Basic Human Neuroanatomy
A Clinically Oriented Atlas 

Case History #188

Date of Consultation: 5-6-1997


This 25-year-old right-handed single white female bookkeeper was referred for neurologic evaluation of her seizure disorder.  The patient began having seizures at 12 years of age (1984).  At the present time, she is averaging about 10 seizures per month, and they tend to occur immediately following her menstrual period or if she is suffering from a systemic illness such as a viral infection or upper respiratory infection.
The patient usually experiences a warning or aura prior to the seizures.  This consists of a funny “butterfly feeling” in her stomach, a fast heart rate and palpitations, and occasionally déjà vu.  These symptoms last less than one minute and sometimes occur in isolation without progression to a larger seizure.  If the seizure activity does progress, the patient develops a blank stare with impaired awareness and responsiveness, lip smacking, eyelid blinking, and picking movements with her fingers.  This phase of the seizure lasts anywhere from 10 seconds to two minutes and is not associated with tongue biting, incontinence, or injury.  Postictally, she is confused, disoriented, and somewhat drowsy.  These symptoms last anywhere from a few minutes to 20 minutes.

The patient has been on multiple antiepileptic medications, including Dilantin, Tegretol, phenobarbital, Klonopin, Felbatol, and Lamictal.  At the present time, she is taking valproic acid and gabapentin.  Prior to consultation, the patient had a routine EEG which was reportedly normal and 3 prior MRI scans, which also were reportedly normal.
In terms of specific epilepsy risk factors, she had no prior head injuries or CNS infections.  She was the product of a normal pregnancy, labor, and delivery, and met her early developmental milestones on schedule.  She has a college education without academic difficulties.  She has no neurocutaneous skin lesions.  She has not had seizures related to alcohol or drug use.  There is no family history of seizures.  However, at 13 months of age, the patient received a measles vaccination, developed a febrile illness, and had two or three febrile seizures.  At that time, the patient was placed on phenobarbital for about 6 months, had no further events, and was tapered off that medication


Mental Status Exam:  Normal.

Cranial Nerves:  Normal.

Motor System:  Normal. 

Reflexes:  Normal. 

Sensory System:  Normal. 

Cerebellar Function:  Normal.

Gait and Stance:  Normal.


1.  How would you classify this patient’s seizure disorder?

2.  Is there anything in the description of the seizures that indicates a precise localization of the onset of the seizures?

3.  Is there anything in the description of the patient’s seizures that indicates which side of the brain the seizures arise from?

4.  Is there anything in the patient’s history that suggests a possible etiology or pathologic process involved in her seizure disorder?  If so, what clinical-pathologic entity (i.e., epileptic syndrome) may be the cause of this patient’s seizures?

5.  What diagnostic procedure(s) would you undertake at this point?


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