Case Presentation: Neurology
Case Presentation: Neurology
• NEUROLOGY
CASE
• Right handed, chemistry teacher from Cebu
• Patient had upward rolling of eyeballs, frothing of saliva, and loss of consciousness. The
attack lasted for 5 minutes. On waking up, he could not reminisce what happened and there
was confusion. These events were narrated by his wife.
• Two weeks ago while taking a nap in the faculty room, he had jerking of the right side of the
body then the rigid spasms of the left side lasting for minutes. These happened 3x, again he
could not remember. His co teachers claimed he seemed dazed after the events, looks sleepy
and weak.
• VITAL SIGNS: Weight =80 kilos BP=160/120 (Hypertensive) HR= 100
RR= 40 (tachypnea)
• PHYSICAL EXAM: Skin: warm with scars on the legs and arms • HEENT:
Conjunctival hemorrhage, slightly yellow sclera • Chest and lungs: decrease
breath sound on the left upper chest but equal chest expansion • CVS: No
murmur, regular rate and rhythm. Pulses are good and bouncing •
Abdomen: Globular hepatic edge more than 3cm, Normoactive Bowel
Sounds. No palpable masses, Not tender nor rigid GUT: negative kidney
punch, No other abnormalities EXT: pulses ok
NEUROLOGY EXAM
• b) Nonepileptic seizures are behavioral events that resemble epileptic seizures but
are not caused by abnormal, hypersynchronous neuronal discharges in the brain.
The term “pseudoseizure” is discouraged, since the events themselves are real and
disabling. Nonepileptic events can be caused by psychological disorders, or they
can be manifestations of other pathological or physiological neurological
conditions.
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res affect both sides of the brain.-Absence seizures, sometimes called petit mal seizures, can
f staring into space.-Tonic-clonic seizures, also called grand mal seizures, can make a person
c. Fall to the ground d. Have muscle jerks or spasms The person may feel tired after a tonic-c
located in just one area of the brain. These seizures are also called partial seizures.- Simple f
ain. These seizures can cause twitching or a change in sensation, such as a strange taste or sm
person with epilepsy confused or dazed. The person will be unable to respond to questions o
ndary generalized seizures begin in one part of the brain, but then spread to both sides of the
n first has a focal seizure, followed by a generalized seizure. Seizures may last as long as a few
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e occurrence of jerky movements and other features of a fit- do not need any treatment with a
surgery
ed as two or more than two unprovoked seizure occurring in an individual- Anti - epileptic dru
responding patients might need surgery
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netic influence- head trauma- brain conditions- infectious disease- prenatal injury- developm
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ften recommended after a seizure: neuroimaging evaluation (eg, brain magnetic resonance imaging [M
canning) and electroencephalography (EEG). For neuroimaging, a CT scan is often obtained in the eme
ructural lesion, but an MRI is indicated if the patient continues to have seizures. In addition, lumbar pu
tion has a role in the patient with obtundation or in patients in whom meningitis, encephalitis, or subara
suspected.
eptic seizures have many causes, and some epileptic syndromes have specific histopathologic abnorma
y, such as brain magnetic resonance imaging (MRI) or head computed tomography (CT) scanning,
ould be the cause of a seizure. If the patient has normal findings on neurologic examination and his
urns to the usual baseline level between seizures, the preferred study is a brain MRI because of its r
depict subtle abnormalities.
study provides the same quality of information. Studies obtained with 3.0 Tesla (T) scanners may s
1.5 T scanners or the "open-sided" scanners of 0.5 T. Brain MRIs obtained for epilepsy should have
E) or fluid attenuation inversion recovery (FLAIR) sequences from the presumed region of epilept
useful for assessing cortical lesions, which may be amenable to potentially curative surgery.
There are many new advances in MRI sequences to help in epilepsy presurgical evaluation
Electroencephalography and Video-Electroencephalography
Interictal epileptiform discharges or focal abnormalities on electroencephalography (EEG) strengthen the
diagnosis of epileptic seizures and provide some help in determining the prognosis. Although the criterion
standard for diagnosis and classification of epileptic seizures includes the interpretation of EEG, the clinical
history remains the cornerstone for the diagnosis of epileptic seizures.
Video-EEG monitoring is the criterion standard for classifying the type of seizure or syndrome or for
diagnosing pseudoseizures; that is, for establishing a definitive diagnosis of spells with impairment of
consciousness. This study can be performed to rule out an epileptic etiology with a high degree of
confidence if the patient has demonstrable impairment of consciousness during the spell in question. Video-
EEG is also used to characterize the type of seizure and epileptic syndrome to optimize pharmacologic
treatment and for presurgical workup.
However, video-EEG monitoring is an expensive and laborious study; therefore, monitoring all patients is
impractical. Only those whose condition does not respond to treatment or in whom pseudoseizures are
suspected should undergo video-EEG. Referral to an epilepsy center should be reserved for patients whose
seizures are refractory to treatment. There is now a formal definition of patients who have medically
refractory epilepsy: individuals who have tried 2 adequate doses of AED without a clinical response. Some
frontal-lobe seizures are considered pseudoseizures for many years until appropriate diagnosis is made by
means of video-EEG.
Differential Diagnosis
• TREATMENT:
• The mainstay of seizure treatment is anticonvulsant medication. The drug of choice depends on an accurate
diagnosis of the epileptic syndrome, as response to specific anticonvulsants varies among different syndromes. The
difference in response probably reflects the different pathophysiologic mechanisms in the various types of seizure
and the specific epileptic syndromes.
• Some anticonvulsants (eg, lamotrigine, topiramate, valproic acid, zonisamide) have multiple mechanisms of action,
and some (eg, phenytoin, carbamazepine, ethosuximide) have only 1 known mechanism of action. Anticonvulsants
can be divided into large groups based on their mechanisms, as follows: