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General Data

General Data. DS 65 year old Female Right- handed. Chief Complaint. “Numbness of the left hand”. History of Present Illness. One hour PTA, (+) inward movement and numbness of the left hand (-) blurring of vision, palpitations, tremors, nausea, vomiting, dizziness, sweating

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General Data

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  1. General Data • DS • 65 year old • Female • Right- handed

  2. Chief Complaint • “Numbness of the left hand”

  3. History of Present Illness • One hour PTA, • (+) inward movement and numbness of the left hand • (-) blurring of vision, palpitations, tremors, nausea, vomiting, dizziness, sweating • (+) disorientation and confusion • (+) stiff? • Rapid and incoherent speech

  4. History of Present Illness • At the ER, • Two episodes of generalized tonic- clonic seizures • lasting 1- 2 minutes • stiffening and jerking of the upper and lower extremities • head tilted to the right • eyes rolling upward • tongue biting

  5. History of Present Illness • At the ACSU • throbbing headache located on the top of her head,(6/10) • (+) generalized weakness • (-) urinary incontinence, blurring of vision, nausea or vomiting • (-) memory of what happened

  6. Review of Systems • General: (-) fever, weight loss • HEENT: (-) tinnitus, colds • Respiratory: (-) difficulty of breathing, coughing • Cardiovascular: (-) chest pains, orthopnea, PND • Gastrointestinal: (-) change in bowel movements

  7. Review of Systems • Genitourinary: (-) dysuria, frequency • Endocrine: (-) heat or cold intolerance, excess thirst, excess sweat • Musculoskeletal/ Dermatologic: (+) dermatoses/ trophic skin changes

  8. Past Medical History • Illnesses • Seizure secondary to CVD infarct January 2010 • Angina 2007 • Hypertension • Diabetes mellitus type 2 2000 • (-) Trauma • (-) History of febrile seizures

  9. Past Medical History • Surgeries: None • Hospitalization: January 2010 • Allergies: None

  10. Past Medical History • Ob- gyne • G3P3(3003) • LMP 55 years old • (+) OCP use for 6 months • (-) hormone replacement therapy • (+) preeclampsia: third pregnancy • (+) blood transfusion: third pregnancy

  11. Medications • Compliant with: • Lantus 40 mg SQ OD • Aspirin 75 mg OD • ISMN (Imdur) 60 mg durule • Bisoprolol 10 mg OD • Perindopril 8 mg OD • Atorvastatin 20 mg/ tab OD • Dipyridamole 200 mg/ tab OD

  12. Family Medical History • Diabetes • Hypertension • Breast Cancer • Stroke • Cardiovascular disease

  13. Personal and Social History • Married with three children • Occupation: nurse • Occasional drinker • Non- smoker

  14. Physical Examination

  15. Physical Examination • Awake, not in cardiorespiratory distress • Height: 165 cm • Weight: 80 kg • BMI = 34 • BP = 160/70 • HR = 73 • RR = 14 • T = 36.5OC

  16. Physical Examination • HEENT • Anicteric sclerae; pink palpebral conjunctiva • No nasal congestion • (-) CLAD, (-) TPC, Non- distended neck veins • Respiratory • Symmetric chest expansion • Clear breath sounds

  17. Physical Examination • Cardiovascular • Adynamic precordium • Apex beat at 5th ICS LMCL • Regular rhythm, normal rate • Distinct S1 and S2 • (-) Murmurs • Abdominal • Flabby, soft abdomen • Normoactive bowel sounds • No tenderness

  18. Physical Examination • Extremities • Full and equal pulses (2+) • (-) edema • Good skin turgor • Skin • Normal hair and scalp, nails • Trophic skin changes/ dermatoses • No pallor or jaundice

  19. Physical Examination • Neuro examination at the ER: • Awake, still confused and disoriented, able to follow some verbal commands; GCS 14 • Primary gaze: midline disconjugate gaze, initially oscillopsia on extreme gaze. • CN II- pupils are equally reactive to light 3 mm; CN III, IV, VI- EOMs full and equal; CN V brisk corneal reflex; CN VII no asymmetry or weakness; CNXIII intact; CN IX- X (-) dysarthria, dysphagia; CN XI no weakness; CN XII tongue midline.

  20. Physical Examination • Neuro examination at the ER: • Motor 5/5 on all extremities except for the left upper extremity 4/5. Minimal spasticity on the left. Left arm can lift 30˚. • Sensory intact. • Supple neck • (-) Babinski reflex • (-) hyper, hyporeflexia

  21. Physical Examination • Neurologic : • MMSE: 28/ 30; GCS 15 • Cranial Nerves • I – Not done • II – Pupils 3mm, equally reactive to light; visual fields full to confrontation • III, IV, VI – Full EOM’s • V – Corneal reflex not done, sensory- intact bilaterally in all three divisions for sharp, dull, touch stimuli; motor- temporal and masseter strength intact • VII – No facial weakness and asymmetry • VIII – Gross hearing intact • IX, X – (+) gag reflex

  22. Neurologic : • Cranial Nerves (cont.) • XI- (+) shoulder shrug, head turn, 5/5 • XII – tongue at midline

  23. Physical Examination • Neurologic • Motor • (-) muscle, involuntary movements • 5/5 on all extremities except for left upper extremity (4/5) • Drift on the upper left extremity • DTRs: ++ on bilateral brachioradialis, ankle; (-) Babinski • Somatic • Reactive to touch/pain on all extremities. Temperature sensation intact bilaterally and symmetrically. Position sense intact bilaterally and symmetrically intact except for left upper extremity • Cerebellar • No dysmetria, dysdiadochokinesia (RAMs, finger to nose, heel along shin intact bilaterally) • Supple neck, (-) Brudzinski, Kernig's

  24. Initial Impression • Post stroke seizure • s/p CVD infarct • Right MCA and left sided residuals, mRS 3 • Hypertension Stage II • Diabetes Mellitus Type 2

  25. Differential Diagnoses

  26. Syncope

  27. Transient Ischemic Attack

  28. Neoplastic

  29. Infection

  30. Stroke

  31. Hypoglycemia

  32. Migraine

  33. Head CT Wedge shaped I'll defined hypodense focus is seen in the cortical subcortical region of the right parietal lobe. Underlying gyrus and sulci are effaced. Patchy hypodensities along the periventricular white matter of both frontal and parietal lobes are also noted. The rest of the grey-white matter interface is maintained. Initial Imaging Studies

  34. CT Malacic changes CBC Hgb 138 Hct .42 WBC 8.5 N .72 L .24 M .04 PC 137 PT 12.2 INR 0.89 ALT 27.04 BUN 4.48 Creatinine 99.01 Na 137 K 3.9 Lipid Profile (results to follow) Initial Diagnostics

  35. Initial Management • Phenytoin • Loading dose 1gm • Maintained at 100 mg/cap TID • Admit to ACSU • Cardiac, CBG monitoring • O2 Support, seizure precautions • Diazepam 5 mg IV • Ketorolac 30 mg IV then q8 prn for headache • Continue maintenance medications

  36. Day 1 -3 (Nov 7-9)

  37. Imaging Results • Cranial MRI • Wedge-shaped Right inferior parietal cortical-subcortical encephalomalacia, gliosis and siderosis, presumably sequelae of a previous water-shed type infarction with hemorrhagic conversion • Mild microvascular white matter ischemic changes on the left centrum semiovale • Mild central cerebral volume loss

  38. Imaging Results • MRA: No aneurysm or any significant stenosis or vascular malformations seen • MRV: No evident cortical vein or dural sinus thrombosis

  39. Day 4 (Nov 10)

  40. Diagnostics • ECG: Atrial Fibrillation, RVR • TFT: • TSH 3.01 uIU/mL • FT3 2 pg/mL • FT4 0.83 ng/dL • EEG: abnormal EEG due to a focal theta slowing on the right temporo-parietal occipital region with wave epileptiform discharges on the right temporo-occipital region consistent with a focal cerebral dysfunction and a tendency toward localization-related seizures at the right temporo-occipital region

  41. Day 5-7 (Nov 11-13)

  42. Take Home Medications

  43. Case Discussion

  44. Pathophysiology Video

  45. Epileptogenesis • Transformation of a normal neuronal network into one that is chronically hyperexcitable • Trauma, stroke, or infection • Injury lowers the seizure threshold in the affected region

  46. CVD is the number one cause of epilepsy in the elderly • Oxfordshire Stroke Community Project (OSCP) • 11.5% of patients with stroke are at risk of developing late-onset post-strokeseizures within 5 years • Naess and colleagues • 10.5% developed post-stroke seizure over mean follow up of 5.7 years. • Hart and colleagues • recurrence after a first seizure after stroke of 40% in 12 months

  47. Early Onset Seizure Late Onset Seizure occurs after two weeks of stroke onset peak 6-12 months after stroke associated with the persistent changes in neuronal excitability and gliotic scarring • occurs w/in first two weeks • peak 24 hrs after stroke

  48. Stroke severity Independently associated with the development of seizures after ischemic stroke (HR, 10; 95% CI, 1.16 to 3.82; P<0.02) Seizures and Epilepsy After Ischemic Stroke OsvaldoCamilo and Larry B. Goldstein, 2004 • Cortical location • Best-characterized risk factor for early seizures after ischemic stroke • Significant risk factor in the SASS study (HR, 2.09; 95% CI, 1.19 to 3.68; P<0. 01)

  49. Management • Antiepileptic Drug Therapy • Goal: completely prevent seizures without causing untoward side effects • Treat the underlying conditions • Reverse the problem and prevent its recurrence

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