EPILEPSY

Case Illustration
Name : Mrs. N
Age : 68 years old
Address : Jakarta

Chief Complain
Patient complained of decreased in consciousness after
multiple seizures attacks.

History of Present Illness
Patient was unconscious after suffering from seizure
attack on her bedroom. According to patients family who
witness the event, patient was in prone position and
suddenly developed muscle stiffness on the upper part of
the body, particularly upper extremities. Patient was also
having upward gaze and asymmetrical face during the
seizure. The seizure lasted for less than 5 minutes.
Afterward, patient looked weak and spoke several
incomprehensible words.
Patient was not alert after the attack. In about the next 30
minutes, patient developed again seizure with the same
pattern but lasted for less than a minute.
Then, patient was brought to the hospital.
History of Present Illness
In the emergency ward, patient developed again another
seizure with the same pattern and was given some kind of
medication by the doctor and the seizure subsided.
There was no headache, no feeling of nausea or vomit
before the seizure. Patient has no problem in controlling
her urination and defecation. After the seizure patient was
unconscious and regain consciousness in about 5 hours
after the last attack in ED.
History of Past Illness
Patient has never suffered from seizure previously.
Patient has hypertension since 30 years ago and was
properly controlled. Patent also has diabetes diagnosed
since 10 years ago, however patient did not take her
diabetic medication regularly.
5 years ago patient has ever suffered from stroke and
caused her face to become asymmetry.
Patient was blind since her childhood.
Physical Examination
Consciousness : CM; look moderately ill
GCS : E4M6V5
Blood pressure : 130/80 mmHg
Heart rate : 86x/min
Respiratory rate : 20x/min
Temperature : 36.8C
Eye : anemic -/-; icteric -/-
Meningeal sign (Lassek, Kernig, Bruzinski) (-)
Pupil : iscokhor 3mm/3mm (light reflex cannot be
assessed due to cataract)
Nerve VII paresis central (+)
No hemihipestesis
All motoric strength 5 (upper and lower extremities)
All physiological reflex ++ (upper and lower extremities)
No pathological reflex

Lab Results
Hb : 13.5 g/dl
Ht : 42.7%
Erythrocyte : 4,840,000/ul
Thrombocyte : 293,000/ul
Leukocyte : 8,870/ul
Diff. count : 0.2/0.7/69.8/19.3/10
ESR : 80mm/h
SGOT : 53 U/L
SGPT : 33 U/L
Total protein : 7.2 g/dl
Albumin : 3.36 g/dl
Globulin : 3.84 g/dl
Total bilirubin: 0.26 mg/dl
Direct bilirubin: 0.08 mg/dl
Indirect bilirubin: 0.18 mg/dl
Ureum : 24 mg/dl
Creatinine : 0.7 mg/dl
Triglyceride : 102 mg/dl
Total cholesterol: 223 mg/dl
HDL : 61 mg/dl
LDL : 139 mg/dl
Na : 142 mEq/L
K : 3.56 mEq/L
Cl : 107.2 mEq/L
PT patient : 10.7 s
PT control : 11.9 s
aPTT patient : 32.2 s
aPTT control : 33.8 s
Fibrinogen : 367.5 mg/dl
D-Dimer : 1100 mg/dl
Glucose : 98 mg/dl
HbA1c : 13.1%
Radiology
Chest X-Ray
CTR < 50%, elongated aorta calcified, normal heart and lung

CT-SCAN
Left and right frontal lobe infarct
Old right thalamus infarct
Senile cerebral atrophy

Working Diagnosis
History of status epilepticus and right VII cranial nerve
paresis in bi-frontal ischemic stroke
Hypertension
Diabetes Mellitus Type II

Management
Nasal cannula O2 at 2l/min
IVFD NaCl 500 cc/12 h
Citicoline
Aspirin 80 mg qD
Simvastatin 20 mg qD
Phenytoin 100 mg TID
Insulin drip
HCT 12.5 mg qD

Discussion
Female 68 y.o. multiple seizures with impaired
consciousness status epilepticus
Possible cause of multiple seizures infarct at bilateral
frontal lobe
Infarct at bilateral frontal lobe no motor deficit
possibly infarct at association area not premotor area
Infarct at both frontal lobe hyperexcitation occur
throughout hemispheres reduction in consciousness
Face asymmetrical due to old right thalamus infarct
Other possible underlying causes of seizure not tumor
(not evidence of mass on CT Scan), not metabolic
(normal glucose and electrolyte)
Discussion
Risk factors (hypertension and diabetes) not adequately
controlled.
HbA1c high bad control of glucose increase risk
of subsequent stroke high anaerobic cellular
respiration high lactate and oxidants damage the
dying brain
Patient need to take antihypertensive and antiglycemic
medication regularly.
Antiplatelet should be given to prevent subsequent stroke
from happening.
Long-term antiepileptic drug need to be taken by patient
to reduce the incidence of seizure