35 y/o m with no significant medical hx has been a chronic binge drinker since the age of 20. Alcohol intake has increased more through the years (1-2 pints of whiskey 3-4 times/week including minimal beer intake). 3 years ago after a weekend of binging, which included cocaine, he had his first clonic-tonic seizure (that was witnessed). ER doc said it was d/t the cocaine. Since then he had stopped using cocaine but continued to have seizures after binging. It has been 3 years of multiple untreated gran mal, partial and/or focal seizures. It mostly happens a few days after stopping the liquor and/or when sleep deprived.

One evening while driving and NOT drinking, he crashed his car and does not remember any of it. At this point he has stopped drinking. 20 days clean and has had 1-2 focal seizures during sleep. How long does AWS last? Do you think his brain is affected by having so many untreated seizures? Should he get on anti-epilectic meds? If these are provoked seizures will an EEG even be worth it? The family has no history of epilepsy. Will his driving be affected? As a physician, do you have to report to the state if someone has provoked seizures or would this be a HIPA violation? Does taking the recommended dose of Nyquil have any affect on provoking a seizure during withdrawal? Would he have a high risk of reoccurrance?

Thank you for your time and advice.
T

Q: How long does AWS last?

A: acute alcohol withdrawal seizures occur about 24 to 48 hours after the last drink. Delirium tremens (during which the patients may have a flurry of seizures) peaks 72 hours after the last drink. We usually like to put patients on Librium or Ativan (lorazepam) to prevent AWS till we see no signs of autonomic instability (such as variations in blood pressure and heart rate), tremors and so forth.

Q: Do you think his brain is affected by having so many untreated seizures? Should he get on anti-epilectic meds? If these are provoked seizures will an EEG even be worth it?

A: while there is no study which clearly shows that the brain is damaged by seizures permanently (and I do not mean status epilepticus–where in neuronal death does occur unless seizures are controlled quickly), ongoing untreated seizures certainly are not desirable.
Whether he needs to be on long term anti-convulsant is a question that can only be answered after reviewing his history at length and after taking into consideration test results such as EEG and MRI brain.
We are assuming his seizures are provoked. It is also possible that he has an inherent epileptogenicity and the alcohol brings it out. Also during this long history,. he may have fallen and now have a secondary seizure focus in the brain. So yes the EEG is worthwhile.

Q: The family has no history of epilepsy. Will his driving be affected? As a physician, do you have to report to the state if someone has provoked seizures or would this be a HIPA violation?

A: The laws with respect to driving and epilepsy vary from state to state. In the state of NY where I practice, I am NOT mandated by law to report to the DMV (department of motor vehicles) that my patient has a seizure disorder. All I have to do is tell the patient that the law in NY is that ” you have to be seizure free on medications for one year before you can drive”. I do this and I document in the chart that I told the patient about not driving. It is left to the patient’s own good judgement that they shall heed my advise and not drive. In the state of NJ, the physician is mandated by law to report this to the DMV. The duration of time you have to be seizure free before you can drive also varies from state to state. The DMV website or the American Epilepsy Society website are good resources for more information.
Now suppose you come to know the patient is still driving (inspite of your advise). Moreover he is driving a school bus. What do you do then? Hmmm tricky and messy situation. Lives are at stake here. I shall confront (maybe not confront but approach) the patient with this information. If he still continues to drive, my responsibility to the public at large exceeds patient confidentality (HIPAA privacy rules). I can then approach the DMV directly.

Q: Does taking the recommended dose of Nyquil have any affect on provoking a seizure during withdrawal? Would he have a high risk of reoccurrance.

A: many medications can lower seizure threshold. I would double check on all his medications to see if he is taking anything which lowers his seizure threshold. The risk of recurrence can only be determined after a detailed history and taking tests like EEG and MRI brain into consideration.

Hope this helps.

Personal Regards,
Nitin Sethi, MD