Nikesh Ardeshna, MD
Dr. Ardeshna is the Medical Director of Adult Epilepsy Services at Royal Oak Hospital, Beaumont Health System, in Royal Oak, Michigan.
A 55-year-old woman with a past medical history of hypertension was brought to a local emergency department by ambulance after a co-worker noticed her repeating the phrase “I have to close the store, I have to close the store” to herself after the store was already closed. The patient did not recall this time period.
In the emergency room a drug screen was negative and a computed tomography (CT) scan of the head was negative. A routine EEG was normal. A diagnosis of a seizure was made and the patient was started on levetiracetam (Keppra) 1000 mg PO q12hrs.
The patient had a consultation with an epileptologist the following week. The consultation revealed that the patient family noticed that she had periods where she would stare, her speech would not make sense, and it would appear as though she was “chewing something.” The patient denied such symptoms. The patient’s family believed these symptoms had been present for at least 5 years, but thought they were due to tiredness. When questioned, the patient recalled at least 2 instances where she has fallen asleep in bed and woken up on the floor.
When asked about potential head trauma, the patient stated she was involved in a car accident 7 months ago, but the cause was not determined. The patient was driving, there was no inclement weather, and her car veered off the road and into the ditch. The patient was not intoxicated. She was not injured as a result of the accident.
Diagnosis: partial epilepsy with and without secondary generalization.
Questions and Discussion:
- Although the patient only recently received an official diagnosis of seizure, it is likely that she was having seizures for many years (at least 5 years per history).
- Because of the long patient history with seizures, the more accurate diagnosis for this patient is complex partial epilepsy with secondary generalization.
- Does a normal routine EEG change the diagnosis?
- No. An EEG can be normal in a patient with epilepsy.
- What further testing should be ordered?
- The standard of care is to use dedicated magnetic resonance imaging (MRI) testing MRI-protocol for epilepsy.
- What was the likely cause of the car accident?
- A seizure was the likely cause of the car accident.