Microsoft word - coma04final.doc
CLINICAL VIGNETTE An 18-year-old woman with medically intractable seizures An 18-year-old woman presented for evaluation of seizures that were not controlled by medical therapy. At the age of 6 months she was hospitalized with a fever and seizures, and was reported to have encephalitis. She lost motor and language developmental milestones, but these were gradually regained and she was treated for a year with phenobarbital and was without recurrent seizures. The phenobarbital was tapered at age 2 but at the age of 6 years she again experienced seizures, which occurred at low frequency until puberty, when the seizure frequency increased to two to three per day. The seizures were characterized by an initial aura of tightness in the head and chest and sweaty palms, followed by impaired consciousness, lip smacking, hand rubbing, and unresponsiveness. During a seizure she was unable to talk but could hear, and could not fully process information. She was treated with a variety of anticonvulsants, including phenobarbital, carbamazepine, phenytoin, valproate, and lamotrigine without significant success in seizure control. Her medical history was otherwise unremarkable. There was no family history of seizures. Physical Examination: Vital signs: normal. Bedside mental status examination: no significant abnormalities. Neuropsychological testing: full-scale IQ of 97, performance IQ of 97 and a verbal IQ of 96; mild difficulty acquiring certain types of information and some difficulty with uncued recall. Speech: normal. Cranial nerves: normal with only minimal, unsustained nystagmus on lateral gaze. Motor and sensory examinations: normal. Muscle stretch reflexes: normal. Coordination and gait: normal. Stop and Consider: What is the classification of her seizures according to the International Classification of Seizures? How should she be treated at this point? Laboratory Findings: CBC, serum chemistries with liver and renal functions, PT, PTT, ESR: normal. MRI: see figure, shows left hippocampal atrophy and increased T2 signal. Interictal EEG: left temporal sharp and slow wave activity suggestive of left temporal onset of seizures. Continuous video-EEG monitoring: several seizures captured. EEG, see figure, next page, shows left mesial temporal (EFO) onset. Interictal positron emission tomography (PET) scan: hypometabolism of the left temporal lobe. Diagnosis: Medically intractable partial complex seizures associated with hippocampal atrophy.