# Clinical Cases: Epilepsy and Seizures

## 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:**
1. Supportive care, position of safety during post-ictal phase
2. Thiamine 100 mg IV, folate, multivitamin (given alcohol use)
3. Monitor for additional seizures or withdrawal symptoms
4. Benzodiazepine PRN for CIWA protocol

**Disposition:**
1. Observation for 24 hours
2. If no further seizures, discharge with education

**Antiepileptic Medication:**
1. **NOT routinely indicated** for first provoked seizure
2. Recurrence risk lower when clear provoking factor identified and eliminated
3. Would start AED if: second unprovoked seizure, EEG shows epileptiform activity, structural lesion on MRI

**Counseling:**
1. Avoid alcohol and sleep deprivation
2. Driving restrictions per state law (typically 3-6 months seizure-free)
3. Water safety precautions (no unsupervised swimming/bathing)
4. Return precautions: if recurrent seizure, seek evaluation

### Clinical Image
![EEG Generalized Spike-Wave](case_01_image.jpg)

**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

---

## Case 2: Focal Epilepsy with Secondary Generalization

### Patient Demographics
- **Age:** 45 years
- **Sex:** Female
- **Occupation:** Accountant

### Chief Complaint
"My right arm starts jerking, then I lose consciousness."

### History of Present Illness
The patient has experienced recurrent episodes over the past 6 months. Each episode begins with a strange "rising" sensation in her stomach, followed by an unusual smell (described as "burning rubber"). She then notices her right arm begins jerking rhythmically while maintaining awareness. If she cannot suppress it, the jerking spreads to involve the whole right side, then she loses consciousness and has a generalized convulsion. Episodes last 2-3 minutes total. She has no memory of the generalized phase. Afterward, she has difficulty speaking for 30-60 minutes (post-ictal aphasia). She had a severe head injury (motor vehicle accident) 10 years ago with prolonged unconsciousness. No recent illness, medication changes, or substance use.

### Neurological Examination Findings (Interictal)

**Mental Status:**
- Alert, oriented, fluent speech
- Normal cognition

**Cranial Nerves:**
- Intact II-XII

**Motor Examination:**
- 5/5 strength throughout
- Normal tone

**Sensory Examination:**
- Intact to all modalities

**Reflexes:**
- 2+ symmetric
- Plantar responses flexor

**Coordination:**
- Normal finger-to-nose and heel-to-shin
- Normal gait

### Seizure Classification
**Focal onset seizure with retained awareness (aura)** → **Focal motor seizure** → **Focal to bilateral tonic-clonic seizure**
- Aura (epigastric rising, olfactory hallucination) = temporal lobe origin
- Focal motor (right arm jerking) = left motor cortex spread
- Secondary generalization

### Neuro Workup
- **MRI Brain with epilepsy protocol:**
  - Left temporal lobe encephalomalacia (post-traumatic)
  - Left hippocampal sclerosis with volume loss and increased T2 signal
- **EEG (routine):** Left temporal intermittent rhythmic delta activity (TIRDA), left temporal sharp waves
- **Video-EEG monitoring (5 days):** Captured 3 seizures, all with left temporal onset (F7/T3)
- **PET scan:** Left temporal hypometabolism (interictal)

### Diagnosis
**Left temporal lobe epilepsy** secondary to post-traumatic encephalomalacia and mesial temporal sclerosis
- Drug-resistant epilepsy (failed 2+ appropriately chosen AEDs)

### Management

**Antiepileptic Drug Therapy:**
1. Current: Levetiracetam 1500 mg BID, carbamazepine 400 mg BID
2. Prior trials: Phenytoin (allergic), lamotrigine (breakthrough seizures)
3. Addition of third drug considered (lacosamide, brivaracetam)

**Epilepsy Surgery Evaluation:**
1. Patient is a **surgical candidate** - focal, drug-resistant epilepsy with concordant data
2. Concordance: Semiology (left temporal), MRI (left MTS), EEG (left temporal), PET (left temporal hypometabolism)
3. Neuropsychology: Left temporal memory deficits, good right temporal function
4. Wada test: Right hemisphere language and memory dominant
5. **Recommendation:** Left anterior temporal lobectomy with amygdalohippocampectomy
6. Expected outcome: 60-80% seizure-free rate

**Counseling:**
1. Driving restrictions until 6-12 months seizure-free (state-dependent)
2. Medication adherence
3. Avoid seizure triggers (sleep deprivation, alcohol)
4. SUDEP risk counseling
5. Reproductive counseling (teratogenicity of AEDs)

### Clinical Image
![Mesial Temporal Sclerosis](case_02_image.jpg)

**Image Description:** Coronal T2-weighted MRI showing left mesial temporal sclerosis with hippocampal atrophy and increased signal intensity compared to the right hippocampus.

**Attribution:** Image from Radiopaedia.org, Case courtesy of Dr. David Cuete. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/mesial-temporal-sclerosis-3

---

## Case 3: Status Epilepticus

### Patient Demographics
- **Age:** 58 years
- **Sex:** Male
- **Occupation:** Bus driver (not currently working due to epilepsy)

### Chief Complaint
EMS: "Continuous seizure activity for 15 minutes, still seizing."

### History of Present Illness
The patient has a known history of epilepsy (focal to bilateral tonic-clonic seizures) for 20 years, on levetiracetam and phenytoin. His wife reports he ran out of phenytoin 3 days ago and was unable to refill due to insurance issues. This morning, she witnessed him have a seizure that has not stopped. EMS administered lorazepam 4 mg IV en route without improvement. On arrival to ED, he is still having rhythmic bilateral clonic movements, now 25 minutes since seizure onset.

### Neurological Examination Findings

**During Status Epilepticus:**
- Unresponsive to verbal or painful stimuli
- Continuous bilateral rhythmic clonic jerking of extremities
- Eyes deviated upward
- Cyanotic, tachycardic (HR 130), BP 180/100
- Incontinent
- O2 sat 88% on room air

**After Seizure Termination (40 minutes):**
- GCS 10 (E2 V3 M5)
- Post-ictal state
- Pupils 5 mm, reactive
- No focal deficits appreciated

### Status Epilepticus Definition
**Convulsive Status Epilepticus (CSE):**
- Continuous seizure activity ≥5 minutes, OR
- ≥2 discrete seizures without return to baseline between
- This patient: 25+ minutes of continuous convulsive activity = **Established Status Epilepticus**

### Neuro Workup
- **Labs:**
  - Glucose: 165 mg/dL
  - Sodium: 136, Potassium: 3.2
  - Calcium: 8.8, Magnesium: 1.7
  - Phenytoin level: <2 mcg/mL (subtherapeutic; goal 10-20)
  - Levetiracetam level: 18 mcg/mL (therapeutic)
  - Lactate: 6.2 (elevated from seizure)
  - ABG: pH 7.22, pCO2 50, pO2 65 (respiratory and metabolic acidosis)
  - CBC, ammonia: Normal
  - Urine drug screen: Negative
- **CT Head:** No acute findings, known left frontal encephalomalacia
- **Continuous EEG:** Electrographic seizure activity confirmed; later shows postictal suppression

### Diagnosis
**Established convulsive status epilepticus** secondary to AED non-compliance (phenytoin withdrawal)

### Management

**Initial Stabilization (0-5 minutes):**
1. Secure airway - bag-mask ventilation, prepare for intubation
2. IV access x2, cardiac monitoring
3. Finger-stick glucose - treat if hypoglycemic (not applicable here)
4. Thiamine 100 mg IV (empiric)

**First-Line Treatment (5-10 minutes):**
1. Lorazepam 4 mg IV (given by EMS) - can repeat once
2. Or: Midazolam 10 mg IM if no IV access
3. Or: Diazepam 10 mg IV

**Second-Line Treatment (10-30 minutes):**
1. Fosphenytoin 20 mg PE/kg IV (loading dose) given - seizure terminated
2. Alternatives: Levetiracetam 60 mg/kg IV, valproate 40 mg/kg IV, or phenobarbital 15 mg/kg IV
3. If seizure recurs, give additional 5-10 mg PE/kg fosphenytoin

**Refractory Status (>30 minutes - would have occurred if second-line failed):**
1. Intubation and mechanical ventilation
2. Continuous infusion of: Midazolam 0.2 mg/kg bolus, then 0.1-2 mg/kg/hr; or Propofol 2 mg/kg bolus, then 30-200 mcg/kg/min; or Pentobarbital 5-15 mg/kg bolus, then 0.5-5 mg/kg/hr
3. Goal: EEG burst-suppression for 24-48 hours

**Post-SE Management:**
1. Phenytoin maintenance dose resumed
2. ICU admission for monitoring
3. Continuous EEG for 24 hours to monitor for non-convulsive status
4. Address barriers to medication access
5. Social work consult for medication assistance program

**Complications to Monitor:**
1. Aspiration pneumonia
2. Rhabdomyolysis (check CK)
3. Neurogenic pulmonary edema
4. Cardiac arrhythmias
5. Neuronal injury from prolonged seizure

### Clinical Image
![Status Epilepticus EEG](case_03_image.jpg)

**Image Description:** Continuous EEG recording showing generalized rhythmic ictal activity consistent with electrographic status epilepticus.

**Attribution:** Image from Wikipedia Commons, public domain. Source: https://commons.wikimedia.org/wiki/File:Status_epilepticus_EEG.png