45 y.o. woman with 45 y.o. woman with head injury and head injury and

seizureseizure

August 2005August 2005

White 10, Team C – Massachusetts General White 10, Team C – Massachusetts General Hospital,Hospital,

Boston – MA, USABoston – MA, USA

Lorenzo AzzaliniLorenzo Azzalini University of Padua University of Padua Medical School, ItalyMedical School, Italy

History of present illnessHistory of present illness 45 y.o. woman45 y.o. woman History of depression, anxiety, HTN, head History of depression, anxiety, HTN, head

trauma and distant seizures in the pasttrauma and distant seizures in the past Presenting with lost of consciousness (LOC)Presenting with lost of consciousness (LOC) She was feeling alright in the last few days, She was feeling alright in the last few days,

except for the fact that she was urinating except for the fact that she was urinating more than her normal habits.more than her normal habits.

One day prior to admission, she drank a One day prior to admission, she drank a couple of cups of coffee. When she was in her couple of cups of coffee. When she was in her friend’s car, seated on the passenger seat, friend’s car, seated on the passenger seat, gradually began experiencing:gradually began experiencing: Visual changes, then loss of visionVisual changes, then loss of vision SOBSOB NauseaNausea Sensation of a strange smell.Sensation of a strange smell.

History of present illnessHistory of present illness Then – as her friend reported – she lost Then – as her friend reported – she lost

consciousness and had tonic-clonic consciousness and had tonic-clonic movements in her extremities and her movements in her extremities and her mouth was foamy.mouth was foamy.

No fecal or urinary incontinenceNo fecal or urinary incontinence She did bite her lips and had headache She did bite her lips and had headache

and neck pain after the LOC, which lasted and neck pain after the LOC, which lasted 3-5 minutes.3-5 minutes.

During the episode, the patient did not During the episode, the patient did not have any trauma.have any trauma.

History of present illnessHistory of present illness The patient’s friend drove her to the ED of The patient’s friend drove her to the ED of

MGH, where she stayed for 23 hours.MGH, where she stayed for 23 hours. She was tapped and given Vancomycin She was tapped and given Vancomycin

and Ceftriaxone for presumptive and Ceftriaxone for presumptive treatment, but later CSF analysis revealed treatment, but later CSF analysis revealed normal TP, Glucose and WBC.normal TP, Glucose and WBC.

The patient experienced fever up to 101.3, The patient experienced fever up to 101.3, chills, headache and diaphoresis. She was chills, headache and diaphoresis. She was given Tylenol. She also received her home given Tylenol. She also received her home medications (alprazolam, fluoxetine, medications (alprazolam, fluoxetine, triamterene-hydrochlorothiazide).triamterene-hydrochlorothiazide).

Cardiac enzymes and CXR were normal.Cardiac enzymes and CXR were normal.

Review of systemsReview of systems As per HPI.As per HPI. Pertinent ROS: upon arrival on the floor, Pertinent ROS: upon arrival on the floor,

lack of photophobia and headachelack of photophobia and headache No fever, chills, nausea, vomiting, chest No fever, chills, nausea, vomiting, chest

pains, palpitations, hematochezia, melena.pains, palpitations, hematochezia, melena. No alterations of mental status.No alterations of mental status. No slurring of speech or unilateral No slurring of speech or unilateral

weakness.weakness. No dysuria.No dysuria. No exposures/ingestions/recent travel.No exposures/ingestions/recent travel.

Past medical historyPast medical history

Depression and anxietyDepression and anxiety – Onset after her – Onset after her child’s death, four years ago.child’s death, four years ago.

Occasional headachesOccasional headaches – Rarely, after – Rarely, after sinusitis.sinusitis.

HypertensionHypertension Head traumaHead trauma – Twenty years ago she had a – Twenty years ago she had a

car accident, with consequent head trauma. car accident, with consequent head trauma. Since then, she had “less than ten seizures of Since then, she had “less than ten seizures of grand mal”. She used to take Tegretol grand mal”. She used to take Tegretol (Carbamazepine), but stopped four years ago, (Carbamazepine), but stopped four years ago, after her child’s death.after her child’s death.

Medications on Medications on admissionadmission

Xanax (ALPRAZOLAM) 1 mg PO Xanax (ALPRAZOLAM) 1 mg PO BID for anxietyBID for anxiety

Prozac (FLUOXETINE) 40 mg PO Prozac (FLUOXETINE) 40 mg PO BID for depressionBID for depression

TRIAMTERENE 37.5 mg + TRIAMTERENE 37.5 mg + HYDROCHLOROTHIAZIDE 25 mg HYDROCHLOROTHIAZIDE 25 mg PO QPM for HTNPO QPM for HTN

AllergiesAllergies – Dilantin (PHENYTOIN) – Dilantin (PHENYTOIN) itchingitching

Social historySocial history – She had two children; one – She had two children; one died in car accident. Lives with her other died in car accident. Lives with her other child. Not married. Unemployed. Denies child. Not married. Unemployed. Denies alcohol and IV drugs abuse. Used to smoke alcohol and IV drugs abuse. Used to smoke 1 pack/day, but quit 20 years ago.1 pack/day, but quit 20 years ago.

Familial historyFamilial history – Father died from a – Father died from a “post-operative infection”, at 60; had “post-operative infection”, at 60; had history of CAD and DM. Mother died history of CAD and DM. Mother died “probably from heart attack”, at 65; had “probably from heart attack”, at 65; had history of seizures.history of seizures.

Physical examPhysical exam

Vital signs – T 98.6, HR 75, BP 119/80, RR Vital signs – T 98.6, HR 75, BP 119/80, RR 18, SatO18, SatO22 97% RA 97% RA

General – the patient appears in her stated General – the patient appears in her stated age and is in non-apparent distressage and is in non-apparent distress

HEENT – NC, AT, PERRL, EOMI, sclera HEENT – NC, AT, PERRL, EOMI, sclera anictericanicteric

Neck – supple, no thyromegaly, no carotid Neck – supple, no thyromegaly, no carotid bruits, JVP not appreciablebruits, JVP not appreciable

Nodes – no cervical or supraclavicular LADNodes – no cervical or supraclavicular LAD CV – RRR, S1 & S2 nl, no m/r/g, no S3, S4CV – RRR, S1 & S2 nl, no m/r/g, no S3, S4

Physical examPhysical exam

Chest – CTABChest – CTAB Abdomen - +BS, NT, ND. No HSM. No Abdomen - +BS, NT, ND. No HSM. No

peritoneal signs.peritoneal signs. Ext – no C/C/EExt – no C/C/E Skin – no rashesSkin – no rashes Neuro – A&Ox3; CN II-XII intact, Neuro – A&Ox3; CN II-XII intact,

Romberg –ve, normal reflexes, Romberg –ve, normal reflexes, strength 5/5 throughout, sensation strength 5/5 throughout, sensation intact throughoutintact throughout

Labs and studiesLabs and studies

BloodBlood

NaNa++ 136136 (135-145)(135-145) mmol/lmmol/l

KK++ 3.2 (L)3.2 (L) (3.4-4.8)(3.4-4.8) mmol/lmmol/l

ClCl-- 105105 (100-108)(100-108) mmol/lmmol/l

COCO22 25.325.3 (23.0-(23.0-31.9)31.9)

mmol/lmmol/l

CaCa2+2+ 9.39.3 (8.5-10.5)(8.5-10.5) mg/dlmg/dl

POPO443-3- 1.1 (L)1.1 (L) (2.6-4.5)(2.6-4.5) mg/dlmg/dl

MgMg2+2+ 1.81.8 (1.4-2.0)(1.4-2.0) mEq/lmEq/l

Labs and studiesLabs and studies

BloodBlood

BUNBUN 1717 (8-25)(8-25) mg/dlmg/dl

CreatinineCreatinine 0.80.8 (0.6-1.5)(0.6-1.5) mg/dlmg/dl

GlucoseGlucose 105105 (70-110)(70-110) mg/dlmg/dl

Total Total proteinsproteins

7.57.5 (6.0-8.3)(6.0-8.3) g/dlg/dl

AlbuminAlbumin 4.14.1 (3.3-5.0)(3.3-5.0) g/dlg/dl

Total Total bilirubinbilirubin

0.20.2 (0-1.0)(0-1.0) mg/dlmg/dl

Direct Direct bilirubinbilirubin

0.10.1 (0-0.4)(0-0.4) mg/dlmg/dl

Labs and studiesLabs and studies

BloodBlood

ASTAST 2525 (9-32)(9-32) U/lU/l

ALTALT 34 (H)34 (H) (7-30)(7-30) U/lU/l

ALPALP 8383 (30-100)(30-100) U/lU/l

CK-MBCK-MB NegativNegativee

NegativeNegative

Troponin-ITroponin-I NegativNegativee

NegativeNegative

TSH 2.402.40 0.50-5.000.50-5.00 U/mlU/ml

Labs and studiesLabs and studies

BloodBlood

RBCRBC 4.084.08 (4.00-(4.00-5.20)5.20)

·10·1099/mm/mm33

HCTHCT 37.937.9 (36.0-(36.0-46.0)46.0)

%%

HgbHgb 12.912.9 (12.0-(12.0-16.0)16.0)

g/dlg/dl

MCVMCV 9393 (80-100)(80-100) flfl

MCHMCH 31.631.6 (26.0-(26.0-34.0)34.0)

pgpg

MCHCMCHC 34.134.1 (31.0-(31.0-37.0)37.0)

g/dlg/dl

RDWRDW 14.6 (H)14.6 (H) (11.5-(11.5-14.5)14.5)

%%

Labs and studiesLabs and studies

BloodBlood

WBCWBC 9.79.7 (4.5-11.0)(4.5-11.0) ·10·1033/mm/mm33

PLTPLT 365 (H)365 (H) (150-350)(150-350) ·10·1033/mm/mm33

PTPT 12.212.2 (11.3-(11.3-13.3)13.3)

ss

APTTAPTT 21.2 (L)21.2 (L) (22.1-(22.1-35.1)35.1)

ss

Labs and studiesLabs and studies

CSFCSFGlucose 6161 (50-75)(50-75) mg/dl

Total protein

4343 (5-55)(5-55) mg/dl

WBCWBC NoneNone (0-5)(0-5) /mm/mm33

ColorColor ColorlesColorlesss

ColorlessColorless

TurbidityTurbidity ClearClear ClearClear

Labs and studiesLabs and studies

UrineUrine

Specific Specific gravitygravity

1.0251.025 (1.001-(1.001-1.035)1.035)

kg/l

pHpH 5.05.0 (5.0-9.0)(5.0-9.0)

WBCWBC 50-10050-100 (0-2)(0-2) /hpf/hpf

RBC 0-20-2 (0-2)(0-2) /hpf/hpf

NitritesNitrites NegativNegativee

NegativeNegative

AlbuminAlbumin 2+2+ NegativeNegative

GlucoseGlucose NegativNegativee

NegativeNegative

BacteriaBacteria FewFew NegativeNegative

ChesChestt

X-X-RayRay

ECGECG

84 BPM. NSR.84 BPM. NSR. Normal axis.Normal axis. QT borderline interval at 474 ms QT borderline interval at 474 ms

corrected.corrected. Good R wave progression.Good R wave progression. No ST or T wave changes.No ST or T wave changes.

Seizures – differential Seizures – differential diagnosisdiagnosis

•Head trauma recent or remote head trauma that is sufficient to produce LOC, prolonged amnesia, depressed skull fracture, dural tear, intracranial hemorrhage, or focal neurologic deficit is associated with a high risk of later development of epileptic seizures.

•Infections bacterial/fungal/viral meningitis/encephalitis, cerebral abscess, parasitic infestations.

•Drugs psychotropic agents, isoniazid, penicillin, lidocaine, clozapine, teophylline, chemotherapeutic agents, drugs of abuse. benzodiazepines, alcohol and barbiturates withdrawal.

•Malignancies seizures are due to metastasis (lung, breast, kidney, GI, melanoma) or primary brain tumor.

Seizures – differential Seizures – differential diagnosisdiagnosis

•Stroke common cause of seizures in the elderly.

•Metabolic or toxic disorders hypoglycemia, hypocalcemia, hyponatremia, hypomagnesemia, hypophosphatemia, uremia, severe alkalosis/acidosis, hepatic failure, hyperkalemia.

•Neurodegenerative disorders Alzheimer’s disease.

•Psychogenic seizures conversion disorder, psychogenic seizures.

•Other causes mesial temporal sclerosis, SLE, acute intermittent porphyria, Whipple’s disease, sickle cell anemia, sarcoidosis, neurofibromatosis.

Seizures – WorkupSeizures – Workup

•Serum glucose and electrolytes r/o hypoglycemia, hypocalcemia, hyponatremia, hyperosmolar states.

•Renal profile and creatine phosphokinase r/o ARF/CRF, rhabdomyolysis.

•Drug screen r/o use of cocaine, amphetamines, phencyclidine, barbiturates, benzodiazepines, alcohol, methanol, ethylene glycol.

•Complete blood count with differential r/o infection. However, a post-ictal leukocytosis is common after tonic-clonic seizures.

•Arterial blood gas analysis r/o hypoxemia, acidosis or severe alkalosis.

•Levels of prescribed anticonvulsivants r/o subtherapeutic anticonvulsivants levels.

Seizures – WorkupSeizures – Workup

•CT or MRI brain scan CT in emergency, MRI later if CT is not useful in determining the etiology of the seizure.

•Lumbar puncture r/o meningitis, encephalitis, subarachnoid hemorrhage, meningeal carcinomatosis.

•Chest X-ray and ECG r/o aspiration pneumonia, non-cardiogenic pulmonary edema, MI as complications of the epileptic seizure.

•EEG not necessary in an emergency procedure. Can be used to classify epileptic seizures.

On further testingOn further testing

Brain CT was negative for masses, Brain CT was negative for masses, hemorrhage or stroke.hemorrhage or stroke.

For a better evaluation for the For a better evaluation for the presence of a seizure focus, we presence of a seizure focus, we ordered a seizure-protocol brain ordered a seizure-protocol brain MRI.MRI.

We also ordered an EEG and a We also ordered an EEG and a neurology consult.neurology consult.

Brain Brain CTCT

Brain CTBrain CT

1. A nonspecific punctate hyperdensity is noted in the left middle frontal lobe. The differential diagnosis would include a tiny calcification versus a vessel or less likely a punctate area of hemorrhage.

2. Focal hypodensity is noted adjacent to the anterior horn of the left lateral ventricle which most likely represents microangiopathic disease in a patient of this age. No evidence of acute territorial infarct is identified.

3. No definite seizure focus is identified; however, a non-contrast CT does not adequately evaluate for the presence of a seizure focus. If this is of clinical concern, a seizure protocol MRI would be recommended.

BraiBrain n

MRIMRI

Brain MRIBrain MRI

1. Non-specific periventricular T2 1. Non-specific periventricular T2 signal abnormalities which may signal abnormalities which may represent chronic microangiopathic represent chronic microangiopathic disease, migraine headaches, disease, migraine headaches, demyelinating disease, Lyme disease, demyelinating disease, Lyme disease, or vasculitis.or vasculitis.

2. No seizure focus identified.2. No seizure focus identified.

EEGEEG

Normal EEG remarkable for the Normal EEG remarkable for the presence of generalized beta-range presence of generalized beta-range activities, likely related to activities, likely related to benzodiazepine intake. No epileptiform benzodiazepine intake. No epileptiform activity was present.activity was present.

““Increased beta activity is frequently Increased beta activity is frequently due to a sedative drug or any centrally due to a sedative drug or any centrally active compound, including most active compound, including most depressants, neuroleptics, depressants, neuroleptics, benzodiazepines, or even alcohol and benzodiazepines, or even alcohol and "illicit" substance.” (UpToDate)"illicit" substance.” (UpToDate)

Assessment and planAssessment and plan This is a 45 y.o. woman with a This is a 45 y.o. woman with a

history of depression, anxiety, history of depression, anxiety, distant seizures in the past, head distant seizures in the past, head trauma, presenting with seizure trauma, presenting with seizure (reported as tonic-clonic) in a (reported as tonic-clonic) in a context of UTI and caffeine intake. context of UTI and caffeine intake. However, also benzodiazepine However, also benzodiazepine withdrawal and history of head withdrawal and history of head trauma might be causes or co-trauma might be causes or co-factors.factors.

Assessment and planAssessment and plan

1)1) SeizureSeizurea.a. Brain CT: assess if there are any masses Brain CT: assess if there are any masses

or other lesions (stroke, hemorrhage). or other lesions (stroke, hemorrhage). Given Mucomyst (Acetylcysteine) 20% 600 Given Mucomyst (Acetylcysteine) 20% 600 mg PO BID x 4 doses for prophilaxis mg PO BID x 4 doses for prophilaxis against contrast-induced ARF.against contrast-induced ARF.

b.b. Brain MRI for further imagingBrain MRI for further imaging

c.c. Carbamazepine 200 mg PO TIDCarbamazepine 200 mg PO TID

d.d. EEGEEG

e.e. Neurology consultNeurology consult

Assessment and planAssessment and plan

2)2) UTIUTIa.a. Bactrim DS 1 tablet x 3 days PO BIDBactrim DS 1 tablet x 3 days PO BIDb.b. Urine culture and urinalysis to monitor Urine culture and urinalysis to monitor

treatmenttreatment

3)3) Depression and anxietyDepression and anxiety Continue Fluoxetine and AlprazolamContinue Fluoxetine and Alprazolam

4)4) HypertensionHypertension Continue Hydrochlorothiazide-TriamtereneContinue Hydrochlorothiazide-Triamterene

Assessment and planAssessment and plan

5)5) DispositionsDispositionsa.a. To home when seizure work-up is To home when seizure work-up is

completedcompleted

b.b. Driving precautions (Massachusetts’ Driving precautions (Massachusetts’ federal law prohibits driving within 6 federal law prohibits driving within 6 months since last seizure)months since last seizure)

c.c. Neurology follow-up in 4-6 weeks.Neurology follow-up in 4-6 weeks.