Case Report

EPILEPSY

Sonya Andzil M. Tori

1808436715

Supervisor:
 dr. Riki Sukiandra, Sp.S

DEPARTMENT OF NEUROLOGY
MEDICAL FACULTY OF RIAU UNIVERSITY
ARIFIN ACHMAD RIAU PROVINCE GENERAL
HOSPITAL
2020
 Patient’s Identity
Name : Mr. M
Age : 46 years old
Address : Pekanbaru
Religion : Islam
Marital’s Status : Single
Occupation : Parking attendant
Admitted to Hospital : Thursday, October, 12th 2020
Medical Record : 9983XX
 Anamnesis

Chief complaint:
Seizure 3 weeks ago before admitted to the
hospital
 Present Illness History
A 46 years old male patient came to Arifin Achmad General
Regional Hospital polyclinic complaining a seizure 3 weeks ago.
The seizure happened when he was sleeping. The seizure
frequency was 1 time/day, the duration was around 5 minutes.
He was unconscious during seizure. His brother said his body
became stiff and followed by jerking, his tongue was bitten, his
eyes were looking upward, and his mouth was froth with saliva.
 Present Illness History

There was no history of fever before seizure. There were no

history of headache, nausea, vomiting, and neck stiffnes. After
seizure, he looked tired and confused around 10 minutes until he
gained his consciousness. He didn’t remember what had
happened and didn’t seek any treatment to health care facility.
He didn’t complain any other seizure afterward.
 Past Illness history
-The patient had a history of seizures since the age of 8 years old. The symptoms
similiar to his last seizure and but he started to consume antiepileptyc drug
regularly from doctor since 20 years old until 26 years old and had been seizure
free since around that time.
-There was no history of infection/ malignancy/ head trauma

Family Ilness history

There is no history of seizure was found in his family.
There is no history of epilepsy in his family.
 Summary
History of seizures since age 8 yo, consume AED since 20 years old until 26 yo
↓

A patient complained a seizure 3 weeks ago

↓
1 time/day, around 5 minutes, unconscious during seizure, his body became stiff and
followed by jerking, his tongue was bitten, his eyes were looking upward, and his mouth was
froth with saliva
↓
after seizure-> he looked tired and confused around 10 minutes
 Physical Examination (October, 08th 2020)

Generalized Condition Physical examination Neurological status

• BP : 180/100 mmHg • Neck : Normal limit • Consciousness:

• HR : 90 bpm • Thorax : Normal limit Composmentis
• RR : 22 x/minute • Abdomen : Normal limit • GCS : 15 E4V5M6
• T : 36,8°C • Noble Function :Normal
• Weight : 60 kg • Neck Rigidity :
• Height : 162 cm Negative
• BMI : 22,9 kg/m2
(normoweight)
 Cranial Nerves
CN. I (Olfactorius)
  Right Left Interpretation
Sense of Smell Normal Normal Normal

CN. II (Opticus)

  Right Left Interpretation

Visual Acuity Normal Normal
Visual Fields Normal Normal Normal
 
Colour Recognition Normal Normal
CN III (Oculomotorius)

Right Left Interpretation

Ptosis - -
Pupil  
Shape Round Round
Side Φ3mm Φ3mm Normal
Extraocular movement Normal Normal  
Pupillary reaction to light    
Direct + +
Indirect + +
CN IV ( Trochlearis)
  Right Left Interpretation

Extraocular movement + + Normal

CN V (Trigeminus)

  Right Left Interpretation

Motoric Normal Normal

Normal
Sensory Normal Normal
 
Corneal reflex + +
CN VI (Abduscens)
  Right Left Interpretation
Eyes movement Normal Normal
Strabismus - - Normal
Deviation - -
CN VII (Facialis)

Right Left Interpretation

Tic (-) (-)
Motor:    
-Frowning Normal Normal
-Raised eye brow Normal Normal
-Closed eyes Normal Normal
-Corners of the mouth Normal Normal
Normal
-Nasolabial fold  Normal  Normal

Sense of Taste Normal  Normal

Chvostek Sign (-) (-)
• CN VIII (Accousticus)
  Right Left Interpretation
Hearing sense Normal Normal Normal
• CN IX (Glossopharyngeus)

  Right Left Interpretation

Normal Normal
Pharyngeal Arch
 
 Flavour sense
Normal Normal Normal
 
Gag Reflex
+ +
• CN X (Vagus)
  Right Left Interpretation
Pharyngeal Arch Normal Normal
Normal
Dysfonia - -

• CN XI (accessorius)

  Right Left Interpretation

Motoric Normal Normal
Trophy Normal Normal Normal
   
• CN XII (Hypoglossus)

  Right Left Interpretation

Motoric Normal Normal  
Normal
Trofi Eutrophy Eutrophy
Tremor - -
- -
Dysathria
 Motoric
  Right Left Interpretation
Upper Extremity
Strength
Distal 5
5
Medial 5
5
Proximal 5
5
Tonus Normal
Normal Normal
Trophy Eutrophy
Eutrophy
Involunteer movement -
-
Clonus -
-
Lower Extremity    
Strenght  
Distal 5 5
5 Normal
Medial 5
5
Proksimal 5
Tonus Normal Normal
Trofi Eutrophy Eutrophy
Involunteer movement - -
Clonus - -
Body    
 
Trophy Eutrophy Eutrophy
Normal
Involuntary movements - -
Abdominal Reflex - -
 Sensory
  Right Left Interpretation
Touch Normal Normal
Pain Normal Normal Normal
Temperature Normal Normal

Propioseptive    
 Vibration Normal Normal
 Position Normal Normal
 
 Two point discrimination Normal Normal
Normal
Normal
 Stereognosis Normal
Normal
 Graphestesia Normal
 Reflex
  Right Left Interpretation
Physiologic    
Biseps (+) (+)
Physiologic reflex is
Triseps (+) (+)
Positive (Normal)
Patella (+) (+)
Achilles (+) (+)

Patologic
(-) (-)
Babinski
(-) (-) Patologic reflex (-)
Chaddock
(-) (-)  
Hoffman Tromer
(-) (-)  
Openheim
(-) (-)  
Schaefer
     
 
     
Primitive Reflex
(-) (-) No primitive reflex
Palmomental
(-) (-)
Snout
 Coordination
  Right Left Interpretation
Point to point movement Normal Normal

Normal Normal Normal

Walk heel to toe
Gait Normal Normal
Tandem Normal Normal
Romberg Normal Normal
 Autonomy System

• Urinate : Normal
• Defecation : Normal
 Other Examination

• Laseque :Not limited

• Kernig :Not limited
• Patrick : -/-
• Kontrapatrick : -/-
• Valsava test : -
 Working Diagnosis
Clinical diagnose • Symptomatic Epilepsy

Topical diagnose • Intracranial (Carotid system)

Etiological diagnose • Post Non Haemmorrhage Stroke

Differential diagnose • Idiopathic Epilepsy

Secondary Diagnose • Hypertension Grade II

 Suggestive Examination
EEG
 Management
Non pharmacologic therapy
• Bed rest
• Airway Management
• Nasal Canule O2 2-4 l/minute
• Observe seizure

Pharmacologic therapy
• IVFD RL 16 dpm
• Injection Phenytoin 3 x100 mg Normal Saline 20 ml iv
• Injection Diazepam 10 mg prn iv
• Injection Citicolin 2 x 500mg iv
• Injection Ranitidin 2 x 30 mg iv
• Amlodipin 1 x 10 mg po
• Aspilet 2 x 80 mg po
DISCUSSION
 Definition
Conseptual:
Brain abnormality-> generate epileptic seizure continuously, with
neurobiologic, cognitive, phsychologic, and social consequences

Operational:
-2 seizures without provocation/ 2 reflex seizure
more than 24 hours apart
-1 seizure w/o provocation or 1 reflex seizure in the presence the probability
of recurrence with the risk of recurrence is two seizures w/o provocation (at
least 60%), which can occur in up to 10 next year
-epilepsy syndrome can be diagnosed
 Etiology
• Structural
• Genetic
• Infectious
• Metabolic
• Immune
• Unknown
 Epidemiology

• 75% live in resource-poor countries with little or no

access to medical services or treatment.
• Incidence-> 50.7 per 100,000 for males and 46.2 per
100,000 for females.
• Incidence -> 20 and 40 yo and greatest increase seen in
>80 yo
 Classification
ILAE 1981 Classification of Epilepsy Based on Seizure Type

Partial seizures beginning locally Partial seizures Generalized seizures

becoming secondarily
generalised
Simple Complex
•With motor symptoms • Beginning as simple partial Absence seizures
•With somatosensory or seizure (progressing to Myoclonic seizure
special sensory complex seizure) Clonic seizures
symptoms •Impairment of consciousness Tonic seizures
•With autonomic at onset Tonic-clonic seizures
symptoms a) Impairment of
•With psychic symptoms consciousness only
b) With automatism
 Pathophysiology
• A seizure-> paroxysmal high-voltage electrical discharge
of susceptible neurons within an epileptogenic focus

• Disruption of mechanisms that normally create a balance

between excitation and inhibition
 Pathophysiology
• Glutamate bind to NMDA and non NMDA receptors-> Na+ and Ca2+
ions enter the cell-> Depolarization

• GABA generates hyperpolarization by increases conductance of Cl-

and associated with opening K+ channels.

• Glia cells disruption ->

-↑ levels of extracellular K+-> ↓ threshold for neuronal firing -↑ levels of
glutamate-> ↑ neuronal activation
 Pathophysiology
• EEG: Generalized seizures start simultaneously in both cerebral
hemispheres-> bilateral symtomps w/ loss of consciousness.

• In GTCS, the spread of excitability to subcortical, thalamic,

brainstem, and spinal cord structures-> tonic phase

• Following this, an inhibitory impulse starts from the thalamus and

interrupts the tonic phase into discontinuous bursts of electrical
activity-> clonic phase.
 Clinical manifestation

A.Partial seizure B. Generalized seizure

• Focal Onset Aware Seizures • Generalized Tonic–Clonic
(Simple Partial Seizures) Seizures
• Focal Impaired Awareness • Absence (Petit Mal) Seizures
Seizures (Complex Partial • Other
Seizures) ·Tonic
·Clonic
·Myoclonic
·Atonic
 Diagnosis

• History
• Physical examination
• Adjunct examination
 Therapy

• Goal
• Starting AED
• Discontinuing AED-> general conditions for stopping AED
and the possibility of recurrence after discontinuing AED
Indications, mechanism of actions, and side effects of
antiepileptic drugs
AED Indication
Carbamazep Partial, generalized tonic-
ine clonic and mixed seizure
patterns
Phenobarbit Generalized tonic–clonic
al and partial seizures in
monotherapy or adjunctive
therapy
Valproic Acid Simple and complex
absence seizures, complex
partial seizures in mono
therapy or adjunctive
therapy
Mechanism of action
Enhance fast inactivation of
sodium channels
Modulates GABA A
receptors; blocks high
voltage activated calcium
channels; blocks AMPA
receptors
Potentiates GABA ergic
activity, membrane
stabilizing effect, may affect
K+ channels
Side effect
Neurosensory, nausea,
vomiting, hyponatremia,
leukopenia, severe rash
Fatigue,drowsiness
sedation,depression,delaye
d intellectual development,
hyperactivity in
children,cognitive
impairment in adults,
porphyria, serious rash
Nausea, vomiting, anorexia,
weight gain, alopecia,
cognitive impairment
 Indications
Phenitoin Generalized tonic–clonic and
complex partial seizures;
prevention and treatment of
seizures following
neurosurgery
Clobazam Adjunctive therapy for
seizures in Lennox-Gastaut
syndrome
Mechanism of actions Side effects
Voltage dependent Nausea, fatigue,
blockade of repetitive drowsiness,
voltage gated sodium sedation,nystagmus
channel activation dizziness, ataxia,
gingival hyperplasia,
facial hair growth
Potentiates Somnolence,
GABAergic drooling,
neurotransmission, constipation,
binds at GABAa aggressive behavior
receptors
 Prognosis
• The overall prognosis for people with newly diagnosed
epilepsy is good, with 70−80% becoming seizure free

• The probability of obtaining seizure freedom-> high in

those with idiopathic generalised epilepsy and normal
neurological examination
 Basic clinical diagnosis

History: 1 time, 5 min

Generalized seizure-> seizure
seizure (stiff followed with loss of consciousness,
Physical
by jerking body), didn’t start focally, both
examination
unconscious during hemispheres affected
was normal.
seizure, confused bilaterally and symmetrically.
±10 minutes.
 Basic topical diagnosis

Seizure (stiffness followed by jerking entire body) and loss

of consciousness
↓
Generalized seizure
↓
Cerebral cortex
 Basic etiological diagnosis
History:
-tonic followed by clonic stage with loss of consciousness during seizure,
tongue trauma, the mouth may froth with saliva,
and full orientation gained in 10 to 30 min

-history of AED consumption ± 20-26 years ago and seizure free since then

↓
Physical examination:
Normal
↓

Idiopathic tonic clonic Grand Mal seizures

 Basic differential diagnosis
• Symptomatic epilepsy-> similiar features, such as tonic
clonic seizure.

• Prolonged epilepsy-> damage the neuron-> start to

relapse-> EEG is suggested
 Basic treatment

• Phenitoin is indicated for generalized tonic–clonic

• Phenitoin works by blocking voltage dependent of

repetitive voltage gated Na+ channel activation ->
↓hyperexcitability.
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