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Case Report

SYMPTOMATIC
EPILEPSY
Rijalun Arridho
1708436508

Supervisor:
dr. Riki Sukiandra, Sp.S

DEPARTMENT OF NEUROLOGY
MEDICAL FACULTY OF RIAU UNIVERSITY
ARIFIN ACHMAD RIAU PROVINCE GENERAL
HOSPITAL
2019
Patient’s Identity
▪ Name : Mrs P
▪ Age : 93 years old
▪ Address : Pekanbaru
▪ Religion : Moslem
▪ Marital’s Status : Married
▪ Occupation : doesn’t work
▪ Admitted to Hospital : November, 11th 2019
▪ Medical Record : 7855XX

Chief Complaint

Seizure a day before


admitted to the hospital
Present Illness History
Before • No condition
Seizure which provoked
• < 5 min, 2 • There were no
times, 5 hours numbness on
“A day before apart with
conciouss
legs and hand
admitted SEIZURE During
Seizure • Stiff and
convulsive
• No headeche or
vomitting
to hospital” movement, • No complaint in
urination and
upward gaze,
unconcious defecation

After • Post ictal


Seizure confusion
Past Illness History
Consumed
anticonvulsan

Cataract Hyper-
tension Paroxismal seizure

Stroke
“Change in behaviour
and lack of memory”

10 years 5 years 2 years 4 month Current


Seizure
Family Disease History
• Hypertension (-)
• Epilepsy (-)
• Stroke (-)
Socio-economic History
• Patient just stay at home with his daughter, since 10
years ago she often forgot the name of its family and
often difficult to understand while communicate with
other.
• History of smoking (-)
Summary

• Paroxismal
seizure with
Change in Currently,
postictal
behaviour and lack generalized tonic
confusion.
of memory, clonic seizure
• Patient have
Hypertension, with postictal
problem with
Stroke confusion
AED program
therapy.
Physical Examination (November, 12th 2019)

Generalized Condition Physical examination Neurological status

• BP : 150/90 mmHg • Neck : Normal limit • Consciousness:


• HR : 80 bpm • Thorax : Normal limit Composmentis
• RR : 22 x/minute • Abdomen : Normal • GCS : 15 E4V5M6
• T : 36,8°C limit • Noble Function :
• Weight : 55 kg MMSE score 8
• Height : 155 cm • Neck Rigidity :
Negative
• BMI : 22,89 kg/m2
(normoweight)
Cranial Nerves
CN. I (Olfactorius)
Right Left Interpretation
Difficult to Difficult to
Sense of Smell Non interpretable
test test
CN. II (Opticus)
Right Left Interpretation
Visual Acuity 5/60 5/60
Difficult to
Visual Fields Difficult to test Low vision
test
Difficult to
Colour Recognition Difficult to test
test
▪ CN III (Oculomotorius)

Right Left Interpretation

Ptosis - -
Pupil
Shape Round Round
Side Φ2mm Φ2mm Normal
Extraoculer movement Normal Normal
Pupillary reaction to light
Direct + +
Indirect + +
▪ CN IV ( Trochlearis)
Right Left Interpretation

Extraocular movement + + Normal

▪ CN V (Trigeminus)
Right Left Interpretation
Normal Normal
Motoric
Difficult to Difficult to
Sensory Normal
test test
Corneal reflex
+ +
▪ CN VI (Abduscens)

Right Left Interpretation


Eyes movement Normal Normal
Strabismus - - Normal
Deviation - -
▪ CN VII (Facialis)

Right Left Interpretation


Tic (-) (-)
Motoric
1. Frowning Difficult to test Difficult to test
2. Raised eye brow Difficult to test Difficult to test
3. Close eyes Normal Normal
4. Corners of the mouth Simetris Simetris
5. Nasolabial fold Simetris Simetris

Difficult to test Normal


Sense of Taste Difficult to test

Chvostek Sign (-) (-)


▪ CN VIII (Accousticus)
Right Left Interpretation
Difficult to Difficult to
Hearing sense Non interpretable
test test
▪ CN IX (Glossopharyngeus)
Right Left Interpretation

Pharyngeal Arch
Difficult to Difficult to Non interpretable
Flavour sense
assess assess
Gag Reflex
▪ CN X (Vagus)

Right Left Interpretation


Pharyngeal Arch Difficult to Difficult to
Non interpretable
test test
Dysfonia - -
▪ CN XI (accessorius)
Right Left Interpretation
Motoric Difficult to Difficult to
assess assess
Non interpretable
Trofi Eutrophy Eutrophy
▪ CN XII (Hypoglossus)
Right Left Interpretation
Motoric Deviation (-) Deviation (-)
Trofi Eutrophy Eutrophy
Normal
Tremor - -
- -
Disartria
Motoric
Right Left Interpretation
Upper Extremity
Strength
Distal 5
5
Medial 5 5
Proksimal 5 5
Tonus Normal Normal Normal
Trofi Eutrophy Eutrophy
Involunteer movement - -
-
Clonus -
Lower Extremity
Strenght
Distal 5 5
Medial 5 5
5
Proksimal 5
Tonus Normal Normal
Trofi Eutrophy Eutrophy
Involunteer movement (-) (-)
Clonus (-) (-)
Sensory
Right Left Interpretation
Touch (+) (+) Normal
Pain (+) (+) Normal
Temperature Not applied Not applied -

Propioseptif
 Vibration Not applied Not applied -
 Position (+) (+) Normal
Difficult to Difficult to
 Two point discrimination Non interpretable
test test
 Stereognosis (+) (+) Normal
Difficult to Difficult to
 Graphestesia Non interpretable
assess assess
Reflex
Right Left Interpretation
Physiologic
Biseps (+) (+)
Physiologic reflex is
Triseps (+) (+)
Positive Normal
Patella (+) (+)
Achilles (+) (+)
Patologic (-) (-)
Babinski (-) (-)
Patologic reflex (-)
Chaddock (-) (-)
Hoffman Tromer (-) (-)
Openheim (-) (-)

Primitive Reflex
Palmomental (-) (-)
Primitive reflex (+)
Glabella (+) (+)
Snout (+) (+)
Coordination
Right Left Interpretation
Point to point movement

Walk heel to toe Difficult to Difficult to Non interpretable


Gait test test
Tandem
Romberg
Autonomy System

• Urinate : Normal
• Defecation : Normal
Other Examination

• Laseque :Not limited


• Kernig :Not limited
• Patrick : -/-
• Contrapatrick : -/-
• Valsava test : Difficult to assess
Working Diagnose
Clinical diagnose • Generalize tonic clonic seizure

Topical diagnose • Intracranial

Etiological • Symptomatic epilepsy


diagnose
Differential • Idiopathic Epilepsy
diagnose

Secondary Diagnose • Hypertension Grade I + Demensia Alzheimer


GAJAH MADA STROKE ALGORITHM

GAJAH MADA STROKE ALGORYTHM (ASGM)

Loss of conciousness (-) Headache (-) Babinski reflex (-)

Non hemorrhage stroke

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SIRIRAJ STROKE SCORE
Consciousness (C) : Composmentis (0)
Vomitting (V) : No (0)
Headache within 2 hours (H) : Yes (1)
Diastolic blood pressure (DBP) : 90 mmHg (90)
Atheroma (A) : Hypertension(1)

SSS = 2,5 C + 2 V + 2 H + 0,1 DBP - 3 A - 12


= 2,5 (0) + 2 (0) + 2 (1) + 0,1 (90) - 3 (1) - 12
= - 4 (non hemorrhage stroke)

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MMSE
SCORE 8
(Impaired
Mental status)

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Suggestion Examination

Lab Study Imaging Study


• Blood routine • Chest X-Ray
• Blood Glucose Profile • Head CT-Scan
• Electrolyte • Electroencephalogram
(EEG)
Management
Non Pharmacologic Therapy
• Bed rest
• Airway Management
• Nasal Canule O2 2-4 l/minute
• Observe seizure

Pharmacologic Therapy
• IVFD RL 16 dpm
• Injection Phenytoin 3 x 100 mg in Normal Saline 20 ml iv
• Injection Diazepam 10 mg prn iv
• Injection Citicolin 2 x 500 mg iv
• Amlodipin 1 x 5 mg po
Laboratory Findings
Blood routine (November, 11th 2019)
▪ Hb : 13,4 g/dL
▪ Leucocyte : 11.200 /mm3
▪ Trombocyte : 255.000/uL
▪ Hematocryte : 41 %
Laboratory Findings
Blood Glucose Profile Chemistry (November, 11th 2019)
▫ Glucose : 137 mg/dl
Electrolyte (November, 11th 2019)
▫ Na : 146 mmol/L
▫ K : 4.00 mmol/L
▫ Cl : 110 mmol/L
Imaging Study

Old infarct in the


right occipital lobe

Brain Atrophy

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FOLLOW UP
S O A P
Headeche (+), CM, GCS 15 Symptomatic Continue therapy
seizure (-), fever (- BP : 120/80 mmHg Epilepsy ec Non Lab test for profil
November 12th ), normal speech Motoric 555/333 Haemmorrhagee lipid
2019 555/333 Stroke +
demensia
alzheimer
Headeche (-), CM, GCS 15 Symptomatic Outpatient
seizure (-), fever (- BP : 130/80 mmHg Epilepsy ec Non (phenitoin tab 3 x
), normal speech Motoric 555/444 Haemmorrhagee 100 mg, citicoline
November 13th 555/444 Stroke + tab 2 x 500 mg,
2019 Profil lipid (Toral demensia amlodipin tab 1 x
Chol 167 mg/dl, alzheimer 5 mg)
LDL 113 mg/dl,
HDL 63 mgf/dl, TG
140 mg/dl)
SYMPTOMATIC EPILEPSY EC
NON HAEMMORRHAGE STROKE
+ HYPERTENSION GRADE I +
DEMENSIA ALZHEIMER
FINAL DIAGNOSE
EPILEPSY
Epilepsy is a disease of the brain defined by any of the
following condition (ILAE official report, 2014)
1. At least two unprovoked seizure occuring > 24 h apart
2. One unprovoked seizure and probability of further seizure similar
to the general recurrence (at least 60%) after two unprovoked
seizure, occuring over the next 10 years
3. Diagnosis of an epilepsy syndrome
EPILEPSY
Epilepsy is considered to be resolved for individual who have
remained seizure-free for the last 10 years, with no seizure medicine
for the last 5 years
POST STROKE SEIZURE

1. Early onset : seizure occuring within 1 week of stroke


onset (acute symptomatic seizure)
2. Late onset : seizure occuring ≥ 1 week after stroke
onset (post stroke epilepsy)
Seizure is less common in posterior circulation stroke

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PHYSIOLOGY
PATHOPHYSIOLOGY
CLASSIFICATION
ILAE1981 classification for the type of epileptic seizure
1. Focal/partial
Simple
Complex
Secondary generalize
2. General (Absance, mioclonic, clonic, tonic, tonic-clonic-atonic)
3. Unclassified
CLASSIFICATION
ILAE1989 classification for syndrome epilepsy
1. Focal/partial (Idiopathic, symptomatic, criptogenic) 3. Unclassified
2. General 4. Specific syndrome
Idiopathic
symptomatic
- nonspecific etiology
- spesific syndrome
- complication to another disease
criptogenic
ETIOLOGY
▪ Idiophatic
▪ Criptogenic
▪ Symptomatic
DIAGNOSE

CLINICAL PHYSICAL RADIOLOGY


HISTORY EXAMINATION EEG

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THERAPY

Overview of drug used for epilepsy and seizure. 2010


THERAPY

Pedoman Tatalaksana Epilepsi. Kelompok Studi Epilepsi – PERDOSSI. 2012


BASIC ETIOLOGICAL DIAGNOSE

Gliosis and meningocerebral cicatrix


Stroke Post Stroke Seizure
may become epileptogenic foci

SYMPTOMATIC
Recurrent
EPILEPSY
BASIC FINAL DIAGNOSE

Anamnesis Physical Head CT


examination Scan
• Paroxismal • TD 150/90 • Old infarct
GTCS mmHg on right
• Changed in • MMSE Score 8 occipital
behaviour and lobes with
lack of
memory
atrophy
cerebri
BASIC TREATMENT

• Bedrest : maintain the adequate


circulation to the brain
Non • Airway management : Maintain
Pharmacology adequate airway
• O2 2-4 l/minute : well-perfusion

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Phamacology
• IVFD NaCl 0,9% 20 dpm is to maintain the euvolemic
condition.
• Inj Phenytoin 3 x100 mg Normal Saline 20 ml iv to
prevent any seizure
• Inj Diazepam 10 mg iv prn to manage seizure
• Amlodipine 1 x 5 mg to maintain his blood pressure
• Inj citicoline 2 x 1000 mg iv is as the neuroprotector
.

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THANK YOU

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Pedoman Tatalaksana Epilepsi. Kelompok Studi Epilepsi – PERDOSSI. 2012

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1. They interfere with the ability to function independently at work or at usual activities.
2. They represent a decline from prior levels of functioning and performing.
3. They are not explained by delirium or major
psychiatric disorder.
4. Cognitive impairment is detected and diagnosed
through a combination of history-taking from the
patient and a knowledgeable informant and of an
objective cognitive assessment, either a bedside mental
status examination or neuropsychological testing.
Neuro psychological testing should be performed when
the routine history and bedside mental status examination cannot provide a confident diagnosis.
5. The cognitive or behavioral impairment involves at
least two of the following domains:
(a) Impaired ability to acquire and remember new
information – symptoms include repetitive questions or conversations, misplacing personal belongings, forgetting events or appointments, and
getting lost on a familiar route.
(b) Impaired reasoning and handling of complex tasks,
poor judgment – symptoms include poor
understanding of safety risks, inability to manage
finances, poor decision-making ability, and
inability to plan complex or sequential activities.
(c) Impaired visuo-spatial abilities – symptoms
include inability to recognize faces or common
objects or to fi nd objects in direct view despite
good acuity, and inability to operate simple implements or orient clothing to the body.
(d) Impaired language functions (speaking, reading,
writing) – symptoms include difficulty thinking of
common words while speaking, hesitations, and
speech, spelling and writing errors.
(e) Changes in personality, behavior or comportment – symptoms include impaired motivation,
initiative, increasing apathy, loss of drive, social
with drawal, decreased interest in previous activities, loss of empathy, compulsive or obsessive
behaviors, and socially unacceptable behaviors.

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