# Clinical Cases: Seizures and Epilepsy ## 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. --- ## Case 2: Juvenile Myoclonic Epilepsy ### Patient Presentation **Demographics:** 17-year-old female **Chief Complaint:** "Jerking movements" in the morning and one "big seizure" last week **History of Present Illness:** The patient reports that for the past 6 months, she has noticed brief "jerky" movements of her arms, usually occurring within an hour of waking up. She has spilled her cereal or dropped her toothbrush multiple times due to these sudden jerks. She thought this was normal or due to being tired. Last week, after staying up late studying for exams and drinking alcohol at a party, she had a generalized convulsion witnessed by her roommate. The roommate described whole-body stiffening followed by rhythmic shaking for about 2 minutes. She also reports occasional "spacing out" episodes lasting a few seconds where her friends say she stares blankly. **Triggers Identified:** - Sleep deprivation - Alcohol consumption - Both present before the generalized seizure **Physical Examination:** - Vital signs: Normal - General: Healthy-appearing adolescent - Neurological examination: Completely normal **Workup:** - **Basic metabolic panel:** Normal - **MRI brain:** Normal - **EEG (with sleep deprivation):** Generalized 4-5 Hz polyspike-and-wave discharges, most prominent in frontal leads; photic stimulation produced a photoparoxysmal response **Diagnosis:** Juvenile myoclonic epilepsy (JME) **Seizure Types Present:** 1. Myoclonic seizures (morning jerks) 2. Generalized tonic-clonic seizure 3. Probable absence seizures (staring episodes) **Treatment:** - Valproate 250 mg twice daily, titrated to 500 mg twice daily - Discussed alternatives (levetiracetam, lamotrigine) given teratogenicity concerns for future pregnancy - Lifestyle counseling: avoid sleep deprivation, limit/avoid alcohol - Driving restriction per state law **Clinical Course:** Myoclonic jerks resolved within 2 weeks of reaching therapeutic valproate dose. No further generalized seizures occurred. At 6-month follow-up, she was seizure-free. She was counseled extensively that JME is a lifelong condition - if medication is stopped, seizures typically return. She was advised to discuss pregnancy planning with neurology given valproate's teratogenicity. **Clinical Pearl:** Juvenile myoclonic epilepsy is the most common idiopathic generalized epilepsy syndrome. The classic presentation includes morning myoclonic jerks (the hallmark), generalized tonic-clonic seizures, and often absence seizures. Sleep deprivation and alcohol are powerful triggers. EEG shows generalized polyspike-and-wave complexes at 4-6 Hz. JME responds well to valproate (but valproate should be avoided in women of childbearing potential due to teratogenicity), lamotrigine, and levetiracetam. Unlike childhood absence epilepsy, JME is usually a lifelong condition requiring ongoing treatment. --- ## Case 3: Status Epilepticus ### Patient Presentation **Demographics:** 45-year-old male **Chief Complaint:** Continuous seizure activity for 15 minutes **History of Present Illness:** EMS was called when the patient was found by coworkers having a generalized convulsion at work. Shaking has continued during transport and upon arrival to the ED - total duration now 15 minutes. He has a known history of epilepsy diagnosed 10 years ago, treated with phenytoin. His wife reports he ran out of phenytoin 4 days ago and has not refilled it. **On Arrival:** - Generalized tonic-clonic movements ongoing - Cyanotic - Incontinent - Not following commands **Initial Assessment:** - Vital signs: BP 168/102, HR 128, T 38.1C, SpO2 84% on room air - Glucose: 142 mg/dL (normal - not hypoglycemic) **Diagnosis:** Convulsive status epilepticus secondary to anti-seizure medication non-compliance **Treatment Protocol:** **0-5 Minutes (Initial Stabilization):** - ABCs: Oxygen via non-rebreather mask, suction, positioning - IV access x 2 - Glucose check: 142 mg/dL (no dextrose needed) - Labs drawn: CBC, CMP, phenytoin level, toxicology **5-20 Minutes (First-Line Benzodiazepine):** - Lorazepam 4 mg IV push - Seizure continues after 3 minutes - Lorazepam 4 mg IV push (second dose) - Seizure stops at 22 minutes total duration **20-40 Minutes (Second-Line Agent):** - Despite seizure stopping, patient given loading dose to prevent recurrence: - Fosphenytoin 20 mg PE/kg IV infusion (patient weight 80 kg = 1600 mg PE) - Cardiac monitor during infusion **Post-Seizure:** - Phenytoin level returns: <1 mcg/mL (undetectable - confirms non-compliance) - Patient remains postictal for 45 minutes, then gradually awakens - By 2 hours, following commands; confused but improving - CT head: No acute abnormality **ICU Monitoring:** - Continuous EEG monitoring for 24 hours: No electrographic seizures - Maintenance phenytoin resumed - Social work consultation for medication access/compliance **Clinical Course:** Patient was extubated (was briefly intubated for airway protection during ongoing seizures). No further seizures occurred. He was discharged on day 2 with phenytoin at previous dose and arrangements for medication assistance program. EEG showed rare interictal epileptiform discharges but no seizures. **Clinical Pearl:** Status epilepticus is a medical emergency defined as seizure activity lasting >5 minutes (the point at which spontaneous termination is unlikely). The treatment protocol follows a time-based escalation: 1. First-line: Benzodiazepine (lorazepam IV, or midazolam IM if no IV) 2. Second-line: Fosphenytoin, levetiracetam, or valproate IV 3. If refractory: Anesthesia (propofol, midazolam infusion, or pentobarbital) with continuous EEG monitoring Medication non-compliance is the most common cause of status epilepticus in patients with known epilepsy. Mortality of convulsive status epilepticus is approximately 20%, with risk of permanent neurological injury from excitotoxicity. --- ## Clinical Image ![EEG generalized spike-wave](case_01_image.jpg) **Image Description:** Electroencephalogram (EEG) demonstrating generalized 3 Hz spike-and-wave discharges, the classic pattern seen in absence epilepsy. This characteristic pattern shows synchronous, bilaterally symmetric spike-and-wave complexes that appear simultaneously across all scalp electrodes, reflecting the generalized nature of the seizure. **Attribution:** Image from Wikipedia (https://en.wikipedia.org/wiki/Spike-and-wave), Creative Commons license.