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Clinical Case 076: post, post-ictal?

This case asks a question to which I do not know the answer.  I am not sure there is an answer – so I am putting it out there for you all to “crowd source” some enlightenment.

49 yo man with a history of an acquired brain injury and subsequent seizure disorder – he has had seizures every few months for a while, despite being on phenytoin and sodium valproate.  His seizures are usually focal with secondary generalisation, lasting 5 minutes. 

All of this information comes from his chart as he is wheeled in by the ambos again.  The story today is as follows:

He was found unresponsive by his flatmate-  he was in bed, covered in vomit and had been incontinent of urine.  The flatmate didn’t actually see him convulsing.  The ambos have checked his sugar and brought him into ED.

On arrival he has a GCS of 11/15, is making unintelligible noises.  He has definite unilateral hypertonicity of his arm on the left and brisk reflexes on that side.  He is localising to pain, but weak on the left arm with a subtle facial droop.

His Obs are all normal: pulse 85, BP 130/80, RR 18/min, Spo2 97%.  No fever.

A bedside VBG – normal electrolytes, BSL 7 mmol/l and a raised lactate = 4.2 (consistent with a fit)

Now  – what is the differential diagnosis for his current neurological findings?

If we assume this is a “post-ictal state” – how long is he allowed to have the neuro signs before we start getting worried ?

  • If he was still weak and GCS 11 at 30 minutes?
  • What if he was still weak and GCS 11 at 1 hour?  4 hours, 12 hours?
  • What if we got nervous and did a CT of his gulliver – which showed the old injury / some frontal leukomalacia?  How long before you might start considering other causes – a new bleed? An infection ? an intoxication?

 OK, let me know.  How long is too long to be “post-ictal”?

Are there any timeframes you work with or is it dependent on the scenario, the background, the pathology?

Casey

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Comments

  1. Andy Neill says:

    Great question. I think it’s a total judgement call based on whatever tenuous evidence you can gather from family friends and the chart.

    I suppose one of the questions is which of the possibly “worrying” reasons we need to know about right now.

    Most bleeds causing seizures will be non surgical. If it was an EDH you’d expect to find trauma.

    If it was tox then a CT won’t help anyhow though you’ll need to raise your index of suspicion

    If it’s an airway thing then you’ll need to tube either way even if it is just post ictal.

    It’ll also depend on the usual politics like time of night and whether the scanner is running or not.

  2. Seth Trueger says:

    Well put, Andy!

    Particularly: “I think it’s a total judgement call based on whatever tenuous evidence you can gather from family friends and the chart.”

    My number 1 philosophy on seizures is that patients with seizures have seizures. The more this one is like the others, the less I worry! Unfortunately that means the less I know about their usual seizures…

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