A Patient Presenting With Seizures

A 65 year old man presents to your clinic after suffering a seizure. An hour back he developed jerking in his right arm and leg which lasted 5 minutes. He also lost consciousness for a brief period. He has smoked > 40 cigarettes for over 30 years. He is normal on examination.
In this case:

1. What is your provisional diagnosis?
2. What is the most likely underlying cause for the seizure?
3. How will you investigate and manage?

Answers:

1. What is your provisional diagnosis?

Answer: Complex partial seizures ( Complex partial seizures start focally within the brain and cause impairment of consciousness) .

2. What is the most likely underlying cause for the seizure?

Answer: In most patients complex partial seizures is due to underlying temporal lobe epilepsy. The causes may includes:

• A brain tumor involving one lobe.
• hippocampal sclerosis
• focal vascular malformations 
• unknown causes

3. How will you investigate and manage?

Answer: 

Investigations:

Laboratory studies should aim to rule out possible causes and triggers for the seizure. The workup should include:

• Serum electrolyte levels ( including sodium and potassium)
• Serum Calcium and Magnesium.
• If patient is already epileptic and taking anti epileptics serum drug concentrations should be obtained.
• Urine drug screening.
• MRI of the brain to exclude any structural lesion in the brain. 
• EEG ( if done within 24 hrs pf the seizure onset is more sensitive and if any epileptiform discharges are present it helps in localizing the focus of the seizure.

Management: 

• The case should be discussed with the patient and the family.
• Patient should be advised not to drive, climb on heights and stay away from stove and fire. 
• Anticonvulsant medication should be started once the diagnosis of epilepsy is made. 
• Start with a single drug and the choice of antileptic should depend upon the side effects and drug interactions. 
• All current anti epileptic drugs except ethosuximide can be used for complex partial seizures. 
• The dose is adjusted according to the requirement needed for seizure control. 
• Anti convulsion drug monitoring and followup is needed.