Neurology · Year 3 · from Neurology
Case 1: New-Onset Generalized Tonic-Clonic Seizure
Patient Demographics
- Age: 22 years
- Sex: Male
- Occupation: College student
Chief Complaint
Roommate called 911: "He was shaking all over and wouldn't wake up."
History of Present Illness
The patient's roommate witnessed him suddenly cry out, then fall to the floor and begin shaking violently. All four extremities were involved with rhythmic jerking. His eyes rolled back, and he was foaming at the mouth. He appeared blue around the lips. The episode lasted approximately 2 minutes, after which the shaking stopped but he remained unresponsive. He gradually became more alert over 20 minutes but was confused and did not remember the event. He bit the lateral side of his tongue. He was incontinent of urine. The patient reports he has been studying for finals with minimal sleep (3-4 hours/night for the past week) and drank heavily (8+ beers) the night before, with last alcohol intake 12 hours prior to the event. No prior seizure history. No recent illness, head trauma, or drug use.
Neurological Examination Findings (30 minutes post-ictal)
Mental Status:
- Drowsy but arousable
- Oriented to person only
- Slow to respond, difficulty with attention
- Post-ictal confusion resolving
Cranial Nerves:
- Pupils 4 mm, equal, reactive
- Lateral tongue laceration (right side)
- No facial asymmetry
- Extraocular movements intact
Motor Examination:
- Moves all extremities spontaneously
- Diffuse muscle tenderness
- No focal weakness
Sensory Examination:
- Withdraws to pain symmetrically
Reflexes:
- 2+ symmetric
- Plantar responses flexor bilaterally
Coordination and Gait:
- Deferred due to post-ictal state
Seizure Classification
Generalized onset tonic-clonic seizure (bilateral convulsive seizure with impaired awareness)
- Tonic phase: Initial stiffening, cry, fall
- Clonic phase: Rhythmic bilateral jerking
- Features supporting generalized: Bilateral involvement, tongue bite, incontinence, post-ictal confusion
Neuro Workup
- CT Head without contrast: Normal, no hemorrhage or mass
- MRI Brain with epilepsy protocol: Normal hippocampi, no mesial temporal sclerosis, no cortical malformation
- EEG (routine): Normal background, no epileptiform discharges (may be normal interictally)
- Labs:
- BMP: Na 138, K 3.8, Glucose 95, Ca 9.2 (normal)
- CBC: Normal
- Prolactin: 45 ng/mL (elevated, supports true seizure vs psychogenic)
- Magnesium: 1.6 (low normal)
- Urine drug screen: Negative
- Blood alcohol: <10 mg/dL
- Ammonia: Normal
Diagnosis
Provoked generalized tonic-clonic seizure secondary to sleep deprivation and alcohol withdrawal
- Timing suggests alcohol withdrawal seizure (typically 6-48 hours after last drink)
- Sleep deprivation lowered seizure threshold
Management
Acute Management:
- Supportive care, position of safety during post-ictal phase
- Thiamine 100 mg IV, folate, multivitamin (given alcohol use)
- Monitor for additional seizures or withdrawal symptoms
- Benzodiazepine PRN for CIWA protocol
Disposition:
- Observation for 24 hours
- If no further seizures, discharge with education
Antiepileptic Medication:
- NOT routinely indicated for first provoked seizure
- Recurrence risk lower when clear provoking factor identified and eliminated
- Would start AED if: second unprovoked seizure, EEG shows epileptiform activity, structural lesion on MRI
Counseling:
- Avoid alcohol and sleep deprivation
- Driving restrictions per state law (typically 3-6 months seizure-free)
- Water safety precautions (no unsupervised swimming/bathing)
- Return precautions: if recurrent seizure, seek evaluation
Clinical Image
Image Description: EEG demonstrating generalized 3-Hz spike-and-wave discharges, a pattern associated with generalized epilepsy syndromes.
Attribution: Image from Wikipedia Commons, public domain. Source: https://commons.wikimedia.org/wiki/File:Spike-waves.png