Profile of Seizure Disorder Presenting in Tertiary Care

3655 words (15 pages) Essay

21st Sep 2017 Health Reference this

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Dennis Varghese Thomas*, Vikram Gowda N R#

Abstract

The present descriptive prospective study was carried to note the profile of seizure disorder as we observe that till date epilepsy is labeled as caused due to unknown origin with the advent of modern radiological and genetic studies the cause for seizures is tried to solve the present situation. In the present study 50 seizure cases were evaluated where we observed that it was commonly presented in second decade of life followed by elderly age group with male predominance. We noted GTC seizures (84%) followed by simple partial (6%), partial with secondary generalization (6%) and complex partial (4%) being the least. Commonest cause of seizure was discontinuation of anti-epileptic drug (28%), vascular origin (20%) with space occupying lesion (16%), other causes are infective origin (14%), eclampsia (12%), 2% of alcohol withdrawal and hepatic encephalopathy cases each. 20% cases showed abnormal EEG findings and 46% showed positive finding in CT/MRI finding which helped in diagnosing the causative agent

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Introduction

In the present context epileptic seizures are the most common serious neurological problem worldwide, affecting approximately 40-100 million persons1. It is estimated in India the burden of epilepsy is around 55 lakh individuals, 3-5% of population has a seizure in their life time and 0.5 -1% of the population is reported to have active epilepsy 2.Seizure disorder may be defined as intermittent derangement of nervous system due to an excessive and disorderly discharge of cerebral neurons on skeletal muscles, the discharge may result in almost instantaneous loss of consciousness, alteration of perception or impairment of psychic function, convulsive movements, disturbance of sensation or combination thereof.

Thus seizure may occur during the course of many medical illnesses always indicating that cerebral cortex being affected by disease either primarily or secondarily which leads to abnormal electrical discharge in brain whilst epilepsy is the tendency to have seizure. Approximately 60% of all epilepsies are cryptogenic and incidence of epilepsy/seizure in any brain pathology is very high. Cerebrovascular disorders are one of the common causes in adults whereas perinatal insults are more common cause in children. The etiology of seizure is multifactorial in any given individual and is best thought of as an interaction between genetically determined seizure threshold, underlying predisposing pathologies or metabolic derangements and acute precipitation factors2.

A study of clinical profile of seizure disorder and its causative agent provides an important clue in management of the disorder and planning of the treatment. The paucity of literature in this part of India regarding the evaluation of seizure disorders in adult considering various etiologies, the present study was designed to evaluate the patients presenting with seizure disorder.

Methodology

A descriptive and prospective study was designed where 50 patients with history of seizures were included in the study attending the department of General Medicine during Nov 2009 to Dec 2010 in PIMS & RC, Thiruvalla, patients less than 12 years and seizures with history of head injury were excluded from the study, the patients were evaluated by a detailed clinical examination involving the nature of seizure duration characteristics, past history of seizures, associated metabolic abnormalities and special preference to diet history was taken which was followed by blood, radiological and EEG examinations, in selected cases for diagnosis CSF examination was done.

Observation

Out of 50 patients studied 18 cases were female and 32 male, 12 years was minimum age of case reported and 75 years the maximum with mean age group around 44 years,. Majority of cases with seizure reported were in the age group of 21-30 years (28%) as shown in table no.1

Table No.1 – Age and sex distribution of cases

Age group

Male

Female

Total

10 – 20

3(6%)

4(8%)

7(14%)

21 – 30

6(12%)

8(16%)

14(28%)

31 – 40

5(10%)

5(10%)

41 – 50

4(8%)

3(6%)

7(14%)

51 – 60

4(8%)

2(4%)

6(12%)

>60 yrs

10(20%)

1(2%)

11(22%)

 

32(64%)

18(36%)

50(100%)

Clinical presentation of cases are shown in Table no.2 as noted 84%(42) cases presented with generalized tonic clonic seizures and simple partial, complex partial and partial with secondary generalization less than 3% each.

Table No.2 – Clinical presentation of seizure in the cases

Presenting type of seizure

No. of Cases

Percentage

Generalized tonic clonic (GTC)

42

84

Simple partial

3

6

Complex partial

2

4

Partial with secondary generalization

3

6

 

50

100

In table no.3 representation of presenting seizure with neurological deficits involving motor, sensory, level of consciousness and involvement of cranial nerves, we observed that generalized tonic clonic seizure was mainly associated with altered consciousness and others as depicted in table no.3

Table No.3 – Seizure associated with neurological defects

Presenting type of seizure

Cases

Associated neurological defects

Motor symptoms

Sensory

Altered consciousness

Cranial nerves

Generalized tonic clonic (GTC)

42

4

2

42

1

Simple partial

3

1

Complex partial

2

1

1

2

Partial with secondary generalization

3

2

2

1

           

Table No.4 Associated clinical symptoms with seizures

Associated clinical symptoms

Presenting type of seizure

GTC

Simple Partial

Complex Partial

Partial with secondary generalization

Total

Fever

10

10(5%)

Headache

28

2

3

33(16.5%)

Vomiting

12

1

13(6.5%)

Frothing

38

2

3

43(21.5%)

Aura

10

10(5%)

Tongue bite

20

1

21(10.5%)

Urinary / Fecal incontinence

17

1

2

20(10%)

Post-ictal phase

29

1

3

2

35(17.5%)

           

Table No. 5 Profile of General Physical examination and Lab investigations in seizure patients

General Physical Examination

No. of cases

Lab Investigations

No. of cases

Fever

10

Haemoglobin (<10gm%)

2

Hypertension

2

Leucocytosis

17

Icterus

2

Hyponatremia

4

Pallor

2

Hypoglycemia

1

Edema

1

Peripheral smear for MP positive

2

Bleeding tendancies

1

Elevated liver enzymes

2

   

Thrombocytopenia

2

The most common presenting clinical symptom with seizures was post-ictal phase and frothing which was followed by headache, tongue bite, urinary or fecal incontinence and less number of cases presented with vomiting, aura or fever as the complaints associated with seizures

Table No.6 Classification of Seizure patients based on CT/MRI findings

CT/MRI finding

No. of cases

Cerebrovascular accidents

Thrombotic

Hemorrhagic

10

8

2

Arteriovenous malformation

Cavernoma

1

Gliosis

3

Neurocysticercosis

3

Tuberculoma

4

Oligodendroglioma

1

Meningioma

1

Normal

22

Table No.7 CSF examination findings of patients with seizures

Total Count

WBC

Chloride

Glucose

Protein

Diagnosis

250

25

120

30

222

Tuberculosis

20

10

56

56

Pyogenic

80

20

10

115

Pyogenic

24

6

56

58

Pyogenic

2

128

68

27

Viral

CSF examination was done for selected cases indicated for CSF examination where one each case of viral and tuberculoma was reported and three cases were pyogenic in origin

Table No.8 EEG findings in Seizure patients

EEG finding

No. of cases

Abnormal EEG waves

Spikes

Spikes & Waves

Slowing

10

3

6

1

Normal EEG waves

6

Out of 50 patients with seizures only 16 patients were subjected for EEG recording where diagnosis was not established and out of them only 10 cases showed abnormal EEG pattern

As shown in table no.9 observing the various etiology for the cause of seizures under metabolic origin hyponatremia and hypoglycemia were 6% of cases. The majority of cases reported were with past history of epilepsy on antiepileptic drug as a result of drug withdrawal 14(28%)

Table No.9 Etiology of seizures

Etiology

Presenting type of seizure

GTC

Simple Partial

Complex Partial

Partial with secondary generalization

Total

Hyponatremia

2

2(4%)

Hypoglycemia

1

1(2%)

Infective

Viral

Pyogenic

Malaria

2

3

2

7(14%)

Vascular

Stroke

AV malformation

5

1

1

1

2

10(20%)

Space Occupying Lesion

Neurocysticercosis

Tuberculoma

Oligodendroglioma

Meningioma

3

2

1

1

1

8(16%)

Hepatic encephalopathy

1

1(2%)

Alcohol withdrawal

1

1(2%)

Eclampsia

6

6(12%)

Epilepsy(due to anti-epileptic drug withdrawal)

12

1

1

14(28%)

           

Discussion

In industrialized countries epilepsy is commonly found in extremes of age spectrum, the peak being in elderly group but this is not the case in developing countries where the highest peak of seizure disorder is found in the age group of 10-20 years3. In contrast our study had increased number of cases in the age group of 21-30years of age along with this following of increased number of cases in elderly age group. Our study is similar to many other studies which showed the condition prevalent in males compared to females likewise in our study males (64%) and females (36%) were reported.

The commonest type of presentation was generalized tonic-clonic (84%) type of seizures followed by simple partial type (6%), partial secondary generalization (6%) and complex partial type (4%) is in agreement with M Gattani et al4. study reported GTC (64.7%), focal onset with secondary generalization (19.8%) and completely focal (15.5%).

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The clinical presentation of cases were 10 with fever, 28 with post ictal headache and 38 patients with frothing, 10 cases with aura and 20 cases with tongue bite, urinary incontinence in 17 patients. According to BM vander Slujis et al.5 presented that transient loss of consciousness accompanied by limb jerking can occur in both generalized epileptic seizures and in syncope. Urinary incontinence is not a helpful sign as this occurs in 17% in GCT seizures and 26% in syncope. The presence of tongue bite strongly suggests epilepsy (occurs in 41% of GCT seizures), although occasionally observed in syncope (2-6%), the site of laceration is typically lateral in epilepsy, but at the tip of tongue in syncope.

15 patients presented with history of epilepsy on anti epileptic drug but discontinued as one of the cause for epilepsy, 4 hypertensive patients withdrawing their antihypertensive medications were presented with seizures due to hypertensive encephalopathy, 2 patients with type II diabetes mellitus presented with seizures due to hypoglycemia, one case was due to alcoholic liver cirrhosis and one case of old stroke presented with seizure was due to scar epilepsy.

Cerebrovascular accidents in form of thrombotic stroke were observed in 8 cases and 2 with hemorrhagic stroke, one each case of cavernoma, oligodendroglioma and meningioma and 3 cases each of tuberculoma, gliosis and neurocysticercosis. EEG should be considered as neuro-diagnostic evaluation with an apparent unprovoked first seizure along with CT and MRI imaging.

Lab tests like serum electrolytes, glucose levels, CSF analysis and toxicology screening may be helpful as determined by the specific clinical circumstances based on history, physical and neurological examination but due to insufficient data to support or refute recommending any of these tests for routine evaluation of adults presenting with an apparent first unprovoked seizure6.

Modern neuro-imaging technology now allows non-invasive diagnostic approach to a wide spectrum of brain lesions which is causative agent for seizure. MRI revolutionized the management of epileptic disorders. According to a study of 31 cases of seizures 26 cases were radiological abnormal of which 16 cases were ring-enhancing lesion tuberculomas and neurocysticercosis in 7 cases and 2 case of seizures no definite causative agent identified7.

More than 90% of patients with solitary cysticercal granuloma (SCG) present with seizures, the risk of seizure recurrence in patients with SCG is related to persistence of brain lesion. Long term follow-up study has shown that seizures associated with SCG have good prognosis and anti-epileptic drug can be safely be withdrawn with the resolution CT lesion8.

There is considerable variability in causes and risk factors for seizures in elderly, the most frequently reported risk being cerebrovascular diseases (30-70%), tumors metastatic or aggressive gliomas are less frequent (10-15%). Metabolic disorders, toxic causes and cerebral hypoxia secondary to various causes of syncope accounts for 10% of all other seizures. There is limited data of etiologies of seizures in Asia and patients with late onset of seizures either will have past history of cerebrovascular accident or head injury as presumed etiology9.

Conclusion

In the present study although the seizure cases were reported in all age groups it was more common in second decade of life and elderly individuals with male preponderance, among the cases GTC seizures were more common and known case of epileptics discontinuation of antiepileptic drug was high. It is possible that various other unknown factors are responsible for epilepsy. This provides a scope for further research in identification of causative agent and early identification of causative agent helps in better management of the seizure, however limitation of this study is small number of patients which may have not provided the exact presence of problem in society.

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