Is it Epilepsy

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					  Is it Epilepsy?
Extra Case 1 (week 3 neuro)
PC
A 45 year old woman presents with new onset seizures and altered
consciousness.

HxPC
Julie was talking to a co-worker when she suddenly stared, turned her head
to the right, began smacking her lips, and then had a generalised tonic-
clonic seizure. The seizure lasted two to three minutes.
Julie does not recall anything immediately prior to or during the event
and was still confused 20 minutes later. Her husband and a co-worker
state that she has not been physically ill recently but over the last two months
has been "having a mid-life crisis".

Julie has NO PMHx, PSHx, current Meds and is NKDA. Family Hx includes
HTN

SHx:
Graphic designer, married with one daughter. Recently decided she wanted
a divorce despite lack of marital conflict. Drinks one glass of wine a day
Q1 Does Julie have epilepsy?
Q1 Does Julie have epilepsy?
Julie has just had a complex partial seizure
  with secondary generalisation (since had
  aura or partial seizure preceded the
  generalized seizure) It is impossible to
  diagnose this episode as part of epilepsy
  yet since this is her first seizure. She is
  also at an age unlikely to develop
  epilepsy. Further investigation is needed!
Q2 What is your differential
 diagnosis? (at least three
       possibilities)
Q2 What is your differential diagnosis? (at least three
                    possibilities)

   TIA
   Infective meningitis / encephalitis
   Psychogenic seizure
   Psychoactive drugs
   Brain tumour
   Epilepsy

All acting as epileptogenic triggers

If Epilepsy
 Partial seizure with secondary generalisation
 Primary generalized tonic – clonic seizure
 Absence seizure associated with generalized tonic - clonic
   seizure
 Q3 What signs will you look for
   on examination, and what
laboratory tests will you order to
        aid in diagnosis?
     Q3 What signs will you look for on examination, and what
        laboratory tests will you order to aid in diagnosis?

O/E
 Obs – (HR, BP, O2sats) – sympathetic overdrive and cyanosis during
  seizure episode
 Temp – infection?
 Lymphadenopathy
 Head trauma – epileptogenic centre or consequence of seizure?
 Organomegaly – storage diseases/ endocrine/ metabolic disease?
 Acute psychosis? MMSE
 CVS exam – risks for cerebrovascular disease
 Neuro exam – signs of increased ICP – blown pupils etc, other focal
  neuro defects. Tests of motor func – pronator drift, tendon reflexes,
  gait, coordination – lesion in motor cortex? And failed double
  simultaneous stimulation may suggest lesion in parietal cortex.
  Unilateral facial droop with contralateral hemiplegia/ hemiparesis
 EEG
 Wet crotch?
 Bitten tongue?
 Any paralysis – still present after a few hours – stroke?
   Q3 What signs will you look for on examination, and what
      laboratory tests will you order to aid in diagnosis?


Investigations
 U+E’s including K, Mg and Ca
 Glucose
 LFT’s
 TFT’s
 Creatinine
 D - dimer
 Alkaline phosphatase
 Drug tox screen
 LP esp in AIDS pts
 MRI > CT for mass lesions, oedema, midline deviation,
  trauma
                             O/E
Afebrile; BP 110/70; HR 76; RR 16

Mental State: initially responds only to simple commands and is
  unable to converse but over the course of your examination
  she improves dramatically and complains of a bifrontal
  headache.

Julie tells you that she had a minor sore throat and possibly a
   low-grade temperature a week ago. She denies having any
   prior headaches or seizures.

When asked about any changes in mood she denies this and says
 that she has not been depressed but feels that she needs to be
 free to pursue her dream of becoming a movie star. She plans
 on divorcing her husband and moving to Los Angeles “to be
 discovered”. She has no training or experience as an actress,
 does not plan on going to acting school and has never
 performed in a play since primary school. She denies any
 hallucinations.
                           O/E
CN II-XII intact

Fundi: no papilloedema. Visual fields NAD

Motor: normal muscle tone and strength bilaterally to testing

Reflexes: 2+ throughout. Babinski signs present bilaterally.

Sensation, Co-ordination & Gait: NAD

Investigations: Bloods NAD

CT scan: poorly circumscribed, hypointense left temporal lobe
  lesion with small foci of haemorrhage and possible early uncal
  herniation, with minimal surrounding oedema.
Q4 What is the most likely
      diagnosis?
               Q4 What is the most likely diagnosis?

Astrocytoma, more specifically a glioblastoma/ glioblastoma
  multiforme creating a mass lesion resulting in uncal herniation
  since these tumours can present commonly with seizures and
  sometimes personality, mood and mental ability changes.
 Haemorrhage suggests aggressive nature (infiltration and
  necrosis), therefore placing provincial diagnosis on GBM (high
  grade IV) over diffuse astrocytoma (grade II) or anaplastic
  astrocytoma (grade III). If endothelial proliferation was
  present, this would rule in GBM
 Location and behavioural Sx suggest Dx of neuronal tumour,
  BUT haemorrhage and Julie’s age don’t add up
 Julie is abit old for embryonal tumours

 Lack of calcification oligodendroglioma less likely

 Location makes ependymoma and meningioma less likely too

 Single lesion make metastatic brain tumour unlikely
Q5 What would be the next step
      in management?
        Q5 What would be the next step in management?


   Treat with anti-epileptics

   Order indicated investigations : MRS, PET
    but NOT LP (unless you don’t like your
    registration – transtentorial herniation
    happens)

   Treat the oedema: IV corticosteroids and
    mannitol
Julie's MRI shows a large,
poorly circumscribed cortical,
left temporal lobe lesion with
areas of haemorrhage and
necrosis. The uncal herniation
is mild with no evidence of
brainstem compression. A
biopsy is taken.
   Q6 What is the most
common primary brain tumour
        in adults?
 Q6 What is the most common primary brain tumour in adults?


Gliomas – High grade infiltrating
  astrocytoma (60 – 80 % of the little
  blighters)
aka ‘the terminator’
Q7 Briefly outline management
      of this condition.
        Q7 Briefly outline management of this condition




   Potato poultice twice daily applied to ear

   53 sessions of chiropractic realignment
ONLY JOKING!
        Q7 Briefly outline management of this condition.

Assuming GBM:
   Biopsy/ Sterostatic biopsy (appropriate management can only
    occure once definitive histological Dx made)
   Preoperative Imaging (determine the functional regions of the
    brain and the location of the lesion in relation to these)
   Surgical Resection as appropriate (Maximal resection whilst
    preserving neurological function)
   Adjunctive Radiotherapy
   Adjunctive Chemotherapy
1.  Temozolomide – oral alkylating agent – 1o
2.  The nitrosurea ‘carmustine – iv alkylating agent – 2o
   Nice things like pt education, support groups etc – most GBM-
    suffers die within a year of diagnosis, even with treatment.
    Less than 2% survive 3 years with the condition.
The End

				
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posted:2/1/2013
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