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What is the cause and treatment for complex partial seizures?

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Dr. Sudhir Kumar

Neurologist

Practicing since :1994

Answered : 5688 Questions

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Posted on Wed, 6 Aug 2014 in Brain and Spine
Question: I’d like to ask if you could suggest a possible diagnosis for my symptoms, which are the following:

About a year ago I started having some sort of 'seizures' (I'll call them seizures but I don't know what they actually are). The first time they happened was after I had my wisdom teeth taken out. (I also have orthodontic braces on my teeth)

The episodes usually come in the morning (but sometimes they wake me up during night) and happen 3-5 times a day on that day. I get such 'seizure' days in about once in six weeks but they are becoming more frequent. During the seizure, I feel a strange sense of pleasure coming from my stomach, then I get something like a dream while awake. It's a sequence combined of memories (things that actually happened) but there are also things which don't exist in the real world. It's extremely fast and lasts for about 10 seconds. There's so many things that happen in the episode that I rarely remember the content afterwards. As the dream approaches the end, I start feeling nausea, but I never actually vomit. After the episode I'm extremely tired for the next week. The episodes essentially feel like I get connected to myself living in a different dimension, where there are some people who exist in my dimension but also some new people who don't actually exist in my dimension. It's really strange. These episodes come completely out of the blue with no possible trigger I'm aware of. (they happen in different times of day in different places).

In addition to these episodes, I've been having some other symptoms, which started in the last 4 months. 4 months ago, I came back home from a conference and I realised that I couldn't remember the name of my cousin. It took me a lot of effort and almost an hour to remember it. I was scared of the sudden inability to use my memory. Since then, I've been having problems with memory that regards words and names. For instance, I can't remember the names of my favourite musicians or friends, or people that I know. Or it takes me much longer to remember things than it used to. The strange thing is that this fluctuates - one day I'm fine and remember everything (albeit slowly), another day it's really bad. Also, I find it hard to find the right words to say in a sentence. The onset of memory problems was sudden.

Since 3 months ago, I've been feeling extremely tired, with unrefreshing sleep. I feel like a walking zombie. I have stiff, clumsy and cold hands. It takes effort to just stretch my fingers. The fatigue didn’t have a sudden onset. Rather, it has been developing for the last few years and it has been getting worse and worse.

I'm getting twitches all over my body, especially in fingers. I have difficulty reading as can't coordinate my eyes properly - they jump over words at wrong intervals so I either misread words for something else or I omit them. My handwriting is also quite strange given my hands are so stiff.

In addition, what is probably the most annoying symptom - I have all body tremor, but especially prominent in my hands. It’s greatest when I use my muscles with low to moderate strength, when I rotate my wrists or when I’m holding something such as fork and knife. I constantly feel all body internal resting tremor, which is, however, not visible. I get most tremor when using my muscles.

I was also getting panic attacks, which prompted me to see my GP who prescribed anti-anxiety medication Propanolol. The medication has stopped the attacks but has not helped with any other symptoms.

I saw a neurologist a month ago, who ran the following blood tests:

full blood count
white cell count
haemoglobin estimation
platelet count
mean corpuscular volume
red blood cell cound
packed cell volume
mean corpusc. haemoglobin
mean corpusc. Hb. conc.
red blook cell distribut width
neutrophil count
lymphocyte count
monocyte count
eosinophil count
basophil count

liver function test
serum alkaline phosphatase
serum total bilirubin level
serum ALT level
serum total protein
serum albumin
serum globulin

plasma glucose level

serum electrolytes
serum sodium
serum potassium
serum creainine
GFR calculated abbreviated MDRD


Thyroid function test
serum free T4 level
Serum TSH level
anti-TG
anti-TPO

Urine microscopy:
white blood cells
red blood cells
bacteria
epithelial cells
crystals
casts


Serum C reactive protein level
Serum vitamin B12
Serum ACE level
Serum folate

Complement C3
Complement C4

erythrocyte sedimentation rate



ALL TESTS CAME OK WITHIN RANGE


In addition, the neurologist did a physical examination:
“on neurological examination, there was no neck stiffness. Fundoscopy did not reveal any signs of papilledema. His pupils were wide but light reactive. His visual fields were full to confrontation. He had full external ocular movements without nystagmus. His visual acuity was normal. There was no facial asymmetry. The lower cranial nerve exam was normal. On the limb exam there was no weakness, no evidence of ataxia, reflexes were symmetrical, plantar response was flexion, sensory was normal, Romberg was negative, gait was normal. In summary, I think the recurrent episodes can be clinical presentation of temporal seizures. "

I also had a MRI of brain done, and nothing was found.

I further saw an otorhinolaryngologist, who did a complete examination and found hypertrophy of nasal turbinate, plus a bent nasal septum to one side. However, he did one sleep study and found nothing (no fluctuation of oxygen during sleep or heart rate; I do snore though). Despite that, I feel the worst after sleeping. I feel the best and least tired late in the evening before going to bed.

What do you think could be happening to me and what would you suggest that I should do? I believe that anxiety and stress could readily explain all of the symptoms, except the seizures, if they are seizures. Could they be psychogenic non-epileptic?

I don't take or have ever taken any drugs, except alcohol and caffeine in small amounts and very occasionally. No history of any illness or epilepsy. No family history of any illness.

I've noticed that the seizures always come several days after I visit my orthodontist to adjust my braces. I don't know if that could be related.

I forgot to add that my grandfather died of multiple myeloma.. but I'm not sure that's relevant.

Thanks for your help.

XXXXXXX
doctor
Answered by Dr. Sudhir Kumar 5 hours later
Brief Answer:
Complex partial seizures with anxiety

Detailed Answer:
Hi,

Thank you for posting your query.

I have noted your symptoms. Thanks for describing in detail about the episodes.

The description is excellent and it clinches the diagnosis of complex partial seizures. History is the most important aspect of diagnosis of seizures. It is not uncommon to have a normal neurological examination and MRI brain in people with epilepsy.

Doing a prolonged video EEG recording and PET scan of brain may be useful for further evaluation in your case.

However, at this stage, I would prefer starting anti-seizure medication such as oxcarbazepine. A three month course of this medication would help us confirm the diagnosis, if your seizure episodes reduce with that.

Your other symptoms can be explained on the basis of anxiety and stress.

I hope it helps.

Best wishes,
Dr Sudhir Kumar MD DM (Neurology) XXXXXXX Consultant neurologist
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Sudhir Kumar 8 hours later
1) I was under a terrible amount of stress this year (more than ever before). Do you think that this could be the factor that caused the epilepsy? (I have no prior history of anything like that).

2) is there any chance these episodes could be psychogenic non-epileptic?

3) is there any chance this could be related to jaw restructuring due to wearing braces? (given the fact I always get the seizure a few days after a check up with orthodontist) I know it could be just coincidence.

Thanks so much!
XXXXXXX
doctor
Answered by Dr. Sudhir Kumar 3 hours later
Brief Answer:
Stress could precipitate seizures.

Detailed Answer:
Thank you for getting back. My replies to your further queries are below:

1. Yes, stress can precipitate or increase the chances of seizures in a person predisposed to them. So, reducing the stress levels would also help reduce seizures. However, stress alone can not cause seizures.

2. Unlikely to be psychogenic non-epileptic given the description of the episodes.

3. Just a coincidence...

Best wishes,

Dr Sudhir Kumar MD DM (Neurology)
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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