Tag: seizures

Post Traumatic Epilepsy: when head trauma leaves behind a seizure disorder

braindiseases9 Comments

Recently I have seen a few patients with post traumatic epilepsy and hence I decided it might be appropriate to talk about the same in more depth.

Before we begin though I want to wish all the readers of my blog from around the world a very Happy and Healthy New Year 2012. May it bring you not just a healthy brain but also a healthy mind.

Ok now to the topic at hand. Just what do neurologists and neurosurgeons mean when they say you have post traumatic epilepsy? As the name suggests post traumatic epilepsy (PTE) refers to epilepsy/seizures starting after a patient sustains head trauma. Let me explain with an example. Let us assume John is involved in an motor vehicle accident. While driving down the FDR drive late one night he falls asleep behind the wheel of his car. The roads are icy! John’s car spins out of control, jumps the curb and hits an embankment.  John who is not wearing a seat belt gets thrown out of the car striking his head first on the windscreen and then on the unyielding asphalt concrete. A passerby witnesses the accident and calls 911. EMS are on the screen within minutes but John is not moving. His neck is stabilized in a hard collar and he is rushed to the nearest hospital. Glasgow coma scale  (GCS) on arrival is documented to be 5. John is not responding to verbal commands and is rushed to the CT scanner for a stat head CT. CTscan shows all is not well. John has sustained significant head trauma. He has a fracture of the right temporal bone and an underlying epidural hematoma. There are bilateral frontotemporal contusions which are increasing in size. In addition there is diffuse subarachnoid hemorrhage. The epidural hematoma is evacuated that night itself by the neurosurgeon on call. It is decided that at present the frontal lobe contusions be closely observed. John is transferred to the neurological ICU where he is further stabilized. A close watch is kept on the intracranial pressure.

Fast forward 3 weeks.

After a rocky course in the neurological ICU, John makes a remarkable recovery taking the extent of his head injury into consideration. He is discharged from the hospital to a rehab facility skilled in traumatic brain injuries (TBI). In the rehab facility John makes a slow but steady progress. It is 12 noon and John as usual is working with his physical therapist. He suddenly stops what he is doing. Utters a loud guttural sound, falls down to the floor with his eyes rolled up. The therapist notes that he stiffens up for a few seconds and then starts to shake while frothing at the mouth. The whole seizure lasts for about 2 minutes and then subsides on its own. Post seizure John is confused and disoriented but slowly returns to his baseline in about 40 minutes. An appointment is made for John to see Dr. Feelgood a neurologist in the nearby community hospital.

Dr. Feelgood takes a detailed history and then examines John. You have post traumatic epilepsy John, he says and recommends that John consider starting anticonvulsant therapy without further delay.

The scenario I describe above is unfortunately not uncommon in patients who sustain significant head trauma. In fact head trauma is one of the leading causes of epilepsy in men and women below the age of 40 around the world. The human brain is well protected by an extremely rigid skull and so the trauma has to be significant to cause brain damage and resulting PTE.

MINOR BUMPS AND BRUISES TO THE HEAD DO NOT LEAD TO POST TRAUMATIC EPILEPSY. Post traumatic epilepsy is thus very rarely reported after closed head injuries aka concussions such as those sustained on the sport fields(please read my post about concussions either here or on my website http://braindiseases.info). On the other hand PTE is particularly common after penetrating head injuries such as gun shot wounds to the head or when the skull bone is fractured (especially depressed skull fracture where the bone fragment presses on the underlying brain) or when there is significant intracranial bleeding (remember what John’s CT scan showed: blood in the epidural space and hemorrhage into both the frontal and temporal lobes).

Seizures can occur at any time after a significant head injury. The patient may start having seizures immediately after sustaining the head injury. This is called early post traumatic epilepsy and at times this has a more favorable prognosis. After the blood in the brain goes away and the swelling/pressure in the brain subsides, the seizures may also stop spontaneously. Hence these patients may not need to remain on an anticonvulsant medication for a long time. Seizures though have been reported as far out as 5 years after the head injury. This is called late post traumatic epilepsy and these patients usually need to take anticonvulsant medication for a prolonged duration, at times even lifelong.

Depending on the extent of head trauma, seizures may be easy or hard to control in these brain trauma patients. They are usually prescribed anticonvulsant therapy and seizure control is then closely monitored. If seizures persist then a second or third anticonvulsant may be indicated.

Dr. Feelgood started John on a seizure medication by the name of levetiracetam. He advised John to follow up with him after 3 months. On the 3 month follow up visit, John walked into Dr. Feelgood’s office unaided and with a broad smile on his face.

I feel good, Dr Feelgood he said.

Types of seizures: a question and an answer

braindiseases1 Comment

One of the readers of my blog sent me this question.  Thank you for the same. My answer follows.

 

QUESTION

I experienced something a few days ago. Without any warning as I was getting out of my chair, I hit the floor hard. I woke up after a few seconds and I was in a cold sweat, shaking and confused. I tried to get up, but, I couldn’t move for another few seconds. I am under a Neurologist’s care and he suspects complex partial seizures due to an abnormality on an EEG, but, he is not too sure. I went to the ER and everything seemed normal. I had another episode a few days later, the same thing, except this time I was just walking from one room to another and it happened. I have no idea what this could be. I have been accused of “spacing out” and I have callouses on my left finger knuckles. I never realized I was rubbing my fingers enough to get callouses. Is this seizure or just passing out? So confused!!

ANSWER

Dear so confused,

thank you for writing in. The episodes do sound suspicious for seizures though as my post indicates there is a broad differential of sudden unexplained loss of consciousness. Broadly speaking there can be three types of seizures:

1. Generalized seizures: as the name suggests in primary generalized seizures, the seizure starts off from the entire brain at the same time. So for example if you were to suffer a generalized seizure while the EEG is running, the EEG will show abrupt onset of epileptiform activity from the entire brain (both the hemispheres). Primary generalized tonic clonic seizures (at times referred to as grand mal seizures) are quite dramatic. If the person is standing when the seizure strikes, he shall suffer loss of body tone and fall down. Patients usually strike the ground hard and may suffer craniofacial injury as a result. There is complete loss of consciousness (so the patient shall be amnestic for the seizure). There is an initial tonic phase where in the body stiffens. This is soon followed by a clonic phase where in rhythmic inphase jerks of the limbs are observed. The patient may suffer a tongue bite or may suffer loss of bladder control during the ictus. The seizure itself lasts for about a minute or two and is followed by a more prolonged post ictal phase during which the patient has stopped shaking but is somnolent and difficult to arouse. The past ictal phase may last for about an hour with slow recovery to complete consciousness and a return to baseline. Of note the staring spells seen in children (also called Absence Epilepsy) is a type of generalized epilepsy.

2. Focal seizures/ partial seizures: as the name suggests these are seizures which arise from a focal area in the brain. Focal seizures are not accompanied by a complete loss of consciousness. Rather there is impairment in the level of consciousness/ awareness. Let me explain further. Let us assume that you are right handed. In people who are right handed, the left hemisphere is the dominant hemisphere and in the left temporal lobe is the speech center. Let us assume you suffer a focal seizure arising from the left temporal lobe. There shall be a sudden arrest in your behavior and you may stop speaking (since the left temporal lobe is now misfiring). If I speak to you at this time, you shall not reply back to me and you may not recall that I had spoken to you later. That said unlike a generalized seizure, you do not fall down and do not convulsive. Patients do display some non purposeful movements such as lip smacking and picking at the clothes. This is referred to an automatisms.  Prior to the onset of the seizure, patients may report an aura. The typical auras which are reported including an unpleasant smell (burning rubber), rising sensation in the tummy, a spinning sensation, unpleasant taste, psychic phenomena such as fear and so forth. This type of seizure is what we doctors refer to as a complex partial seizure (complex because awareness is impaired).

3. Focal seizure with secondary generalization: I think this is simple to understand now. The seizure starts off as a focal seizure but then spreads and crosses over to the other side of the brain and very soon (in a matter of milliseconds) the entire brain is showing the epileptiform activity. So initially you have a behavioral arrest and cannot speak but then very soon your entire body tenses up and you start convulsing.

There are other types of seizures some of which occur in the pediatric age group. At present I shall not dwell on them.

I hope I have been able to explain seizures to you in very simple terms. Follow up with your doctor. My very best to you.

Personal Regards,

Nitin Sethi, MD

Alcohol and seizures: a few questions and their answers.

braindiseases2 Comments

One of the readers of my blog asked me a few questions. His questions and my answers to them follow.

Hello Dr Sethi! To begin with, I’d like to thank you for clarifying and educate us about seizures.(esp. rum fits, alcohol withdrawal seizures and Dts seizures)

I have some questions:

1. How would I differentiate between epilepsy and alcoholic fits? Ignoring any test(EEG,CT), i mean based on the clinical manifestation?eg. duration of fits?the sequence of occurence (pattern of seizure)?etc…

2. how would i differentiate between epilepsy and the ‘fits’ that is seen in patients with hysteria (conversion disorder)?

3. is treatment necessary for alcohol fits? or just allow the patient to relax in the recovery position and let the fit go away?

4. how would you distinguish between: alcohol withdrawal syndrome and DT? is there any special cardinal symptom that will give me a clue that the patient is in DT.?

Thank you very much Dr Sethi. looking forward to hear from you.

Dr. Ronny Gooriah (doing Internship)

Dear Dr. Gooriah,
thank you for writing in to me. I am glad you found the information presented useful. Now without further delay, let me answer your questions.

1. If I understood your question you want to know how to differentiate between seizures caused by alcohol (alcohol fits) from seizures/epilepsy caused by other conditions. As you may be well aware of, epilepsy is a condition which predisposes the patient to multiple convulsions in his/her lifetime. There are numerous causes of epilepsy. Broadly speaking epilepsy can be idiopathic , symptomatic or cryptogenic. Seizures may also occur secondary to a medical condition which may or may not involve the brain like for example a brain tumor, head trauma, meningitis or encephalitis and in the setting of multiorgan failure such as sepsis, renal or hepatic failure. There is no absolute way of differentiating a seizure caused by alcohol (excessive use or sudden stoppage) from epilepsy (whether idiopathic, symptomatic or cryptogenic) specially early in the course of the disease. One needs to take a thorough history which should include a history of alcohol intake. How much? what kind? over what time frame were the drinks consumed? were drinks mixed? were recreational drugs taken along with the alcohol and so forth. Other history which may be helpful in determining if the patient has epilepsy include: a history of febrile convulsions, family history of seizures, history of meningitis or encephalitis, history of significant head trauma and if seizures have occured in settings where the patient was not abusing alcohol. The answer to all these questions and the results of tests such as EEG and neuroimaging (MRI brain) shall help in determining whether the patient has epilepsy per se or whether all his seizures can be attributed to alcohol.

2. Nonepileptic events (pseudoseizures) may occur as a manifestation of a somatoform or conversion disorder. These patients have events that look like seizures (sudden shaking of the body and the patient may appear to suffer loss of consciousness) but there is no EEG correlate to these events. Meaning that the EEG shows the patient is not having a seizure. Patients who exhibit nonepileptic events (some doctors refer to them as hysterical convulsions) usually fall in two categories. Either they are doing this for a secondary gain (seeking attention, disability or financial compensation aka they are malingering) or these events are really not under their conscious control (usually these patients are under severe mental stress or may have history of physical or sexual abuse). A trained eye (such as a neurologist) simply by looking at the clinical event shall at times be able to determine if it is a true seizure or a pseudoseizure/ hysterical convulsion. At times though the differentiation is indeed difficult (if solely based on the description of the event). A video-EEG in these cases is extremely helpful. As the name suggests the patient is attached to a EEG machine while under video surveillance. The idea is to capture a typical seizure on the camera and look at the EEG at the same time.

3. If the patient suffers a single alcohol related seizure, no treatment may be necessary apart from simple observation and making sure the patient does not hurt himself. On the other hand if the patient suffers a flurry of seizures one after the other, you may have to give medications to stop the seizures at least acutely. Whether such patients warrant long term anticonvulsant therapy is another issue and needs careful consideration.

4. Patients who are in DT or have impending DT usually have dysautonomia. They are frequently tachycardic or have irregular heart rate, their blood pressure may be high and have wide swings, they may have profuse sweating and are disoriented, confused and agitated (hence the word delirium). DT has a high mortality and hence these patients need close supervision and aggressive treatment usually in an intensive care setting.

I hope I have answered your questions to your satisfaction.

Personal Regards,

Nitin Sethi, MD

Seizures: a question and an answer

braindiseases2 Comments

One of the readers of my blog wrote to me recently. His question and my reply to it follows. I think some of you may find it helpful.

 

Hello Dr. Sethi,
 
I came to your site/blog while doing a Google search regarding delirium tremens, which I found extremely helpful!  So I thought I would ask for your opinion about a diagnosis my neurologist gave to me about half a year or so ago.  Please feel free to remove my email and name and post on your blog!
 
So my history is that I’m 20 years of age and have had two seizures in the past…36 months or so.  I have had no family history of seizures or epilepsy, one case each of diabetes (treated with metformin), stroke (no known treatment), and breast cancer (treated by partial mastectomy).  Both sides of my family are on high blood pressure medications.  I myself have a history of reactive airway disease.  I have also been prescribed lots of co-actifed and have developed a bit of an addiction to using drugs that cause sedation; among the things I can list are: codeine, diphenhydramine, Actifed, lorazepam, and tramadol (I would say this is probably significant), and I often self dose; with high amounts of codeine, and often double or triple the recommended doses for benadryl and Actifed (as on the box); these three are the most common drugs I take to sleep, I realize I am developing a tolerance to them.  I am trying to stop using these as a way of falling asleep. 
 
Anyway, so the first incidence of my seizure happened when I was working on my computer, writing up a laboratory report that I was working on for a while.  I had been sitting there for several hours already.  I had been taking tramadol on and off for the couple of months or so.  I fell into a seizure and my mother found me.  Nobody saw what happened as I slipped into a seizure, I just fell backwards. 
Key things I remembered/observed:
-I did not have an aura
-I did not have incontinence
-I instinctively bit down, but I do not know if I bit my tongue because my mom had put her finger in my mouth
-I had nausea when I woke up
-The whole sequence of events I believe lasted around 5 or so minutes. 
 
The ER doc and the paramedics had concluded the seizure was due to tramadol. 
 
The second incidence of seizure happened when I was sleep deprived, though arguably I was sleep deprived in the first incidence too.  I had only slept several hours the night before and I did not nap (which I usually do for several hours during the day).  I spent the whole day awake, and I went to a friend’s house afterwards.  I was playing a poker game, which often makes me feel really stressed (I get sweaty palms, feeling of coldness, a bit of light-headedness, and sometimes I get slight dizziness).  I remember that I had not eaten much at dinnertime and I was hungry, so I ate a bunch of chips as a snack, with an iced tea to drink.  I remember I had slipped into a seizure, again with the same symptoms as the first time, lasting about 5 minutes.  The key issue is that I did NOT bite my tongue. 
 
Again, I was taken to the ER and the ER doc was not sure what could have caused it.  I do not recall taking any drugs throughout the course of the day but I might have taken some diphenhydramine to sleep the night before.  I realize that these act on the nervous system.  The ER doc immediately prescribed me phenytoin and referred me to a neurologist, and an EEG ordered. My neurologist subsequently ordered an MRI.
 
 
When I went to see my neurologist, she examined me as usual and asked for the same details I have given above.  Her conclusion given her initial diagnosis was an epileptic seizure of cause unknown.  Her suspected trigger was sleep deprivation.  A second neurologist I visited repeated the diagnosis. 
 
Following the EEG and MRI, I went back to see my neurologist (this was after several visits).  The EEG had come back normal.  I did not lose consciousness (aside from the sleeping phase of the test) nor was ever informed that I had a seizure during the course of the test.  The MRI had also come back as negative in anything in my brain.  I was not informed of any other explanation other than a “possible” epilepsy condition.  Neurologist placed me on phenytoin, which I took for three weeks before having an allergic reaction and had to be switched over to levetiracetam.  Following that I saw the neurologist again due to severe depression and mood disorder.  We decided mutually not to take the medication, of which she warned me that there was a 75% chance of a third seizure in the following year. 
 
To this date, I have not had another seizure, and about 7 months has passed since the incident.  Again I have not taken any antiepileptics aside from occasional (several days to several weeks in between doses) lorazepam 1mg. 
 
I should note also that while having taken lorazepam 1mg-2mg (and being off of it for a week), I have subsequently drank more alcohol than I usually do and taken a ranitidine 150mg before going to drink (supposedly to prevent hangovers and being able to drink more).  The amount I drank was about 2 shots and a beer, before I started to experience delirium tremens.  The odd thing is, however, that exactly one week after that incident, I drank the same amount of alcohol but did not have delirium tremens (without having taken the ranitidine).  I understand how alcohol works in the brain by depressing the nervous system. 
 
I understand that the medication is preventative, but I am worried that I might have another seizure.  It puzzles me since my lack of taking medication should therefore result in seizures if I really have epilepsy.  I understand that drugs can cause seizures, especially in overdosing amounts, however, I would really like a second opinion about whether or not I really do have epilepsy.  Of course I understand that your opinion is only an opinion since I have not been examined by yourself, but I have provided as much relevant information as I can.  I also understand that there are many triggers of epilepsy, and often the cause isn’t really clear.  I would like to be seizure free of course and not have to take medication, but my neurologists are telling me otherwise, which concerns me. 
 
Please reply to me with your opinion as your time allows.  Oh please feel free to also use medical jargon if you wish in your replies, I am actually studying as a pre-med student myself, which might be where the stress is coming from. 
 
With Regards and thanks,
 
xx
Dear XX,
                               thank you for writing in to me. You gave me a very detailed and thorough history. While as a rule I do not and should not diagnose someone over the Internet since I have neither taken the history myself nor examined them, I do have a few words of advice. It is likely you have an underlying tendency to have a seizure. It is also well known that sleep deprivation, excessive use of over the counter antihistamincs and other prescribed medications such as lorazepam, codeine and Tramadol can lower the seizure threshold especially when you are mixing these medications with alcohol.
 
Let me explain in another way. Two of your doctors (ER physician and neurologist) feel that you have epilepsy and prescribed anti-convulsant therapy. A normal EEG and a normal MRI brain do not rule out epilepsy. Infact many epileptics may have a normal routine (40 minutes) EEG study. Hence to increase the yield sometimes a more prolonged EEG study is ordered (such as a 24 hour ambulatory EEG study or an inpatient video-EEG study). If the EEG study clearly shows interictal epileptiform discharges, it strengthens the argument that you suffer from epilepsy and that it shall be prudent to continue taking an anti-convulsant since the chance of a third seizure is high. On the other hand if the EEG study comes back normal, we are back to square one. It does NOT rule out epilepsy. Levetiracetam has been reported to cause psychogenic side-effects such as anxiety. It can also make patients frankly depressed. So a mutual decision between you and your physician was made to stop levetiracetam.
 
If I understand your email right, at present you are NOT on any anti-convulsant therapy. Your physician rightly informed you of the risks of taking this approach. You should remain in close follow up with your neurologist. Also since you have already suffered two convulsions (and have decided not to continue anti-convulsant therapy), it shall indeed be prudent if you make significant lifestyle changes. Namely avoiding alcohol completely or if that is not possible drinking in extreme moderation. I would also advice cutting down your use of over the counter sedatives, antihistaminics and other sleeping aids. You should maintain seizure and fall precautions at all times. Remember seizures are associated with falls and sometimes fatal injuries have occured. I always tell my patients  “you do not want to have a seizure at the wrong place and at the wrong time”. You should not drive as per the law of the state you reside in. Maintain good sleep hygiene and again remain in follow up with your physician. He/she shall be the best person to guide your care going forward.
 
Personal Regards,

Nitin Sethi, MD

Alcohol and seizures: a question and an answer

braindiseases4 Comments

T

HI
My Father is an aolcoholic and last Sept he was admitted to hospital after a fall when drunk – whilst in hospital he had a fit – understandable he was cold turkey whilst there. He was treated and sent home. Since Dec he has reduced his drinking and now generally consistantly drinks 1 bottle red wine a day – yes this is still too much but about 50% what he used to drink – he reduced gradually and has maintained this intake for a few months now.
What I find strange is that all i can find about these alcohol withdrawl fits relates to 2-3 days without alcohol – Dad had a fit a few mornings ago after a normal day and normal alcohol consumption levels. The hospital saw alcohol in his notes and packed him off home again with some Vitamin B tablets.
How many alcoholics normally get fits whilst they are still drinking? How normal is this? He is eating better these days than he was but still could do with eating more. He borderline underweight and 74 years old – he has been dependant for more years than I can imagine but probably the last 12 years have been the worst. He does not drink in the morning but the first drink in the day is normally 3/4pm and last drink 6/7pm before bed. This one bottle of wine is often enough for him to fall when on his way to bed or even a few hours later I have had to carry him back to bed if he falls in the bathroom. His body just doesnt seem to be able to cope with alcohol any more – less alcohol to get drunk – is this why he is having the fits?
My apologies for long winded questions but the question needed some context to make sense I think. Any I am not delusional about his alcohol intake – I monitor it and he has no other way or place to stash any.

Thank you so much in advance

P.S. the fit was 6.30 am Thursday and now Sat pm he is still very unsteady and his memory is worse than before. What is the normal recovery from these fits?

 

Braindiseases

Dear T,
thank you for writing in to me about your father. There is no one set limit above which alcohol can induce a seizure. The limit varies from person to person. Rum fits (seizures which occur at the height of binging) of course occur when one consumes too much alcohol in too short time. Alcohol withdrawal seizures classically occur 24-48 hours after the last drink (they occur in people who are chronic alcoholics/ people who consume heavy alcohol on a daily basis and who then suddenly stop drinking). Again not every chronic heavy drinker gets alcohol withdrawal seizure if he/she stops drinking suddenly. Usually it is the person who is chronically malnourished and dehydrated who is more predisposed to an alcohol withdrawal seizure in the setting of sudden cessation of drinking. These people as you can well imagine are deficient in multiple vitamins and minerals (commonly the B group of vitamins such as Vitamin B1, B2, B6, folic acid and B12). Their electrolytes are also more likely to be off (meaning they serum sodium, potassium, magnesium is low). They may also have alcoholic liver disease (alcoholic steatosis or fatty liver, alcoholic hepatitis and finally cirrhosis). During their prolonged drinking years they may also fallen down and struck their head. So it is a combination of factors (meaning the overall health status) and not just the sudden cessation of drinking which predisposes some alcoholics to alcohol withdrawal seizures.
Finally over the course of years of heavy drinking, some alcoholics develop epilepsy. The reason for this may be any of the above I have listed. My personal feeling is that these patients likely have underlying epilepsy and alcohol (in excess or sudden cessation after years of drinking) just helps to unmask it.
Now let me answer your last question about time frame of recovery. Again if his pre-existing neurological status is compromised (his memory is already bad after years of drinking, his general medical condition is poor or if he has coexisting medical problems such as chronic lung or liver disease, diabetes or congestive heart failure) his recovery from a convulsion shall be slow as compared to a young person with no pre-existing medical problems.
I hope I have addressed some of your concerns. I wish you both my very best.

Personal Regards,

Nitin Sethi, MD

Brain tumors: going over the basics

braindiseases3 Comments

Recently I have seen many patients with brain tumors in my office and that shall be the focus of my post.  Brain tumors are tumors (cancers) that arise in the brain or spread to the brain. We call these primary brain tumors (tumors arising in the brain itself) or metastatic tumors to the brain (the primary tumor/ cancer is somewhere else for example in the lung or breast but then spreads to the brain).

Let us now spend a moment to talk about how brain tumors present clinically. Many of you shall be surprised to learn that the brain itself is insensitive to pain (meaning if I was to put a knife through your brain tissue, you shall feel no pain!!!).  So a small brain tumor may be silent, causing no pain or discomfort. It is usually when the brain tumor increases in size and starts involving (stretching the blood vessels in the brain) or the covering of the brain (meninges) that the patient may complain of headache. Blood vessels and covering of the brain (meninges) are richly supplied by nerves and hence are exquisitely pain sensitive.  So first and foremost not all brain tumors present with headache. The corollary to that is that not all headaches are due to brain tumors. Most of the times when patients present to a doctor for evaluation of headache, a “benign” cause such as migraine or tension headache is found and not a brain tumor.

If I am examining a patient with headache, there are certain red-flags in the history and the examination which shall make me think about a possible brain tumor.

Laterality of the headache:  Headaches associated with brain tumors are usually holocranial (the whole head hurts). Remember migraines are typically hemicranial (patient complains of a throbbing headache on one side of the head). This though is not a hard and fast rule and I would not base my opinion on the laterality of the headache.

Is the headache associated with projectile vomiting: Because a large brain tumor  shall lead to an increase in the intracranial pressure (pressure inside the brain),  patients with brain tumors may have projectile vomiting. This again is not a hard and fast rule as patients with migraines are frequently nauseated and may throw up.

Does the headache awaken the patient at night from sleep? Headache associated with brain tumor may awaken the patient from sleep. Classically the headache is worst when lying down and abates in the morning when the patient gets up and starts to move around. Migraines usually do not awaken a patient from sleep, infact sleep frequently helps to abort a mgraine attack. Again a weak point and I would not base my opinion on this alone.

History! History! History!: 

Let us compare two different histories in two patients:

Patient number 1 (age=53 years male)

“Dr Sethi, I have never had a headache in my life, never had a headache in my adolescence but recently I am waking up with a severe headache.”–THE THOUGHT OF BRAIN TUMOR DOES CROSS MY MIND WHEN I HEAR THIS

Compare this to:

Patient number 2 (age 26 years female)

“Dr Sethi, I have headaches since my college days. Frequently I shall get a throbbing headache on one side of my head and at that time bright lights shall bother me. I used to feel nauseated when I had my headaches and at times threw up. My headaches went away in my 30s but now I am again having bad headaches” –MIGRAINE IS THE FIRST THOUGHT THAT CROSSES MY HEAD AND NOT BRAIN TUMOR.

Other presentations of brain tumors: brain tumors at times may present more dramatically. Patients may present with a generalized convulsion. When these patients are imaged (via a CT scan or a MRI brain scan) the brain tumor may be detected. At times patients present with progressive neurological deficits. The type of neurological deficit depends frequently on the location of the brain tumor. Let me explain this further. Let us assume the brain tumor is pressing on the optic nerve or other nerves which control eye-movements: patients may present with visual problems (such as blurring of vision, double vision or diplopia, cuts in their visual fields and so forth). If the tumor presses on the motor or sensory system: patients may present with weakness or numbness on the contralateral side of the body. If the tumor is in the cerebellum, they shall complain of balance problems or lack of coordination. If the tumor involves the auditory nerve, their presenting complaint shall be of hearing loss (usually though unilateral hearing loss may not be appreciated by the patient).

Finally the neurological examination is of great help. Patients with migraines, tension type headaches and other “benign” headaches have a normal (we call this non-focal) neurological examination. On the other patients with brain tumors may have some subtle and other more prominent neurological findings. Thus your doctor shall examine you: check your cranial nerves (does the patient have a symmetrical smile, are eye-movements intact, is the visual field intact, do thay have any sign of increased pressure inside the brain (this is determined by looking into the eye to visualize the optic nerve head), is motor strength and sensory system intact,  are there any signs of cerebellar dysfunction (incoordination, ataxia–balance is off and so forth).

Patients with headaches who have an abnormal neurological examination should be imaged. Your doctor may then recommend either a CT scan of the head or a MRI scan. Frequently this is done with and without contrast. I shall dwell into different types of brain tumors and their management in my next post.

Nitin Sethi, MD

Infantile spasms: a few questions and answers

braindiseases4 Comments

 

Dear Dr,
My son is diagnosed with hypsarhythmia and he is 18 months. As of now we do not see notice any delay in his development.Is there a chance for developmental delay?? He is on ACTH treatment. His symptoms are Head Dropping.

Thank You!
R

 

 

 

 braindiseases

 

 

 

  

Dear Mr.R ,
thank you for writing in to me. I am happy to learn that your son is doing so well and that you have not noticed any developmental delay or developmental regression. It suggests that his infantile spasms are well controlled. My advise would be to keep him under the close observation of his pediatrician and pediatric neurologist. At some point of time, they might like to repeat his EEG to assess seizure control. Sometimes a prolonged EEG study is very useful in this regard.

Personal Regards,
Nitin Sethi, MD

 

 

 
 

 

 

 K

 

 

 

  

Hi There,
Our daughter is 18months, has had infantile spams since 2wks old. We have tried phenobarb, vigabatrin, nitrazepam, topirimate, b6, clobezam, epilim, lamotrigine & prednisolone. None have worked on our wee girl, her development is so far behind, she can sit & thats all, no reaching out, focusing etc. I am at my wits end with what to do next, Paeds dont seem to be really trying to get her sorted, Mri came back with no abnormalities, shes had bloods, urine & lumber puncture, all clear. Eegs show a lot of electrical activity. What do you think we should do? Im really wanting to get a second opinion & someone that will help us.
Cheers

 
 

 

 

 braindiseases

 

 

 

  

Dear K,
thank you for writing in to me. From what you tell me it seems your daughter’s seizures have proven to be refractory to multiple anticonvulsant drugs. Extensive investigative work-up revealed no cause for her infantile spasms. We call this condition cryptogenic or idiopathic infantile spasms (cryptogenic because a cause for infantile spasms is suspected but has not been identified).
I can understand your frustration K. This is what I advise. It might be worth the time and effort to have her evaluated at a comprehensive epilepsy center. Special diets like the ketogenic diet at times work wonders. Also some new drugs are now available. Acthar (ACTH) gel at times works–though it is frightfully expensive and may not be covered by insurance. Neurostimulation devices like the vagus nerve stimulator (VNS) can be tried though to my knowledge there is little data on its efficacy in infantile spasms.

Personal Regards,
Nitin Sethi, MD

 

 

 

 

 

 

 

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

braindiseases1 Comment

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

  

When a seizure is not a seizure (pseudoseizures)

braindiseases5 Comments

When a seizure is not a seizure (pseudoseizures)

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

The month of Feb finds me in New Delhi, India. I have been invited to present a talk on psychogenic non-epileptic seizures (PNES). You may now be wondering what does that mean. Well that is what I plan to discuss in this post of mine. Let us look at the term again:

P–stands for psychogenic  meaning the event has a psychological basis to its existence.

NES–stands for non-epileptic seizure meaning the event is not a epileptic seizure.

So let me put it all together in simple language.  Let us assume our character for this short story is Michelle. Now Michelle is a 25-year-old young lady who is married to John. All looks great from outside. Michelle has a good job, a fun life in Manhattan and a good circle of friends. But all is not hunky dory. Michelle and John have been having some problems. John is verbally and lately physically abusive to her. Michelle feels trapped in a loveless marriage but sees no way out.

So one day Michelle and John are at a dinner party.  Seated at their table are few close friends as well as some strangers. As the main course is served, Michelle suddenly leans back, she utters a cry. Then her eyes are noticed to roll up.  John and Michelle’s friends quickly ease her to the ground. She is then noted to have vigorous side to side shaking movements of her head, asynchronous out of phase thrashing movements of her arms and legs. All this time her eyes are open and she is muttering help me, help me.

Michelle is rushed to the hospital where a doctor like me is called to consult on her.  What happened to Michelle?  Seizure or not a seizure, is the question. To help determine the etiology, her doctor orders a video-EEG study.  Michelle is admitted to the hospital and electrodes are pasted on the top of her head to record her brain waves (encephalogram). The encephalogram is time locked to the video camera mounted on the ceiling which records Michelle’s movements. Hence the name VIDEO-EEG.

So imagine Michelle. Sitting in bed, wires attached to her head, surrounded by friends, family and most importantly an extremely concerned John by her bedside. And then it happens again. A dramatic event where she yells a bone chilling cry and then shakes all over.  Now everyone wants to know what is plaguing Michelle.

So what did the video-EEG record?  Was it a seizure or not? Surprisingly when the EEG data is analysed, at the time when Michelle is having her “seizure” the EEG shows no change in the brain waves.  Meaning than Michelle is not having a true seizure, the event is non-epileptic.

Events such as the above are called PNES. They are psychogenic since they have a psychological basis to them. In Michelle’s case they likely reflect her struggles in her marriage and may be a sign for help. Some patients have psychogenic seizures/ pseudoseizures voluntary.  Meaning they might malinger a “seizure” for a secondary gain such as to get social security payments, to escape school and so forth.

PNES  are common and difficult to diagnose and treat.  As you may imagine patients are frequently misdiagnosed. Some are misdiagnosed as true seizures/ epilepsy and started on anti-convulsant drugs which have their own side-effects.  When one drug fails to stop the “seizure”, new drugs are tried.  So frequently these patients are on multiple anti-convulsants and their “seizures” still continue.

PNES do not stop till the underlying psychological issues are tackled. In Michelle’s case simply telling her that she does not have true seizures is not the end of the road. She needs to be referred to a psychiatrist and a therapist. Only then she may be cured.

Alcohol and seizures: few questions and their answers

braindiseases6 Comments

One of the readers of my blog asked me a few very specific questions with respect to alcohol intake and seizures.  Many times your excellent questions and my answers to them get lost in the sea of information here. So I decided to post her questions and my reply to them as a main post. I feel many of you shall find them informative.  I have removed the reader’s name and email id.

T

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
braindiseases Dear T,
thank you for writing in. You ask specific questions and hence I shall answer them likewise.

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