:02 She slumped over in a chair or described slumping over in the restaurant, in a chair.

    02:07 That slumping over altered awareness puts us into a certain category of possible seizure.

    02:13 And then after the event, particularly with the first one she's disoriented or confused, which is consistent with an epileptic phenomenon.

    02:21 There are also some wildcard features here.

    02:23 She's had multiple spells, all stereotypic, and really the review of seizure symptoms is all negative for any potential nidus that would have contributed to this.

    02:33 So what's the diagnosis? Is this seizure/epilepsy, syncope, TIA, or GI pathology? Well, we don't like syncope.

    02:42 The clinical description just does not support syncope.

    02:45 The events are not provoked by standing.

    02:48 and there's not the lightheadedness or fainting appearance.

    02:51 It's not convulsive syncope that's described.

    02:54 This is inconsistent with the description of syncope.

    02:57 TIA.

    02:58 TIAs can present with sudden onset of neurologic symptoms, post to your circulation, ischemia can cause sudden alteration in awareness and consciousness.

    03:09 But these are very stereotypic in their description.

    03:13 This rising nausea happens at the beginning of each of them.

    03:16 There's post event confusion.

    03:18 They're very short in the description of the actual event itself, which is inconsistent with what we'd see with a TIA.

    03:25 And that would be much lower on our differential.

    03:28 How about GI pathology? She describes this nausea and this sense of abdominal pain.

    03:32 And GI symptoms can be seen as a result of seizure.

    03:35 And here with the co-occurrence of all the other symptoms in this patient, we would not favor GI pathology.

    03:42 The right answer is seizure or epilepsy.

    03:45 These events are stereotypic, meaning the same event occurs in the same way every time.

    03:50 That's critically important when we're evaluating these patients and should raise suspicion for a seizure.

    03:58 So let's talk about what happened for her.

    04:00 She was sent to a cardiologist for a syncope evaluation, had a negative EKG and TTE.

    04:06 Except she did have a clinically insignificant Patent Foramen Ovale.

    04:09 And a negative tilt table test.

    04:12 She was sent to a GI physician who performed a CT chest, abdomen, pelvis to work up the abdominal pain and rising nausea, which was negative.

    04:19 Then had an EGD or an upper endoscopy that was also negative for GI pathology.

    04:25 She was then sent to a neurologist where EEG was normal.

    04:29 And the MRI was normal except for some subtle chronic microvascular changes on the brain, which are likely unrelated.

    04:36 So what treatment would you select? Ethosuximide, levetiracetam, phenobarbital, or the ketogenic diet? Ethosuximide is a great anti-epileptic but it's used primarily for primary generalized epilepsy and specifically for patients with absence epilepsy or childhood absence epilepsy.

    04:57 This patient's description is inconsistent with a generalized epilepsy.

    05:00 And so ethosuximide would not be the treatment of choice.

    05:05 Phenobarbital is a commonly used medication for status epilepticus.

    05:09 And the historically was one of our first seizure medications.

    05:13 It is used for focal-onset epilepsy.

    05:16 And it's typically not used for patients where we're concerned about drug-drug interactions.

    05:21 There's a risk of sedation and other side effects.

    05:23 And so it's frequently reserved for patients who have refractory epilepsy who fail other therapies.

    05:30 How about the ketogenic diet? This is something we do use in epilepsy.

    05:34 It's typically reserved for pediatric patients or patients with medically refractory epilepsy.

    05:40 And so it would not be the first choice of an intervention for this patient.

    05:45 So the right answer here is levetiracetam.

    05:47 This is an appropriate treatment for a focal-onset epilepsy, and it's one of the most commonly used medications for a first line agent for new onset epilepsy or seizures.

    About the Lecture

    The lecture Case: 57-year-old Woman with Seizure-like Episodes by Roy Strowd, MD is from the course Seizures and Epilepsy.

    Included Quiz Questions

    1. Stereotypic aura with nausea or déjà vu
    2. Asymptomatic postictally
    3. Loss of consciousness prior to convulsions
    4. EEG with simultaneous depolarization
    5. Ethosuximide is the preferred treatment

    Author of lecture Case: 57-year-old Woman with Seizure-like Episodes

     Roy Strowd, MD

    Roy Strowd, MD

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