A 32-year-old right-handed woman with no significant past medical history is brought to the emergency department with a generalized tonic-clonic seizure. Before the seizure, her husband noticed the patient fumbling with the buttons on her shirt and smacking her lips. Following the seizure, she appeared to be confused for 30-40 minutes. The patient states that she could not sleep the night before due to a deadline at work. She has no history of head trauma, fevers, headaches, or vision problems.
Her vital signs are within normal limits. She is awake, cooperative, and follows commands. Her speech is fluent and her repetition is appropriate. The remainder of her mental status and neurologic examinations shows no abnormalities.
Magnetic resonance imaging of the brain reveals an infiltrating 2-cm lesion in the temporal lobe that produces no mass effect and is most consistent with a low-grade glioma.
Neurosurgery evaluation is pending.
What is the best next step in management of this patient?

Question

A 32-year-old right-handed woman with no significant past medical history is brought to the emergency department with a generalized tonic-clonic seizure.  Before the seizure, her husband noticed the patient fumbling with the buttons on her shirt and smacking her lips.  Following the seizure, she appeared to be confused for 30-40 minutes.  The patient states that she could not sleep the night before due to a deadline at work.  She has no history of head trauma, fevers, headaches, or vision problems.
Her vital signs are within normal limits.  She is awake, cooperative, and follows commands.  Her speech is fluent and her repetition is appropriate.  The remainder of her mental status and neurologic examinations shows no abnormalities.
Magnetic resonance imaging of the brain reveals an infiltrating 2-cm lesion in the temporal lobe that produces no mass effect and is most consistent with a low-grade glioma.
Neurosurgery evaluation is pending.
What is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient presents with a single provoked complex partial seizure that secondarily generalized in a structural lesion in the brain. A complex partial seizure is a focal seizure that arises from a cerebral hemisphere and causes alteration/loss of consciousness or awareness. During a complex partial seizure, some patients may display semi-purposeful behaviors called automatisms (eg, lip smacking, pacing, grooming behavior, repetitive swallowing). Patients are completely unaware of these behaviors and have no memory of them after the seizure. Complex partial seizures can arise from any region of the cortex but are seen most frequently in patients with mesial temporal lobe epilepsy. In general, neurologists do not treat with an antiepileptic drug (AED) unless the patient has had > 2 unprovoked seizures separated by more than 24 hours. In this patient, the seizure was provoked by an underlying structural lesion in the brain. Therefore, treatment with an AED is indicated as the risk of seizure recurrence is high. Given that this patient is of reproductive age, lamotrigine alone or levetiracetam is the best AED to start as it has the fewest teratogenic side effects. Valproic acid is generally contraindicated in young women of reproductive age due to potential teratogenic effects. (Choice A) An electroencephalogram (EEG) for risk stratification is not necessary in this patient as she is already at high risk for seizure recurrence given the presence of a structural lesion on brain imaging. An EEG is helpful for risk stratification in patients with normal brain imaging. (Choice D) Lorazepam is the initial drug of choice for status epilepticus, defined as a prolonged single seizure of > 5-10 minutes or repetitive seizures without return to baseline clinical status between episodes. This patient's presentation is not consistent with status epilepticus. Educational objective: A single focal seizure due to a structural brain lesion has a high risk of recurrence and requires treatment with an antiepileptic drug. __________ References: Management of provoked seizure. (http://www.ncbi.nlm.nih.gov/pubmed/21633606) Management issues for women with epilepsy-focus on pregnancy (an evidence-based review): II. Teratogenesis and perinatal outcomes: Report of the Quality Standards Subcommittee and Therapeutics and Technology Subcommittee of the American Academy of Neurology and the American Epilepsy Society. (http://www.ncbi.nlm.nih.gov/pubmed/19507301)

A 32-Year-Old Right-Handed Woman with No Significant Past Medical History