The coexistence of focal seizures and secondary generalized seizures in this patient and the respective EEG and MRI findings constitute her peculiar epilepsy syndrome.
A 67-year-old woman was seen in the emergency department following of an episode of syncope. She described recurrent episodes of vertigo during the past 6 months. Most recently she had been talking on the telephone with her grandson when she experienced a sensation she described as “the room spinning” accompanied by a generalized sensation of coldness. She then fell to the ground and lost consciousness. When she regained consciousness, she felt extremely tired and weak.
She sustained a bruise to her chin and left anterior chest wall from the fall. She estimated the episode to have lasted a few minutes. Her grandson, who accompanied her, had rushed to her home and called 911 after she had stopped responding on the phone and he heard the sounds of her fall.
The patient had been worked up for a similar episode (including a fall and loss of consciousness) 6 months earlier with no significant findings. She had been discharged with a supply of meclizine to take “as needed” but had several more episodes of non-positional vertigo with no temporal pattern. She had no repeated episode of syncope, however, until the current one.
She denied limb weakness, headache, excessive drowsiness, nausea, and vomiting. She claimed no palpitations, chest pain, and shortness of breath. Her exercise tolerance was preserved. She denied tinnitus but reported a long-standing history of reduced hearing in her left ear that followed a tympanic membrane rupture several years ago. Further probing revealed a mechanical fall with blunt head trauma earlier in the year; the current symptoms began approximately 1 month after this event.
Past medical history was significant for diabetes mellitus type 2, hypothyroidism, hyperlipidemia, and hypertension, all of which were well controlled with medications: aspirin, hydrochlorothiazide, rosuvastatin, glyburide, metformin, synthroid, and valsartan.
On physical examination, the patient’s vital signs were stable with no orthostasis. Glucose level was 107 mg/dL based on finger stick test. A tongue bite with bruising, as well as the bruises on her chin and chest wall were noted. Findings from the rest of the examination were unremarkable. Dix-Hallpike maneuver was negative. Serology revealed only a mild chronic microcytic anemia.
An ECG revealed normal sinus rhythm. A chest radiograph was unremarkable and a CT scan of the brain was negative. Results of recent workup done after the similar episode 6 months earlier, including carotid Dopplers and echocardiogram, were normal.
Our clinical assessment was syncope (neurogenic versus cardiac etiology) with posttraumatic seizures highly suspected.
The patient was admitted to a telemetry floor where cardiac etiologies again were excluded. An electroencephalogram (EEG) showed a sharp left occipital spike with polymorphic slowing in the left posterior region representing an epileptogenic focus or infarct (image not available). A brain MRI ordered to exclude an infarct was negative.
A complex partial seizure disorder (focal seizure with secondary generalization) secondary to head trauma was diagnosed. She was discharged home on a regimen of lamotrigine with neurology follow-up scheduled.
New-onset seizures are not uncommon in adults older than 65 years; they are usually the result of identifiable structural brain disease1 and, consequently, tend to be focal (partial) in nature and may present as recurrent vertigo. It is not uncommon for patients with seizure disorders to experience more than one seizure pattern, which together make up their unique epilepsy syndrome. The coexistence of focal seizures and secondary generalized seizures in this patient and the respective EEG and MRI findings constitute her peculiar epilepsy syndrome.
Epilepsy remains a clinical diagnosis and detailed history taking remains the cornerstone
of the diagnostic process. Physicians need a good index of suspicion and patients may need to be probed repeatedly to obtain historic details, which they may regard as irrelevant and neglect to mention. Trauma is a well-recognized cause of adult-onset seizures.2,3 The seizure focus, however, may not be apparent on brain MRI or EEG.
This was an unusual presentation of a complex partial seizure. In retrospect, the accompanying sensation of cold most likely represented an aura and the vertigo, the initial partial phase of her seizure (which did not always progress to generalization). On this occasion, the tongue biting that was apparent on examination was a good clue that the cause of her syncope was probably a generalized seizure and the subsequent weakness and tiredness represented the postictal state. This progression of symptoms is suggestive of a partial seizure with secondary generalization.
EEG findings suggested a left-sided cerebellar focus, which would explain her vertiginous symptoms. Even in the absence of confirmatory EEG findings, this patient would still benefit from a trial of antiepileptic drugs in view of her history and physical examination findings.
1. Sander JW, Hart YM, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: newly diagnosed epileptic seizures in a general population. Lancet. 1990;336:1267-1271. (Abstract)
2. Bruns J Jr, Hauser WA. The epidemiology of traumatic brain injury: a review. Epilepsia. 2003;44(suppl 10):S2-S10. (Abstract)
3. Hiyoshi T, Yagi K. Epilepsy in the elderly. Epilepsia. 2000;41(suppl 9):S31-S35. (Abstract)