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

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.