A Woman Presenting With A Second Episode Of Loss Of Consciousness

A 24-year-old right-handed woman presents to you in the Emergency Department after her second episode of loss of consciousness. The first spell occurred 6 months ago and was associated with a 60 second loss of consciousness and jerking movements of her arms and legs. Following the spell, she was confused for about 15 minutes. At that time, her initial ED evaluation was unremarkable.
She presents today following a spell that occurred about 45 minutes ago. Her friends observed her to fall to the ground and shake her arms and legs for about 2 minutes. They could not get her to respond during this time. Afterward, she was confused and they brought her to the ED. Upon arrival in the ED, she is mildly drowsy but otherwise oriented. She has no memory of the earlier events. Her general medical examination and neurological examination are unremarkable.

Which of these tests would be helpful in determining the etiology of this spell?


Answer: The tests that would be helpful in determining the etiology of the unconsciousness spell include:

• Urine toxicology screen
• Electrolytes. 
• Neuroimaging (head CT or MRI).

Discussion: Evaluation of a first-time seizure should include assessment for alcohol or other drug withdrawal (especially benzodiazepines and barbiturates) as well as drug intoxication (cocaine, methamphetamine, and other sympathomimetics). Infection, including meningitis and encephalitis, can provoke a seizure. Hyponatremia, hypernatremia, hypocalcemia, hypoglycemia, hyperglycemia, hypomagnesemia, hypophosphatemia, and uremia are all associated with seizures. To rule out structural lesions (e.g., tumor and AV malformation) and hemorrhage, neuroimaging should be performed. Although MRI has greater sensitivity, it is often not available in a timely manner, and thus, CT is the modality of choice.

Case Followup :
Evaluation in the ED, including electrolytes, CBC, brain CT scan, and urine toxicology, is unremarkable. An electroencephalogram (EEG) is obtained in the ED and read as normal. The patient is feeling well and does not wish to remain in the hospital. Her friends assure you that they will be with her over the next 24 hours. She returns to your clinic in 2 days.

After reviewing her test results with her, what do you recommend for further management?

Answer:  Video/EEG monitoring.

Discussion: This is this patient’s second seizure. In adults with a first seizure, only 30– 60% will go on to have a second seizure. In patients who have a second seizure, the likelihood of going on to have a third is 80–90%; therefore, after a second unprovoked seizure, treatment is recommended.
Video/EEG monitoring is appropriate for classifying spells of unclear etiology. In order for video/EEG to be an effective tool, the patient should have spells frequently enough to capture them during a reasonable inpatient stay (3 days average).