A question from a father and some answers for seizures due to hypoglycemia

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

Seizures due to hypoglycemia–a couple of questions and answers.

I got a few insightful questions from my readers which I am sharing here. My reply to them follows.

K

Is it possible to have hypoglycemia and suffer with seizures without diabetes?

My Blood sugar level after a seizure is high though quickly drops down (Shock?)

Can Hypoglycemia be a random problem caused by diet at the time and stress etc?

 
  braindiseases  

Dear K,
thank you for writing in. You ask a good question. There can be many causes of hypoglycemia, diabetes mellitus is one of the more common causes. In diabetes mellitus hypoglycemia commonly occurs in the setting of a missed meal (by that I mean, a diabetic patient takes his anti-diabetic medication/ insulin but forgets to take his meal). Another setting may be if one has what is called brittle diabetes. This is a condition in which the blood sugar varies quite a lot. Such patients need fine control of their blood sugar level to prevent episodes of hypoglycemia or hyperglycemia.
Seizures occur due to hypoglycemia per se (low blood sugar), not because of hypoglycemia due to diabetes. What I mean to say is that hypoglycemia due to any cause can cause a seizure provided the blood sugar falls below a critical level (usually less than 50 mg/dl).
Personal Regards,
Nitin Sethi, MD

  S  

hi
im not here to ask a question sorry, just to ponder your mind a little,
ive had type 1 diabetes since the age of 4 (16 years) and i am now 20. when i was 7 i had my 1st seizure. time went on and since ive been 15 ive had around 20 + full on seizures ive had 2 in the street both ive recovered from, but the rest was in my sleep, with no warning atall. i go ridged and ALWAYS bite my tounge and injure myself, suck as banged my head off the cooker, the floor, raidiator etc. after this happens i get sugar rubbed in my gums by my family or friends till i come round, (no paramedic or hospital service involed) but the confusing thing was when i had them in the street and i came around WITHOUT sugar or anything. witch was also confusing for the hospital and my gp. witch also brings me to my next thing.
ive been to my local gp and also im back attending the hospital on a weekly basis.
as ive now been to see my gp today, and gave him details etc. of each seizure. hes now under the idea of sending me to a neurologist as he dosent beleive that my seizures are in anyway linked to my diabetes.
also ive just had my insulin changed from human mixtard 30 (twice daily) to lantus(morning) & novo rapid(breakfast, lunch, dinner).

what i was wondering was, what your thoughts would be on this ?

 
  braindiseases  

Dear S,
thank you for writing in. This is what I feel. I think it shall be worth your time to see a neurologist and get a thorough evaluation for your seizure disorder. Some of your seizures likely can be accounted for by hypoglycemia (the ones in which you make a rapid recovery when sugar is rubbed onto your gums). It is also possible that you have underlying epilepsy/ seizure disorder. This may result in convulsions which are unrelated to hypoglycemic episodes. Also why should you be having hypoglycemia induced seizures if your diabetes is well controlled? As you can understand there are bits in your history which do not “gel”.
So I feel you need a good work-up. A neuroimaging study of the brain (ideally a MRI scan of the brain) and an electroencephalogram (EEG study) may be warranted. Your doctor may then decide to treat you with an anti-convulsant medication.

Personal Regards,
Nitin Sethi, MD

 

Diabetic neuropathy: a question and an answer

One of the readers of my blog emailed me this query. A very good question and I wanted to reproduce it here, my answer follows.

Bree Johnson on November 28, 2008 said: Edit Link

I am very confused about whether I have diabetic neuropathy or not. I have been a diabetic for 21 years. A podiatrist confiremd recently that I have VERY good sensation in the feet & there is no evidence of neuropathy. I do not experience any numbness, pins & needles as such but I do have signficant pain at times in the my feet. The pain is largely due to a heightenend sensitivity at skin level. For example having things brush against my skin is unbearable, or putting on my shoes is also uncomfortable or walking on rough surfaces. But applying direct pressure on my feet – as in reflexology – is not painful. The podiatrist could not explain what this heightened sensitivity is due to.

I am however prone to occasional bouts of deep aching pain the feet & legs – which seems to always be the case now when I am a bit rundown & tired.

I also do have electrical type of stabbing pains that come & go – they can be quite painful stabs. Again they seem to be apparent only when rundown & tired.

Can you please offer any comments on the above? It would be greatly appreciated.

Bree

Dear Bree,

Thank you for writing in. You ask a very good question and that is what I shall attempt to answer. First at the onset let me tell you that most diabetics (especially those who have had long standing diabetes, in your case for over 21 years) shall have clinical evidence of diabetic neuropathy if one subjects them to a thorough clinical examination and electrodiagnostic testing (we use tests like nerve conduction velocities (NCV) and electromyogram (EMG) to unearth evidence of nerve damage/ neuropathy).  

Diabetes can cause different kinds of neuropathies depending upon what kind of nerves are preferentially involved:

(large nerves that carry sensations like joint sense and vibration versus smaller nerves that carry sensations of crude touch, pain and temperature)

(motor nerves that help in moving muscles and joints versus sensory nerves which carry sensation)

THE MOST COMMON NEUROPATHY THOUGH IN DIABETES IS A MIXED MOTOR SENSORY POLYNEUROPATHY WHICH USUALLY INVOLVES THE SMALL NERVES WHICH CARRY SENSATIONS LIKE PAIN, CRUDE TOUCH AND TEMPERATURE. MEANING THAT AT LEAST INITIALLY IN THE DISEASE COURSE THE MOTOR NERVES AND THE LARGE SENSORY NERVES (CARRY SENSATIONS OF VIBATION, JOINT SENSE AND POSITION SENSE) MAY BE SPARED OR AT LEAST WE DO NOT SEE EVIDENCE OF THEIR DEGENERATION ON NERVE CONDUCTION TESTING.

Patients who have small nerve fiber involvement commonly have what we refer to as allodynia and hyperpathia. What is allodynia you may ask?

Well allodynia is when a normally non-painful stimulus becomes painful. Let me explain with the aid of an example. You are lying in the bed, settling down to sleep. You pull the sheets over your bare legs. The sheets touch your legs, now they are silk sheets that is not a painful stimulus. But a patient with diabetic neuropathy may find it excruciatingly painful. THERE THAT IS ALLODYNIA.

They also have hyperpathia. What is hyperpathia? Well lets take another example. I take a pin and stab you with it. Now that is a painful stimulus and everyone shall find it so.  A normal person may say “ouch”, a patient with diabetic neuropathy though may jump out of his seat. SO HYPERPATHIA IS WHEN YOU FEEL A GREATLY EXAGGERATED PAIN SENSATION TO A PAINFUL STIMULI.

So in conclusion, it is more that likely that you have diabetic neuropathy. My advise to you would be to see a neurologist. If you do indeed have diabetic neuropathy, there are many good medicines out there that can treat the pain and more over prevent the progression of this painful and disabling condition.

Personal Regards,

Nitin Sethi, MD

Alcoholic neuropathy

Continuing with the posts on the neurological manifestations of alcoholism, I shall cover the topic of alcoholic neuropathy here. Simply put alcohol is a neurotoxin especially when it is consumed in excess. People who consume large amounts of alcohol on a chronic (daily) basis frequently develop neuropathy. It does not depend upon the kind of alcohol consumed (top of the shelf Scotch whisky Vs a cheap rum) rather it depends upon the amount and frequency of use. Patients develop a predominantly sensory neuropathy and have complaints of pain, burning, tingling, pins and needle sensation in the feet and sometimes in the finger tips. Rarely if the neuropathy is severe patients may also develop peripheral weakness (motor symptoms).

Alcoholic neuropathy is also thought to be not entirely due to alcohol, rather it is a nutritional neuropathy and occurs due to lack of essential nutrients and vitamins in the marginal diets of alcoholics. It is uncertain whether the neuropathy would develop in an alcoholic who supplements his diet with essential nutrients and vitamins. Alcoholic neuropathy is more commonly seen in patients who have other neuropathic conditions like diabetes. In this subgroup of patients, alcohol acts as an additional neurotoxin and makes the neuropathy worse. The same principle applies to cancer patients been treated with neurotoxic chemotherapy medications or an HIV patient been treated with neurotoxic antiretroviral medications.

Thus the message is simple.

Drink alcohol in moderation applies to all of us.

People who have diabetes should avoid alcohol if possible or if that is not possible consume as little.

Patients been treated with neurotoxic medications should also avoid alcohol.

Supplement your diet with at least one to two tablets of a good multivitamin every day.

Alcoholic neuropathy is treated much the same as any other neuropathy (see my post on diabetic neuropathy http://braindiseases.info)

Nitin Sethi, MD

Neuropathy

Neuropathy

In this section we shall discuss neuropathies. This is a vast topic and I shall try to make it simple. First lets start with the basics. What is neuropathy? Neuropathy refers to disease and dysfunction of the nerves.  There are different types of nerves in the human body: some nerves supply the muscles of the head, face and neck example the facial nerve supplies the muscles of the face ( it is this nerve which helps you to smile or frown).  Another  example is the auditory nerve which helps you to hear. These nerves which supply the muscles of the head and face are referred to as Cranial Nerves.

Apart from the cranial nerves there are other nerves which supply the muscles of the arms and legs and carry sensations of pain, temperature, pressure, joint sense, vibration and light touch. As these nerves supply the muscles in the periphery of the body they are referred to as peripheral nerves. Peripheral nerves are of three types:

1) Motor nerves : nerves which carry out motor functions example closing and unclosing your fist , walking etc

2) Sensory nerves: nerves which carry sensation of pain, temperature, touch, joint sense, vibration and position sense from the periphery back to the brain.

3) Mixed nerves: nerves which carry out both the above functions.

Neuropathies can thus be of different types based on which type of nerve is involved by the disease process. So you can have a motor neuropathy, a sensory neuropathy and a mixed motor-sensory neuropathy.

Another way to classify neuropathies is on the basis of the size of the nerve fibers involved. Pain, temperature and crude touch is carried by small sized nerve fibers and hence neuropathy of the small sized sensory nerves is referred to as small fiber neuropathy. Vibration, position sense and joint sense are carried by larger diameter nerve fibers and hence neuropathy of larger diameter nerve fibers is referred to as large fiber neuropathy.

Contact me at :

neurologistnyc@yahoo.com

 

Braindiseases.info