A father from the Netherlands recently wrote to me about his son. I thank him for his question. He asked me a few very specific questions. I am reproducing them here as I feel it shall aid other people. My response to his questions follows. Names have been removed to maintain privacy.
QUESTION:
My son is diabetic type 1, since his 5th year. And he had several seizures in the last 5 years. Mostly once a year, every time he had a hypoglycaemia.
The last time he had a epileptic seizure, with a fracture of thoracic vertebra 2. I have made a MRI scan of the brains, but everything seems normal.
Are there other investigations necessary to be sure it is an epileptic insult due to hypoglycaemia, instead of real epilepsy
HK
ANSWER:
Dear HK,
thank you for writing in to me. If I get you right you are saying that all of your son’s seizures have occured in the setting of hypoglycemia. Do you by any change recall what was his blood sugar during these ictal episodes. For a seizure to occur due to hypoglycemia, the blood sugar has to usually fall down to an extremely low level (we call this neurohypoglycemia). As you are aware the brain needs sugar for energy and its metabolism so when blood sugar falls down to the range of 60 mg/dl or less, that is when a seizure occurs. The seizure in the setting of hypoglycemia is usually a generalized convulsion. That said I and many other physicians have seen patients presenting to the ER with focal findings suggestive of a stroke only to find them completely reverse once the blood sugar was corrected.
I do have a few practical suggestions for you:
–have a home blood glucose meter and check your son’s blood sugar at various times during the day such as in the early morning when he wakes up (fasting blood sugar), prior and after lunch (post prandial blood sugar) and finally before he heads to bed during the night. Do this for about 2 weeks and keep a record of the values in a notebook. This shall prove to be tremendously helpful to you as a parent and his physician to see how his blood sugar fluctuates during the day. Are there times when his blood sugar falls down/ bottoms out unexpectedly.
–a seizure due to hypoglycemia is rapidly reversible and in fact can be aborted with intravenous dextrose solution. Now it may be hard to administer intravenous dextrose at home.
–another very important point which comes to mind is why is he having so frequent hypoglycemic episodes. This shall require a thorough review by his endocrinologist. His insulin dose may need to be adjusted and/or he may warrant frequent small meals during the day to prevent his sugar from suddenly dropping.
–now to your final question: does your son actually have underlying epilepsy per-se. The answer to that depends upon this:
-has he ever had a seizure in the setting of normal glucose level?
-an EEG study shall be extremely useful. If the electroencephalogram shows inter-ictal epileptiform activity then likely your son does suffer from epilepsy. Remember in patients with seizures due to hypoglycemia per-se, the EEG between the seizures should be normal.
-a routine EEG (30 minutes study) can fail to reveal an answer. In that case a long term EEG monitoring study (24-72 hours either in the hospital or in an outpatient setting) may aid in characterization of his typical events.
-as you may have guessed right, patients with seizures due to hypoglycemia per se do not need to be on anti-convulsant therapy. In these patients what we need to ensure that they do not become hypoglycemic. No hypoglycemia means no seizures. On the other hand if your son does have underlying epilepsy, he shall warrant anti-convulsant therapy.
-also a neuroimaging study (ideally MRI of the brain) may he helpful to rule out any intracerebral structural cause of seizure.
I hope you find this information helpful. Please feel free to contact me again.
Personal Regards,
Nitin Sethi, MD
Braindisease's Weblog 
Dear Suresh,
thank you for writing in to me. Unfortunately you have given me very little medical information concering your father. From what you describe it seems he is mute and stiff (we call this spasticity). The question that comes to my mind though is what is the cause of his current clinical state. Does he have dementia? Has he suffered small strokes in the brain? Does he have a reversible medical condition.? If you can get me more information, I shall be glad to advise you further.
Personal Regards,
Nitin Sethi, MD
Dear Dr. Sethi,
Last month something happened between my boyfriend and I and I was angry and almost left his apartment without telling him but he saw me and he was really upset because he thought I was leaving him and not just his house. So he started crying and we sort of me-angrily and he-sadly talked for a bit and then he kind of frowned and walked to the nearest wall and leaned his head against it. I didn’t say anything and all the sudden he just kind or slumped down the wall and kind of sat/crouched there for a second and didn’t move. I didn’t know what was going on, and I thought he was just being dramatic, and then all the sudden he kind of flung backwards and and sort of waved his arms over his head and banged his head against the ground. But it was strange because his head kind of fell between another wall and the bottom of a staircase, and it kind of looked like he was trying to push on the stairs and kind of hit his head onto the ground from side to side. But it was all very jerky, but not really fast jerky like how I would think a convulsion might look like. It looked kind of like he was doing it on purpose. And his eyes were open while he was doing this, like a kind of vacant frown. Then all the sudden his expression just flat out changed, and he looked around like he had no idea where he was. He slowly sat up after, then crouched into a ball and cried. I wasn’t very sympathetic at first like “What the f*** was that?” Then I kind of just…like realized he hadn’t done it on purpose which sounds dumb but it happened really fast and I was pissed off. But it really scared me and right after when I asked him about it (and checked his head, which was apparently just aching dully) he said right before all he thought was “I’m sick, I’m gonna throw up,” and then he just like woke up on the ground, and he said for a while he didn’t know how he got there, or even where he was. I have no idea what happened, but I’m scared he had a seizure. Or fainted then had a seizure or something. What do you think? Do you think it was fainting or something more? Should I make him go see a doctor? What about the circumstances, can you really have a seizure just from too strong and too sudden emotions? Also, this whole thing happened not too long after we got up, and we hadn’t eaten. Do you think its just a one time thing? He’s 23, and he says nothing really like that has happened before.
I’d be grateful for any reply you could give me, thanks for your time,
Aryn
Dear Mr. Dasgupta,
thank you for writing in to me. When the blood sugar drops, signs and symptoms of hypoglycemia appear. The initial symptoms may be very subtle. An inner restlessless (anxiety like feeling) may be felt, you may become a little snappy. Weakness, light headedness, shakiness and tremulousness may be felt . When the blood sugar falls below 50mg/dl, that is the time when neurological signs and symptoms manifest. The patient may suffer a seizure, they may have loss of consciousness or at times the findings may be focal resembling a stroke (weakness in an arm or leg, blurring of vision and slurred speech).
As for what should be done, the goal is to get sugar (glucose) into the body as quickly as possible. The fastest route of course is intravenously. If that is not feasible and the patient is still conscious, one may attempt giving the person some simple sugar via the oral route (mouth).
Personal Regards,
Nitin Sethi, MD
My question is: my teenage son had a nighttime seizure and was taken to the ER. They did both blood and urine tests but I was never told any results. What do they test for normally? After I came home lots of people asked what his blood sugar was, I had no idea, do I assume they would test for that? Thank you.
I have a question regarding MRI results. My teenage son an MRI during an ER visit for a seizure and I was told all was normal. A month later at a follow up visit the neuro casually mentioned fluid behind one of his ears, my son had actually complained weeks before his seizure of pain behind that same ear. He is prone to swimmers ear and has seasonal allergies where his ears are affected. I told the neuro this and he seemed unconcerned, is that ok? Is that fluid ok sitting there?
Thanks… Dr Sethi.. I found this reply to a father very informative,clear and with sympathy which he deserved…pure Indian style!
All regards to you..
Dr Arbind Kumar, Gaya, Bihar,India