GRAND ROUNDS CASE PROTOCOL

“ Carpe diem “

October 21, 2022 (Friday)

8:00 AM to 10:00 AM
East Avenue Medical Center (Hybrid via Face to Face and Zoom Teleconferencing)

Presenter:
John Christopher V. Ruiz, MD
Year Level II Adult Neurology

Moderator:
Myrelle Frances F. Isidoro, MD
Year Level III Adult Neurology
OBJECTIVES:
1. To present a case of a 21 year old male who came in with Seizure Episodes
2. To review the etiology, anatomy, clinicopathology, radiologic and differential diagnosis of
Young Patients with Seizure Episodes
3. To enumerate the work-up, diagnostics and treatment for Young Patients with Seizure Episodes
4. To discuss about the Different Types of Neuronal Migration and Cortical Development

DEMOGRAPHIC DATA:
CB is a 21-year-old, male, right-handed, single, Filipino, Mormons, Information Technology
Student from Montalban, Rizal who was admitted for the first time in our institution last August 1,
2022.

CHIEF COMPLAINT:
Upward Rolling of Eyeballs (Seizure Like Episodes)

HISTORY OF PRESENT ILLNESS:

Patient is a 21/M, right- handed from Montalban Rizal came in for upward rolling of eyeballs

5 Years PTA (2017).

5 years PTA, during his High School Years patient started to see pillars of bright light after
working a lot on the computer which occurs about once a month and spontaneously resolves.
There were no associated headache, loss of of consciousness, visual changes, fever, change in
behavior and personality. No consult was done and no medications were taken.
During the interim, symptoms persisted and was not aggravated or alleviated by other factors. This
seemed normal to the patient and was not bothersome for him.

2 weeks PTA (July 2nd Week)

2 weeks PTA, patient had an overnight with his school works, having a ton load of paper works.
Patient was able to see Pillars of bright light after working which lasted for a minute and
spontaneously fades away. During this time, patient denied presence of headache, seizure, fever,
trauma and nausea or vomiting. The following day, patient woke up feeling tired and hungry
prompting the patient to take a glass of water. Upon drinking, patient had an unexplainable feeling
that he was more aware to all his surroundings. Patient’s vision was enhanced as if he was able to
see things on a magnified level and was associated with palpitations. As the moments passed by,
the patient felt lightheaded prompting the patient to run to his parents for help. Patient’s parents
saw the patient with flexion-like movement of the right arm with right facial asymmetry
eventually progressing to involve stiffening of all extremities with associated impairment of
awareness. This episode lasted for about 1 minute and there was noted regain of consciousness
after and was not associated with salivation, cyanosis, or bladder or bowel incontinence. After 1
hour interval, patient had another episode with the same semiology. After the episode, patient had
generalized body weakness associated with headache described as band-like in character with a
pain scale of 5/10, lasting for a few minutes, not associated with other symptoms and was relieved
spontaneously.
During the interim patient was apparently well. No consult was done and no medications were
taken.
1 day PTA, (July 31, 2022)
1 day PTA, during lunchtime patient was at his NSTP program feeding the community. After this,
patient had an intense basketball game with his teammates for about 1 hour and after the game,
patient rested. When patient stood up, the patient had a familiar feeling that this experience
already happened before and he experienced light-headedness associated with enhanced vision
and palpitation. Patient then had seizure which was the same semiology of flexion-like movement
of the right arm and right facial asymmetry progressing to stiffening of all extremities and there
was noted impairment of awareness lasting less than 1 minute. Patient was eventually brought to
our institution leading to the subsequent admission. In transit, patient was already awake but had
no recall of the seizure episode.

REVIEW OF SYSTEMS:

GENERAL (-) Easy fatigability, (-) Loss of appetite, (-) Weight loss, (-) Malar
Rash
HEAD AND NECK (-) Nasal congestion, (-) Otalgia, (-) Otorrhea, (-) Neck enlargement,
(-) photosensitivity (-) Carotid Bruits
CHEST AND LUNGS (-) Cough, (-) Dyspnea, (-) Pleurisy
CARDIAC (-) Chest pain, (-) Exertional Dyspnea, (-) Palpitations,
(-) Orthopnea
ENDOCRINE (-) Heat/cold intolerance, (-) Polyuria, Polydipsia, and Polyphagia
GASTROINTESTINAL (-) Abdominal pain, (-) Bleeding
GENITOURINARY () Dysuria, (-)Nocturia
REPRODUCTIVE (-) Abnormal vaginal discharges, (-) Bleeding
MUSCULOSKELETAL (-) Joint malalignments, (-) Muscle pains, (-) Arthralgia
PSYCHIATRIC (-) Behavioral changes

PAST MEDICAL HISTORY:

Impacted Cerumen (2007)

- Sought Consult at Children’s Hospital and was given unrecalled medications. Patient recurrent
visits at the hospital for this Ear problem.
No history of childhood or febrile seizure
FAMILY HISTORY:

No history of diabetes, heart problem hypertension, or stroke in the family.

No relative with similar symptoms. No relatives with stroke in the young. No known relative with
autoimmune disorder. No known seizure episodes in the family.

PERSONAL AND SOCIAL HISTORY:

BS Information Technology, Second Year College, Collegio de Montalban- Present
Patient is the youngest among 4 children and is currently living with his father, mother and three
older sisters. Their house is bungalow type house situated in a community with houses beside each
other, less than a meter apart.
Patient denies alcohol intake
Patient denies smoking
Patient denies illicit drug use
Patient has a pet dog for about 2 years now
There was no history of exposure to toxic chemicals, doves, or cats and other pets.

PHYSICAL EXAMINATION:

Vital Signs: BP – 130/80 mmHg, CR – 106bpm, RR – 21 cpm, Temperature – 36.5 C, Oxygen

Saturation 98% @ RA
Height – 165 cm, Weight – 60kg BMI : 22kg/m2

The patient was seen awake, conversant, not in Cardiorespiratory Distress

Anicteric Sclera Pink Palpebral Conjuctivae
Equal Chest Expansion, Clear Breath Sounds
Adynamic Precordium, Normal Rate Regular Rhythm, Distinct Heart Sounds
Flat abdomen, Normoactive Bowel Sounds
Full and Equal Pulses, Capillary Refill Time < 2 seconds

Neurologic Examination:

I. MENTAL STATUS EXAMINATION & HIGHER CORTICAL FUNCTION

The patient was mesomorphic, well-kempt, and wore appropriate clothing. Speech had normal
flow, formal tone and normoproductive. The patient was silent and calm during the interview and
displayed a broad affect. No signs of agitation or emotional lability. Illusions, hallucinations,
delusions, and misinterpretations were not observed. Patient was oriented to 3 spheres. Patient’s
registration was intact. The had good attention span and concentration -able spell the word
MUNDO forward and backward correctly and patient was able to do serial 7’s. Patient also had
good recall. There was absence of glabellar tap, palmar grasp reflex, rooting reflex, sucking, or
palmomental reflex.
The patient was able to identify watch, pen, and cup correctly. He was able to repeat the phrase,
“Walang ng papero-pero pa”. He was able to write a complete sentence and copy the figure with
interconnecting lines. He was able to draw the shape of the clock and place the hands correctly
at 10 minutes past 11. He was able to button his shirt correctly. He was able to say “hinlalaki”
when asked to name the right thumb. He was able to differentiate right and left. He was able to
show how to brush his hair correctly. He was able to dictate correctly the steps on how to cook
rice. He was able to roll back and forth the key when asked to identify it when it was placed on his
palms with his eyes closed. He was able to identify the single digit, circle and square shape written
on both his palms. He correctly identified on which side the examiner was touching while his eyes
were closed. Patient was able to identify 3 colors and has good visual tracking.

II. CRANIAL NERVE EXAMINATION

CN I: Able to distinguish coffee on both nostrils while eyes were closed.

CN II: Visual acuity:20/20 OD 20/20 OS via Pocket Snellen Chart; 20/20, both eyes with use of
corrective glasses. The pupillary sizes were 3 mm in size, equally round and briskly reactive to
light and accommodation. Patient has intact direct and indirect pupillary light reflex. There were
no visual field defects on confrontation testing and finger counting. Fundoscopic findings included
presence of red-orange reflex on both eyes. With prominent vessels and distinct disc margin on
both eyes. No AV nicking, cotton wool exudates, or subhyaloid hemorrhages.

CN III, IV, VI: Primary gaze was at midline with EOMS full on visual tracking.

CN V: There was 100% sensation equally felt on all V1 to V3 distribution upon touch, pain,
vibratory and temperature stimulation. The masseter and temporalis muscles have good tone.

CN VII: The patient was able to wrinkle forehead, maintain eye closure against forceful eyelid
opening, smile and puff cheeks. Patient was able to distinguish sugar and salt on the anterior 2/3
of the tongue.

CN VIII: There was good gross hearing. No lateralization on weber’s test. Air conduction was
greater than bone conduction on Rinne’s test.

CN IX, X: The gag reflex was intact bilaterally with equal palatal elevation.

CN XI: The patient was able to shrug and he was able to turn his head to the side against
resistance..

CN XII: The tongue was at midline with no fasciculations or atrophy.

III. MOTOR EXAMINATION

There were no tremors seen on both hands at rest. There were no muscle atrophies and
fasiculations observed. There was good muscle bulk and tone. The motor grade was 5/5 on the
right upper and lower extremities and 5/5 on the left upper and lower extremities.

IV. REFLEXES

A grade 2 reflex was elicited on right bilateral biceps, triceps, brachioradialis, patellar and
Achilles and grade 3 reflex was elicited on left patellar left brachioradialis . There was no
Babinski reflex.

VI. CEREBELLARS

No scanning speech and nystagmus seen. No truncal ataxia, dysmetria, and dysdiadochokinesia on
both right and left. The patient was able to do heel-to-shin test.

VII. SENSORY

The patient was able to sense light touch, pain, and temperature sensation on all extremities and
was graded 100% equally. There was intact position and vibration sense.

VIII. MENINGEAL SIGNS:

There was no nuchal rigidity noted when passively moved on all sides. There was absence of
Brudzinski and Kernig’s signs.

INITIAL WORKING IMPRESSION:

Focal onset sensory with impaired awareness to Bilateral Tonic Clonic Motor Seizure probably 1.
structural from mesial temporal sclerosis 2. Idiopathic Epilepsy of Childhood

COURSE IN THE WARDS:

1st Day
Patient was then managed as case of GTC Motor Seizure with Impaired Awareness probably
Idiopathic Epilepsy of Childhood and was hooked to PNSS 1L to run for 120cc/hr scheduled for
Plain Cranial CT Scan, Cranial MRI With Contrast, 21L- EEG, Covid RT- PCR and subjected to
electrolyte testing. Patient was given Leviteracetam 500mg/IV Q12 and Paracetamol 500mg/ IV
Q6 prn for headache

2nd Day- 11th Day

Patient has no seizure recurrence and was then managed as case of Multiple Intracranial Mass vs.
Abscess and was hooked to PNSS 1L to run for 120cc/hr and was still being scheduled for Cranial
MRI with Contrast, blood CS x 2 Sites and was started on Ceftriaxone 2g/IV Q12.
13th Day
Patient claims to have ear Itchiness, however was not associated with fever
still being managed as case of Multiple Intracranial Mass vs. Abscess and still hooked to PNSS 1L
to run for 120cc/hr and was started on Ceftriaxone 2g/IV Q12. Patient was referred to ENT
Service for
16th Day
Patient was still being managed as case of Multiple Intracranial Mass vs. Abscess and was hooked
to PNSS 1L to run for 120cc/hr and now has completed Ceftriaxone Treatment for 2 weeks. The
Department of ENT diagnosed the patient with Impacted Cerumen Right and Otomycosis Left and
was started with Clotrimazole TID on the Left Ear and Baby oil for 3 days TID on the right ear for
1 week and the service signed no objections for discharge
17th- 18th Day
Patient was managed now as a case of Periventricular Nodular heterotropia and was sent home
with Leviteracetam 500mg/tab BID and referred to Neurosurgery for possible biopsy and was sent
home with a follow- up schedule

FINAL DIAGNOSIS:

Focal onset sensory with impaired awareness to Bilateral Tonic Clonic Motor Seizure probably
Idiopathic Epilepsy of Childhood from T/c Periventricular Nodular Heterotropia; Otomycosis AS,
Impacted Cerumen AD

LABORATORY AND DIAGNOSTIC WORK UP:

CBC with Platelet

Date WBC Hgb Hct Neu Lymp Mono Eos Baso Plt BT
7/31/2022 20 159 48 81 12 7 0 0 326 A+

Blood Chemistry
Date Crea BUN Na K Cl Ca Mg Phos AS AL RBS
T T
7/31/2022 81.5umol/l 4.1 141.1 3.94 101.9 1.11 1.05 0.80 56 134 98.91

Urinalysis
Color Transparency pH RBC WBC Epi Mucus Bact Prot Blood

7/31/2022 Yellow Turbid 5.0 0-1 3-4 Occ Occ Mod Neg
Coagulation Factors
Date PT Control INR %act PTT Control
7/31/2022 13.1s 12.2s 1.05 76% 32.1s 31.5s

Chest X-ray
7/31/2022 EXAMINATION: CHEST PA UPRIGHT
Radiographic findings:
There are no evident parenchymal infiltrates.
The heart is normal in size.
The aorta is unremarkable.
Both hemidiaphragms, costophrenic sulci, and visualized bones are intact.
Impression:
Chestnegauve.

Non Enhanced Cranial CT Scan

7/31/2022 Multiple contiguous axial images of the head were obtained without intravenous
contrast.
There are no abnormal density changes in the brain parenchyma. The parenchymal
gray-white interface is normal. The ventricles, cisterns and sulci are normal in size
and shape. There is no midline shift, mass, or mass effect.
The mastoid air cells and visualized paranasal sinuses are well aerated. The visualized
osseous structures are unremarkable.
Incidental finding: Nonspecific soft tissue density, bilateral external auditory canals,
likely cerumen.
IMPRESSION:
No abnormal density changes in the brain parenchyma.
Incidental finding: Retained cerumen, bilateral external auditory canals.
Follow-up plain cranial CT scan or MRI is suggested if clinically warranted.
Remarks: The above-mentioned report is a subjective medical opinion only based on
the objective radiographic findings and should be correlated
clinically, before it can be used as a basis for management.
Cranial MRI with Contrast
8/11/2022 Comparison: None
Findings:
Acute intracranial hemorrhage: None evident
Acute infarction: None evident.
Brain parenchyma: Multiple round nodular lesions that is isointense to cortical gray
 matter in both periventricular regions and corpus callosum, along the lining of the
occipital horns of both lateral ventricles, resulting in irregular ventricular outline. No
abnormal contrast enhancement demonstrated.
Cortical sulci: Intact.
Cerebellar folia: Intact
Midline shift: None evident.
Ventricular system: No frank evidence of hydrocephalus seen.
Sella: Unremarkable.
Cerebello-pontine angles: Unremarkable.
Extra-axial spaces: No abnormal collections or areas of abnormal leptomeningeal
enhancement seen.
Visualized paranasal sinuses: unremarkable.
Visualized mastoid air cells: Essentially clear.
IMPRESSION:
Subependymal grey matter heterotopia, as described.
No abnormal extra-axial collections or areas of abnormal leptomeningeal
enhancement.

EEG Result 8/15/2022:

An EEG was performed for approximately 30 minutes during awake, drowsy and asleep state in
this 21 years old male diagnosed with seizure maintained on Levetiracetam
Technical Summary:
The patient was awake at the start of the study. During wakefulness, the posterior background
activity consisted of semirhythmic activity of 9-10 Hz with voltage of 20-40 UV. The central head
regions showed an activity 8-9 Hz activity with voltage of 20-60 UV. The temporal head regions
showed an activity 8-9 Hz activity with voltage of 20-40 UV. Muscle and blink artifacts were
noted. During the drowsy state, the posterior background activity consisted of semirhythmic
activity of 6-7 Hz with voltage of 10-30 UV. The central and temporal head regions showed an
activity 5-6 Hz activity with voltage of 10-40 uV. During the asleep state, the posterior
background activity consisted of semirhythmic activity of 4-5 Hz with voltage of 10-30 V. The
central and temporal head regions showed an activity 4-5 Hz activity with voltage of 10-30 uV.
There were no epileptiform discharges noted. Photic stimulation was done on different flash
elicited a driving response. Hyperventilation was done and did not elicit abnormal paroxysmal
response. A single lead EKG monitoring showed a heart rate of 72 beats per minute.
EEG Classification:
NORMAL
Impression:
This EEG done in awake state is normal. The posterior background rhythm is within normal limits
for the patient's age. Correlation with clinical history is suggested.