EPILEPSY   58A

A middle-aged man is transported to the emergency department accompanied by a hospital nurse. She states that the patient was in line in front of her in the hospital cafeteria when he suddenly fell to the floor. He then had a “generalized tonic-clonic seizure” and was then unconscious. With assistance, she brought him to the emergency department. No other history is available. On physical examination, the patient is drowsy, confused, and unresponsive to commands. He is breathing adequately. Vital signs are temperature, 38°C; blood pressure, 170/90 mm Hg; heart rate, 105 beats/min; respiratory rate, 18 breaths/min; and oxygen saturation, 99% (on 2 L of O₂). Neurologic examination is notable for reactive pupils of 3 mm, intact gag reflex, decreased movement of the left side of the body, and positive Babinski signs bilaterally. Examination is otherwise unremarkable.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Witnessed seizure activity; postictal confusion; immediate neurologic abnormalities

How to think through: Can a syncopal event include myoclonic seizure-like movements? (Yes. Syncope—lack of sufficient blood flow to the brain [definition that distinguishes it from seizure]—can be associated with myoclonic jerks.) What features help identify this event as a seizure? (Postictal confusion and drowsiness, transient neurologic abnormalities consistent with Todd paralysis. Tongue biting and incontinence are also common with seizure and not with syncope.) Knowing nothing about this patient’s history, what are the primary causes of seizure to consider? (Hypoglycemia, hyponatremia, alcohol or benzodiazepine withdrawal, medication or illicit sympathomimetic toxicity [e.g., cocaine], and central nervous system [CNS] mass effect from tumor, trauma, stroke, or infection.) How should he be managed upon arrival in the emergency department? (First, review the ABCs [airway, breathing, circulation]. Establish intravenous access. Administer thiamine and glucose. Send a complete blood count [CBC] and serum electrolytes, glucose, and calcium. Pending history and clinical course, consider CNS imaging.) What defines epilepsy? (Recurrent seizures.) What features constitute a tonic-clonic seizure? Can a patient have a bilateral tonic-clonic seizure and remain conscious? (No. Both hemispheres are involved.) How are seizures classified? (Focal vs. generalized.) What are common anticonvulsants? (Phenytoin, carbamazepine, valproic acid, phenobarbital, others.)

EPILEPSY   58B

What are the essentials of diagnosis and general considerations regarding epilepsy?

Essentials of Diagnosis

Recurrent seizures (epilepsy should not be diagnosed on basis of a solitary seizure)

Characteristic electroencephalographic (EEG) changes may occur

Postictal confusion or focal neurologic deficits may follow and last hours

General Considerations

Genetic epilepsy onset ranges from the neonatal period to adolescence or even later in life.

Metabolic disorders such as hypoglycemia, hyperglycemia, uremia, hyponatremia, or withdrawal from CNS depressants such as alcohol may manifest as seizures.

Tumors and other space-occupying lesions result in seizures that are often focal.

Vascular disease and neurodegenerative disorders may cause seizures in later life.

CNS infections (meningitis, encephalitis, or brain abscess) must be considered in all age groups as potentially reversible causes of seizures.

Other important causes of seizures include trauma, febrile seizures in young children, and CNS vasculitis (e.g., systemic lupus erythematosus).

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