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Dr. Andrew Rynne

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Suggest treatment for recurrent non epileptic seizures

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Dr. Dariush Saghafi

Neurologist

Practicing since :1988

Answered : 1822 Questions

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Posted on Mon, 6 Mar 2017 in Brain and Spine
Question: I have been diagnosed with non epileptic seizures, and have not been taking any medications except for Xanax when the episodes occur. They affect the left side of my body only. Blood pressure is very high and Leg is like lead and same with arm and face. Only half of my body. Is this normal? Should I seek out a different opinion. The episodes are happening once every couple of weeks

To give you a more detailed history, I have suffered 2 injuries to my body:
1) 2011 I had a brachial nerve damage during Physical Therapy.... to upper arm after a rotator cuff tear. After that I started having tingling, spasm and numbness in left side. Formal diagnosis was CRPS or RSD. Lyrica has helped take care of this 225mg 2 x day.

2) 2013 fall to tailbone, and herniated 2 disc in L4 L5, had a subsequent discectomy

After the discectomy ...2 weeks post op, I experienced my 1st seizure: Left side paralysis. Face, neck, arm, leg. Right side was mildly impacted. Went to ER and was prescribed Valium, the symptoms went away after about 30-45 min.

Since that time, the episodes seemed to occur only after high periods of stress or surgical procedures (nerve conduction test, RFA, SNRB injections). I have chronic pain (back, glut left leg) and so in 2015 a Dr prescribed Effexor which caused my seizures to increase to 6-8 x day. I went into hospital and had a video monitor set up to follow the seizure's and rule out epilepsy. It was determined I had "non epileptic seizures". My question is, can a person experience seizures in only one part of their body? My last episode was yesterday and I felt as if lead was being poured in the left side...from the top of my head, all the way down to my leg. I could not more my left side....but my right side felt normal. Is this epilepsy, a panic attack or something else?
doctor
Answered by Dr. Dariush Saghafi 1 hour later
Brief Answer:
Video monitoring is highly sensitive in picking EPILEPTIFORM problems

Detailed Answer:
Thank you for your question. I've read your comments and note that after video monitoring the diagnosis of NON-EPILEPTIFORM seizure disorder has been made. However, when seizures do occur they affect only the left side of the body. They often occur in the face of EFFEXOR dosing, periods of high stress, or just after operative procedures. You have also been diagnosed with CRPS and Lyrica seems to be controlling that particular problem.

2 weeks after a discectomy for a herniated disc at L4/L5 you had your 1st seizure. The left side was paralyzed with right being mildly affected which resolved 30-45 minutes after being given Valium at the ER. When taking Effexor seizure frequency went from once every couple of weeks to 6-8 episodes/day.

Yesterday was your last episode and you describe the left side as feeling like LEAD while the right felt perfectly normal.


Question:

1. Can a person experience seizures in only one part of their body?
2. Is this epilepsy, a panic attack, or something else.


Here are the answers to your questions from what I've read and ascertained in your presentation:

1. Yes, a person can experience what is called a simple partial motor seizure on one side of their body if a seizure focus is located in the motor cortex or somehow there is an abnormality along the pathway of the circuit tied to the OPPOSITE hemisphere of the brain.

2. I must say that while a diagnosis of NON-epileptiform seizure is very tempting to accept on the basis of the video monitored EEG....there is something preventing me from accepting that diagnosis as the full explanation to what's going on since it is clearly not the norm for episodes of NON-EPILEPTIFORM origin to be so hemicorporeally isolated. If the video monitor were, on the other hand able to capture at least 2-3 episodes of where half your body is seizing while the EEG shows "all quiet on the Western Front" then, I would be more apt to accept the diagnosis.

Here's the caveat about NON-EPILEPTIFORM seizures. It is not uncommon and in fact, is probably more common than we think to find both ORGANIC BRAIN DISEASE epilepsy coexisting in the same person as NON-epileptiform seizure disorder and as I said...from a rocking chair distance I am unable to completely accept the diagnosis as the unique and full explanation as to what's going on.

My hesitancy is based upon the fact that EFFEXOR is known to enhance epileptiform activity in EPILEPTICS....it would be expected to make things BETTER...just as valium does...in NON-epileptiform disorders. Therefore, this is a red flag for me. Also, I don't know anything about your post-ictal or even your ictal phase as to what your awareness is like, before, during, and after an attack, how you FEEL after having had an episode....How do you feel after having 6 episodes? Are there any other things going on just prior to the onset of the episodes either on the EEG or clinically? In other words what are you doing or what are you feeling several seconds before the convulsive movements begin? Is there a quiescent period in the EEG at all before the shaking starts?

Have you also been checked out metabolically with your thyroid, adrenal glands, MRI of the brain with what we call a seizure protocol? How many STANDARD or conventional EEG's were obtained prior to the video monitoring. Were any 60 minute prolonged and/or sleep deprived studies done prior to the video recording? How long was the video recording done for?

This is not a clearly BLACK AND WHITE case to me...notwithstanding the results of the video EEG monitor and if this were my son or family member and the diagnosis were NESD with these sort of other clinical features I would seriously consider the possibility of getting some more recordings as well as having the recording that was read re-read by an epileptologist at an academic center without giving much background information since this can sometimes taint the diagnostician when looking at an EEG and/or video recording. Sometimes on a 2nd opinion like this one...I will keep the 2nd reader a bit in the dark except for things such as age, gender, medications, and some other very basic but non-descript facts and see what they see......you'd be surprised how many REAL seizures can be MISSED by good readers simply because they're being information ahead of time that this patient is very "anxious, very stressed, only gets these after painful procedures, etc. etc."

Frankly, the story of your 1st event occurring 2 weeks after your surgery doesn't strike me as being related to the surgery or pain following that at all....2 weeks is way to long to have completely NON-epileptiform episodes....not impossible mind you....but just odd that something didn't happen sooner (that would've been my expectation).

Bottom line....I would start to keep a journal of your events, medications you're taking, what you actually feel...be as specific as possible.....what your state of mind is like...are you having any fuzziness of thinking, any drooling, increased salivation, etc. etc. within 1-2 minutes before these things hit....and then, how do you feel afterward? Perfectly normal, ready to get back in the ball game as if nothing happened....or something else? Do these happen primarily at work, at home, in front of witnesses, etc. Can anybody video you on their phone if it happens? That way an exact timing is availability as well as audio. Have someone ask you to recite the alphabet backwards during one of these things or give you answers to multiplication tables.....have someone look at the trajectory of your eyes, your tongue, your lips....anything else going on of interest?

I would get a couple more studies of either a sleep deprived nature with prolonged recording of 60 minutes as well as potentially another video monitoring done by a different epileptologist..preferably at an academic center after they've reviewed the first video monitor. Make sure they DO NOT read the report from that study before looking at the study.

If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating? Again, many thanks for submitting your inquiry and please let me know how things turn out.

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 47 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Dariush Saghafi 44 minutes later
Dear Dr. Saghafi,
I cannot thank you enough for your excellent and detailed response!
I feel validated that someone is finally on my side and viewing my symptoms in a holistic manner! I would like to send you a video of myself as I am experiencing one of the episodes so that you are able to see what I am talking about. Episodes have occurred primarily at home, although one occurred while I was on the airplane, and yesterday's occurred in the grocery store. All episodes I had someone with me, who was able to administer the Valium...and then symptoms relieved within about 30 minutes. I am fully cognizant during all episodes, however, my speech is impaired, with sometimes quite a strong stutter.
I also have a brother who is a P.A. working for a neurosurgeon in Michigan, and he asked many of the same questions about my presentation during these events.
I can tell you that after an episode my left side is extremely weak, heavy and face feels numb (as if it has been injected with Novocaine).
also fyi, I have had several MRIs (cervical, brain, lumbar) all coming back normal.
I have not been checked out for thyroid, so I will look into that immediately.


Dear Dr Saghafi,
I apologize, but I am not able to send you the video as there does not seem to be a place for me to upload them to.
If you have an email address perhaps I can try doing it that way?
I have a couple of excellent samples of my seizure episodes.
There is not a lot of spasm or shaking that occurs, it is mostly a feeling of paralysis along with speech difficulties.
Thank you so much and I am happy to give you an excellent review!
doctor
Answered by Dr. Dariush Saghafi 19 hours later
Brief Answer:
No worries regarding video

Detailed Answer:
Thank you for your return message. There is actually no need for me to watch any video since what a video recording "looks like" in a case of epileptiform vs. non-epileptiform event disorder has a very low degree of sensitivity or specificity associated with it. What locks in the diagnosis is what the EEG records at the time the convulsive (or non-convulsive) activity is occurring. Therefore, the more fruitful effort on your part would be to locate an epileptologist (preferably one in an academic center) who is very familiar with diagnosing NON-EPILEPTIFORM disorders to review the video and EEG that's already been done and to consider other testing such as interictal PET scanning, SPECT studies, fMRI's, etc. These are more sophisticated imaging studies that go beyond the normal MRI in order to find very small and sometimes "hidden" epileptic foci which could be masked or hidden during attacks.

Also, keep in mind what I had said before which is that there is a fair number of folks who suffer from BOTH epileptiform and NON-epileptiform disorders and the capturing of one without the other doesn't necessarily rule its sister disorder out. There has to be an index of suspicion.

I still stand by the recommended workups for metabolic as well as additional imaging as well as other EEG studies such as 60 min. prolonged sleep deprived or even 6.5 hr. sleep deprived studies which we do in our hospital when there are questions before going to video monitoring.

Also, keep the EVENT JOURNAL or diary since this will be very helpful in making a decision whether or not a repeat video study should be done.

All the best and please do let me know if you find anything out one way or the other....remember, we very well could be looking at a pure case of NON-epileptiform seizure disorder and if so then, so be it...at least we've maximally ruled out other possibilities.

Take at look at this link which has a lot of good resource information from the Epilepsy Foundation. TAKE A LOOK AT THE VIDEO sidebars on this link:

http://www.epilepsy.com/learn/types-seizures/nonepileptic-seizures-or-events.

Once again, your favor in CLOSING THE QUERY and including some fine words of feedback along with a 5 STAR rating? Again, many thanks for submitting your inquiry and please let me know how things turn out.

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 73 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.


Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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