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Diagnosed with epilepsy, MRI features are described in favor of mild cerebral atrophy. Suggestion?

Patient Age : 26 Years • 1st epileptic fit occurred in 2005 during sleep. Convulsion, foam in mouth. Lasted for about a minute or two. Patient unable to recall what happened after he came into senses in about 30 minutes. Next day his mood was off, ate nothing, feeling nausea all day (type 1 fits ). • Treatment was started and No fit occurred until 2008 ( Sodium Valporate). • In Dec 2008, 2nd fit occurred at night. Patient slept late that night and woke up early accidentally with mobile alarm which resulted in fit with same symptoms as above. • Now frequency of fits increased occurring every week or two. ( Sodium Valporate CR) • Tremors in hands developed gradually. • Occasionally patient complained about difficulty in walking down the slope and on even surfaces but this problem was too small at that time. • In 2009 one morning when patient was walking, he suddenly stopped complaining that he can’t walk more. He stopped for a while and then when started walking again after taking a few steps patient fell followed with a seizure. It was 1st seizure in awake. • After this incident patient felt difficulty in walking, used to take a few steps n stop otherwise seizure used to occur if trying to take another step. • After this seizure of 2009 in awake, frequency of seizures increases even more, occurring almost daily. These seizures were identical in symptoms to above mentioned symptoms except that patient said he does hear and understand us during seizure. Also after seizure patient mood use to be normal. He eats normally and no nausea or vomiting follows the fit. These fits occur both in sleep and awake (type 2 fits). • Patient is on 3 epileptic medicines now. Type 1 Fits with symptoms given on top are reduced a lot, occurring in months but type 2 seizures occur every now and then in awake or during sleep. • Most troublesome thing for us is his inability to walk. Can’t take 2,3 steps. Full body muscles test and blood tests are all normal. His legs tremor a lot when he stands and patient can’t control it. If forced to stand more than a few seconds or to take a step, patient would fall often accompanied by a mild seizure (type 2). • Patient had been diagnosed with epilepsy because of type 1 fits. Type 2 fits were diagnosed as psychogenic by neurologists and psychiatrists . • Psychogenic fits during sleep often decreases when patient admitted in hospital. • MRI report of 25/12/12 Multi Echo & Multi planar imaging through the brain was performed. Ventricular system and extra ventricular CSF Spaces show mild prominence, suggestive of Mild Cerebral Atrophy . No evidence of intra/extra axial mass or hemorrhage. Basal Ganglia, Thalami, Brainstem and both Cerebellar hemispheres appear normal. Pituitary Gland and optic chiasm are normal. 7th & 8th Nerve complexes are normal & symmetrical bilaterally. Note is made of Giant Cisterna Magna. Impression: MRI Features described are in favor of Mild Cerebral Atrophy.
Asked On : Fri, 4 Jan 2013
Answers:  1 Views:  77
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Neurologist 's  Response
Nov 2013

Thank you for posting your query.

I appreciate the detailed description provided by you regarding the patient's illness.

It is clear that patient has two types of seizures- epileptic and non epileptic seizures. Non epileptic seizures are also called as psychogenic seizures.

As you have mentioned, the epileptic seizures have been well controlled on sodium valproate. However, psychogenic seizures are not. For this he needs to consult a psychiatrist and counselling may be required.

MRI brain report does not show any significant abnormality in this patient.

Best wishes,
Dr Sudhir Kumar Md DM (Neurology)
Senior Consultant Neurologist
Answered: Wed, 13 Feb 2013
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