Is it Epilepsy?Is it Epilepsy?

Extra Case 1 (week 3 neuro)Extra Case 1 (week 3 neuro)

PCPCA 45 year old woman presents with A 45 year old woman presents with new onset seizuresnew onset seizures and altered and altered consciousness. consciousness.

HxPC HxPC Julie was talking to a co-worker when she Julie was talking to a co-worker when she suddenly stared, turned her suddenly stared, turned her head to the right, began smacking her lips, and then had a generalised head to the right, began smacking her lips, and then had a generalised tonic-clonic seizuretonic-clonic seizure.  The seizure lasted .  The seizure lasted two to three minutes. two to three minutes. Julie Julie does not recall anything immediately prior to or during the event does not recall anything immediately prior to or during the event and was still confused 20 minutes laterand was still confused 20 minutes later.  Her husband and a co-worker .  Her husband and a co-worker state that she has not been physically ill recently but over the last two months state that she has not been physically ill recently but over the last two months has been "has been "having a mid-life crisishaving a mid-life crisis". ".

Julie has NO PMHx, PSHx, current Meds and is NKDA. Family Hx includes Julie has NO PMHx, PSHx, current Meds and is NKDA. Family Hx includes HTNHTN

SHx:SHx:Graphic designer, married with one daughter.  Recently Graphic designer, married with one daughter.  Recently decided she wanted decided she wanted a divorce despite lack of marital conflica divorce despite lack of marital conflict.  Drinks one glass of wine a day t.  Drinks one glass of wine a day

Q1  Does Julie have epilepsy?Q1  Does Julie have epilepsy?

Q1  Does Julie have epilepsy?Q1  Does Julie have epilepsy?

Julie has just had a complex partial Julie has just had a complex partial seizure with secondary generalisation seizure with secondary generalisation (since had aura or partial seizure (since had aura or partial seizure preceded the generalized seizure) It preceded the generalized seizure) It is impossible to diagnose this is impossible to diagnose this episode as part of epilepsy yet since episode as part of epilepsy yet since this is her first seizure. She is also at this is her first seizure. She is also at an age unlikely to develop epilepsy. an age unlikely to develop epilepsy. Further investigation is needed!Further investigation is needed!

Q2  What is your differential Q2  What is your differential diagnosis?  (at least three diagnosis?  (at least three

possibilities)possibilities)

Q2  What is your differential diagnosis?  (at least three Q2  What is your differential diagnosis?  (at least three possibilities)possibilities)

TIATIA Infective meningitis / encephalitisInfective meningitis / encephalitis Psychogenic seizurePsychogenic seizure Psychoactive drugsPsychoactive drugs Brain tumourBrain tumour EpilepsyEpilepsy

All acting as epileptogenic triggersAll acting as epileptogenic triggers

If EpilepsyIf Epilepsy Partial seizure with secondary generalisationPartial seizure with secondary generalisation Primary generalized tonic – clonic seizurePrimary generalized tonic – clonic seizure Absence seizure associated with generalized tonic - Absence seizure associated with generalized tonic -

clonic seizure clonic seizure

Q3  What signs will you look for Q3  What signs will you look for on examination, and what on examination, and what

laboratory tests will you order to laboratory tests will you order to aid in diagnosis?aid in diagnosis?

Q3  What signs will you look for on examination, and what Q3  What signs will you look for on examination, and what laboratory tests will you order to aid in diagnosis?laboratory tests will you order to aid in diagnosis?

O/EO/E Obs – (HR, BP, O2sats) – sympathetic overdrive and cyanosis during Obs – (HR, BP, O2sats) – sympathetic overdrive and cyanosis during

seizure episode seizure episode Temp – infection?Temp – infection? LymphadenopathyLymphadenopathy Head trauma – epileptogenic centre or consequence of seizure?Head trauma – epileptogenic centre or consequence of seizure? Organomegaly – storage diseases/ endocrine/ metabolic disease?Organomegaly – storage diseases/ endocrine/ metabolic disease? Acute psychosis? MMSEAcute psychosis? MMSE CVS exam – risks for cerebrovascular diseaseCVS exam – risks for cerebrovascular disease Neuro exam – signs of increased ICP – blown pupils etc, other focal neuro Neuro exam – signs of increased ICP – blown pupils etc, other focal neuro

defects. Tests of motor func – pronator drift, tendon reflexes, gait, defects. Tests of motor func – pronator drift, tendon reflexes, gait, coordination – lesion in motor cortex? And failed double simultaneous coordination – lesion in motor cortex? And failed double simultaneous stimulation may suggest lesion in parietal cortex. Unilateral facial droop stimulation may suggest lesion in parietal cortex. Unilateral facial droop with contralateral hemiplegia/ hemiparesiswith contralateral hemiplegia/ hemiparesis

EEG EEG Wet crotch?Wet crotch? Bitten tongue?Bitten tongue? Any paralysis – still present after a few hours – stroke?Any paralysis – still present after a few hours – stroke?

Q3  What signs will you look for on examination, and what Q3  What signs will you look for on examination, and what laboratory tests will you order to aid in diagnosis?laboratory tests will you order to aid in diagnosis?

InvestigationsInvestigations U+E’s including K, Mg and CaU+E’s including K, Mg and Ca GlucoseGlucose LFT’sLFT’s TFT’sTFT’s CreatinineCreatinine D - dimerD - dimer Alkaline phosphataseAlkaline phosphatase Drug tox screenDrug tox screen LP esp in AIDS ptsLP esp in AIDS pts MRI > CT for mass lesions, oedema, midline MRI > CT for mass lesions, oedema, midline

deviation, traumadeviation, trauma

O/EO/EAfebrile;  BP 110/70;  HR 76;  RR 16Afebrile;  BP 110/70;  HR 76;  RR 16

Mental State:  initially responds only to simple commands Mental State:  initially responds only to simple commands and is unable to converse but over the course of your and is unable to converse but over the course of your examination she improves dramatically and complains examination she improves dramatically and complains of a bifrontal headache.of a bifrontal headache.

Julie tells you that she had a minor sore throat and Julie tells you that she had a minor sore throat and possibly a low-grade temperature a week ago.  She possibly a low-grade temperature a week ago.  She denies having any prior headaches or seizures.denies having any prior headaches or seizures.

When asked about any changes in mood she denies this When asked about any changes in mood she denies this and says that she has not been depressed but feels and says that she has not been depressed but feels that she needs to be free to pursue her dream of that she needs to be free to pursue her dream of becoming a movie star.  She plans on divorcing her becoming a movie star.  She plans on divorcing her husband and moving to Los Angeles “to be husband and moving to Los Angeles “to be discovered”.  She has no training or experience as an discovered”.  She has no training or experience as an actress, does not plan on going to acting school and actress, does not plan on going to acting school and has never performed in a play since primary school.  has never performed in a play since primary school.  She denies any hallucinations.She denies any hallucinations.

O/EO/ECN II-XII intactCN II-XII intact

Fundi: no papilloedema.  Visual fields NADFundi: no papilloedema.  Visual fields NAD

Motor: normal muscle tone and strength bilaterally to testingMotor: normal muscle tone and strength bilaterally to testing

Reflexes: 2+ throughout.  Babinski signs present bilaterally.Reflexes: 2+ throughout.  Babinski signs present bilaterally.

Sensation, Co-ordination & Gait: NADSensation, Co-ordination & Gait: NAD

Investigations:   Bloods NADInvestigations:   Bloods NAD

CT scan:  poorly circumscribed, hypointense left temporal CT scan:  poorly circumscribed, hypointense left temporal lobe lesion with small foci of haemorrhage and possible lobe lesion with small foci of haemorrhage and possible early uncal herniation, with minimal surrounding oedema.early uncal herniation, with minimal surrounding oedema.

Q4 What is the most likely Q4 What is the most likely diagnosis?diagnosis?

Q4 What is the most likely diagnosis?Q4 What is the most likely diagnosis?

Astrocytoma, more specifically a glioblastoma/ glioblastoma Astrocytoma, more specifically a glioblastoma/ glioblastoma multiforme creating a mass lesion resulting in uncal multiforme creating a mass lesion resulting in uncal herniation since these tumours can present commonly with herniation since these tumours can present commonly with seizures and sometimes personality, mood and mental ability seizures and sometimes personality, mood and mental ability changes. changes.

Haemorrhage suggests aggressive nature (infiltration and Haemorrhage suggests aggressive nature (infiltration and necrosis), therefore placing provincial diagnosis on GBM necrosis), therefore placing provincial diagnosis on GBM (high grade IV) over diffuse astrocytoma (grade II) or (high grade IV) over diffuse astrocytoma (grade II) or anaplastic astrocytoma (grade III). If endothelial proliferation anaplastic astrocytoma (grade III). If endothelial proliferation was present, this would rule in GBMwas present, this would rule in GBM

Location and behavioural Sx suggest Dx of neuronal tumour, Location and behavioural Sx suggest Dx of neuronal tumour, BUT haemorrhage and Julie’s age don’t add up BUT haemorrhage and Julie’s age don’t add up

Julie is abit old for embryonal tumoursJulie is abit old for embryonal tumours Lack of calcification oligodendroglioma less likely Lack of calcification oligodendroglioma less likely Location makes ependymoma and meningioma less likely tooLocation makes ependymoma and meningioma less likely too Single lesion make metastatic brain tumour unlikelySingle lesion make metastatic brain tumour unlikely

Q5 What would be the next step Q5 What would be the next step in management?in management?

Q5 What would be the next step in management?Q5 What would be the next step in management?

Treat with anti-epilepticsTreat with anti-epileptics

Order indicated investigations : MRS, Order indicated investigations : MRS, PET but NOT LP (unless you don’t like PET but NOT LP (unless you don’t like your registration – transtentorial your registration – transtentorial herniation happens)herniation happens)

Treat the oedema: IV corticosteroids Treat the oedema: IV corticosteroids and mannitol and mannitol

Julie's MRI shows a large, Julie's MRI shows a large, poorly circumscribed cortical, poorly circumscribed cortical, left temporal lobe lesion with left temporal lobe lesion with areas of haemorrhage and areas of haemorrhage and necrosis.  The uncal herniation necrosis.  The uncal herniation is mild with no evidence of is mild with no evidence of brainstem compression.  A brainstem compression.  A biopsy is taken.biopsy is taken.

Q6  What is the most common  Q6  What is the most common  primary brain tumour in adults?primary brain tumour in adults?

Q6  What is the most common  primary brain tumour in adults?Q6  What is the most common  primary brain tumour in adults?

Gliomas – High grade infiltrating Gliomas – High grade infiltrating astrocytoma (60 – 80 % of the little astrocytoma (60 – 80 % of the little blighters) blighters)

aka ‘the terminator’aka ‘the terminator’

Q7  Briefly outline management Q7  Briefly outline management of this condition.of this condition.

Q7  Briefly outline management of this conditionQ7  Briefly outline management of this condition

Potato poultice twice daily applied to Potato poultice twice daily applied to earear

53 sessions of chiropractic 53 sessions of chiropractic realignmentrealignment

ONLY JOKING!ONLY JOKING!

Q7  Briefly outline management of this condition.Q7  Briefly outline management of this condition.

Assuming GBM:Assuming GBM: Biopsy/ Sterostatic biopsy (appropriate management Biopsy/ Sterostatic biopsy (appropriate management

can only occure once definitive histological Dx made)can only occure once definitive histological Dx made) Preoperative Imaging (determine the functional regions Preoperative Imaging (determine the functional regions

of the brain and the location of the lesion in relation to of the brain and the location of the lesion in relation to these)these)

Surgical Resection as appropriate (Maximal resection Surgical Resection as appropriate (Maximal resection whilst preserving neurological function)whilst preserving neurological function)

Adjunctive RadiotherapyAdjunctive Radiotherapy Adjunctive ChemotherapyAdjunctive Chemotherapy1.1. Temozolomide – oral alkylating agent – 1Temozolomide – oral alkylating agent – 1o

2.2. The nitrosurea ‘carmustine – iv alkylating agent – 2The nitrosurea ‘carmustine – iv alkylating agent – 2oo Nice things like pt education, support groups etc – Nice things like pt education, support groups etc –

most GBM- suffers die within a year of diagnosis, even most GBM- suffers die within a year of diagnosis, even with treatment. Less than 2% survive 3 years with the with treatment. Less than 2% survive 3 years with the condition.condition.

The EndThe End