A 60-year-old woman is admitted to the hospital after a loss of consciousness. She had a “strange feeling” before losing consciousness. Her husband stated that she fell to the ground and had generalized stiffening and then shaking. She was unresponsive for approximately 1 minute, had urinary incontinence, and was confused for a few minutes after regaining consciousness. She had a similar episode 2 months ago; evaluation at that time, which included electrocardiography, stress electrocardiography, and a continuous-loop event electrocardiographic recorder, revealed no abnormal findings. The patient takes no medications.
Physical examination including a full neurologic examination is normal.
MRI of the brain and electroencephalogram (EEG) during waking and sleeping are also normal.
1. What is the most likely diagnosis?
The patient likely had a seizure. Seizure is classified according to the history and physical examination. Diagnostic testing is used to confirm or clarify the suspected cause. When a patient has loss of consciousness with urinary incontinence and stiffening and shaking lasting 1 to 2 minutes, seizure should always be considered as the cause until proven otherwise. When there is a high clinical suspicion of epilepsy, normal MRI of the brain and EEG do not rule out that diagnosis.
The first step in evaluating a patient with a suspected seizure is to rule out other conditions, such as syncope or a transient ischemic attack. As is most often the case, a complete history and physical examination are essential. Based on the results of those examinations, one pursues appropriate diagnostic testing. If a seizure is suspected, the next step is to distinguish between provoked (secondary) and unprovoked (primary) seizure. Acute symptomatic seizures are usually secondary to an acute neurologic event or to a metabolic problem.
Appropriate management should be aimed at correcting the underlying cause. Antiseizure medication is reserved for refractory seizures or primary seizures (epilepsy) only. Epilepsy is a condition of at least 2 or more unprovoked seizures. It is appropriate to get a neurology consult when the diagnosis is unclear or when medication choice is difficult. Otherwise neurology consultation is often unnecessary.
In the majority of patients with epilepsy, no reversible cause of the seizures is found. Elderly patients more commonly have an identified etiology. Cerebrovascular disease is responsible for approximately 30% of seizures in older patients.
Seizures are classified into 2 types: generalized and partial. Generalized seizures affect both sides of the brain and are not usually associated with a cerebral lesion. Partial seizures arise from a localized area and may indicate the possibility of an underlying lesion.
Seizures may be accompanied by loss of consciousness. Three seizure types include a loss of consciousness: complex partial seizures, absence seizures, and generalized tonic-clonic seizures. Since patients have lost consciousness ...