Neuroscience · Year 2 · from Neuroscience
Case 1: New-Onset Focal Seizure with Secondary Generalization
Patient Presentation
Demographics: 58-year-old male
Chief Complaint: Wife witnessed patient having a "convulsion" this morning
History of Present Illness: The patient's wife reports that this morning, her husband suddenly stopped talking mid-sentence and "got a strange look on his face." His head then turned forcefully to the right, and his right arm began jerking rhythmically. Within about 30 seconds, the shaking spread to involve his whole body - both arms and legs stiffened, then began jerking rhythmically. She notes he made a "groaning" sound at the onset and turned slightly blue. The generalized shaking lasted approximately 2 minutes. After it stopped, he was unresponsive for about 5 minutes, then confused for another 30 minutes, unable to recognize her initially. He has no history of seizures. He has hypertension and smokes one pack of cigarettes daily.
Physical Examination (2 hours after event):
- Vital signs: BP 158/92, HR 88, T 37.1C
- General: Appears tired, occasional word-finding pauses
- Neurological:
- Mental status: Alert, oriented, slightly slow; residual mild word-finding difficulty
- Cranial nerves: Intact
- Motor: Subtle right arm weakness 4+/5, right leg 5/5, left side 5/5
- Lateral tongue laceration (bitten on left side)
- Incontinent of urine during event (per wife)
Key Observation: Focal onset (head version and right arm jerking = left hemisphere onset) with secondary generalization; Todd's paralysis (postictal right arm weakness); tongue bite on lateral aspect (characteristic of seizure)
Workup:
- Basic metabolic panel: Normal sodium, glucose 98 mg/dL, no metabolic derangement
- CBC: Normal
- Toxicology screen: Negative
- EEG: Focal slowing and sharp waves over left frontotemporal region
- MRI brain with epilepsy protocol: 3 cm ring-enhancing mass in left frontal lobe with surrounding edema, suspicious for malignancy
Diagnosis: New-onset focal seizure secondary to left frontal brain tumor (structural/symptomatic seizure)
Treatment:
- Levetiracetam 500 mg twice daily (anti-seizure medication that does not interact with chemotherapy/steroids)
- Dexamethasone 4 mg every 6 hours for cerebral edema
- Neurosurgery consultation for tumor resection
- Oncology consultation
- Driving restriction counseled
Clinical Course: Biopsy confirmed glioblastoma multiforme. The patient underwent surgical resection followed by radiation and temozolomide. He remained seizure-free on levetiracetam throughout treatment. The postictal right arm weakness resolved completely within 6 hours.
Clinical Pearl: New-onset seizures in adults require investigation for underlying structural cause. Features suggesting focal onset include: version (head/eye turning - toward the side opposite the seizure focus), unilateral clonic activity, focal postictal weakness (Todd's paralysis), and postictal aphasia (if dominant hemisphere). The lateral tongue bite is highly specific for generalized tonic-clonic seizures. Seizure provoked by a structural lesion is not "epilepsy" per se, but the lesion creates an ongoing seizure predisposition requiring treatment.