CONVULSIONS

CONVULSIONS: Excerpt from Algorithmic Diagnosis of Symptoms and Signs

Ask the following questions:

1. Are the episodes of loss of consciousness really seizures? Real seizures, especially grand mal, present with incontinence and/or tongue biting. Hysterical seizures with actual tonic or clonic movements may occur, but there is no tongue biting or incontinence. Syncope usually is not accompanied by convulsive movements, but it occasionally can be after the drop in blood pressure or anoxia to the brain has continued for a period of time. If there are no convulsive movements to the blackouts, then the possibility of syncope must be considered. In addition, cerebrovascular accidents, narcolepsy, and breath-holding attacks must be considered when there are no definite convulsive movements.
2. Is there a history of drug or alcohol abuse? Alcohol withdrawal seizures and seizures due to cocaine abuse are becoming more common. Patients frequently lie about their use of illicit drugs or alcohol. In young adults and teenagers, a urine drug screen should be done.
3. Is there fever? Fever should make one think of meningitis or encephalitis, or if it has been extended over a longer period of time, a cerebral abscess. In children, one should consider the possibility of febrile convulsions.
4. What type of seizure disorder is it? If there are convulsions, are they focal or jacksonian type? That would certainly suggest a space-occupying lesion as opposed to a generalized convulsion. Loss of awareness with no actual collapse for 1 minute or less is suggestive of a petit mal type seizure. In these seizures, the patient just simply stares. Longer attacks of loss of awareness are more likely to be due to complex partial seizures and occasionally an observer will note unusual behavior during these episodes. The patient may note unusual odors.
5. Are there focal neurologic signs and papilledema? These findings are more typical of a space-occupying lesion such as a cerebral tumor, cerebral abscess, or a subdural hematoma.

DIAGNOSTIC WORKUP

All patients should receive a CBC, urinalysis, sedimentation rate, ANA, VDRL test, and chemistry panel. Patients with high-risk behavior should have HIV testing. In older patients, a chest x-ray should be done to look for the possibility of a primary lung tumor. A urine drug screen is useful especially in young adults. All patients also need a wake-and-sleep EEG. Ambulatory EEG monitoring can now be done in the hospital or an outpatient setting with a digitrace device. In the elderly, four-vessel angiography or magnetic resonance angiography may be needed to distinguish transient ischemic attacks from epilepsy. There is some argument over whether a CT scan or MRI should be done on all patients with definite convulsions. The author believes that a CT scan should be done on all patients, even those without focal neurologic signs or papilledema. Isotope brain scans, arteriography, and pneumoencephalography are no longer indicated unless something is found on the CT scan that needs further clarification. A spinal tap should also be done when there is fever or when central nervous system lues or multiple sclerosis are suspected. VEPs and BSEPs may also help diagnose multiple sclerosis. It should be noted that seizures occur in 7% of cases with multiple sclerosis. In patients with frequent attacks, a trial of anticonvulsant drugs may be diagnostic.

A consultation with a neurologic specialist can be done at any point in this workup. Certainly, it would be very important to have it done early if there are focal neurologic signs or papilledema.

Book Source Details

• Book Title: Algorithmic Diagnosis of Symptoms and Signs
• Author(s): R. Douglas Collins
• Year of Publication: 2003
• Copyright Details: Algorithmic Diagnosis of Symptoms and Signs, Copyright © 2003 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Algorithmic Diagnosis of Symptoms and Signs Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 0-7817-3805-9

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