Case History #188
Date of Consultation: 5-6-1997
HISTORY OF PRESENT ILLNESS:
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
NEUROLOGICAL EXAMINATION:
Mental Status Exam: Normal.
Cranial Nerves: Normal.
Motor System: Normal.
Reflexes:
Normal.
Sensory System: Normal.
Cerebellar Function: Normal.
Gait and Stance: Normal.
Questions
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?
