Brief Answer:
Need more data but starting AED appears reasonable under circumstance

Detailed Answer:
Thank you for your question to my attention. I also have read the detailed response of my good colleague Dr. Spaho. There are newer guidelines currently being disseminated among the neurological community on the threshold that neurologists should have with respect to first seizures. In the past, it was stated that a first unprovoked seizure should not necessarily trigger the use of antiepileptics but now there is the recommendation that strong consideration should be made to start patients on medications (even in an unprovoked situation) while workup is conducted and more information is gathered. This is for the purpose of PREVENTING a 2nd seizure. The committee which decided upon this set of newest guidelines did so by also taking into consideration the potential side effects of antiepileptic medications vs. the possible benefits.

Now, in this patient's case we have a different scenario. There is a 56 year old patient who suffered an EMBOLIC stroke nearly 1 year ago. This means that the CORTEX OF THE BRAIN is definitely known to be damaged. Although the seizure activity you mention did not happen for nearly this entire time it is still the case that it happened. I believe that under the circumstance of the new guideline for starting AED therapy for a 1st UNprovoked seizure epileptologists would likely agree that with the concrete history of an event clearly known to place patients at risk for seizure (cortical infarcts) that a first seizure (and especially if it can be shown or suspected that the focus is in the right hemisphere) is the definite warning flag that anti-epileptic medications should be started, adjusted for optimal therapeutic levels, and likely NOT discontinued in order to prevent future seizures. The benefit of WAITING is clearly not in the patient's benefit anymore since a first event has occurred and the risk of a 2nd event (in my opinion) is now much greater than if this were an unprovoked episode.

Having said that-- I believe it is also the case that there could be other things which may have tripped this first seizure off such as an infectious process especially something such as URINARY TRACT INFECTION which is commonly seen in post stroke victims. Also, pneumonia or other upper respiratory tract infection could be present..even subclinically..except for the seizure and should be looked for and treated if present. If the seizure can be definitively linked to some other process that is easily treatable or reversible then, one MAY MAKE the argument that AED therapy in a committed fashion could be avoided in the patient even though she clearly has substrate that can trigger epileptic activity.

Does the EEG show sharp wave activity or postictal slowing in the stroked area of the right hemisphere? If so then, again in my opinion that would be enough of a smoking gun for me to start her on medication prophylaxis...AT LEAST UNTIL A THOROUGH workup can be accomplished to look for other causes as I stated above such as infections, electrolyte disturbances/imbalances, or other phenomenon.

Her crying spells may be due to frustration with her inability to properly speak OR it may be due to, or at least contributed to, by something called pseudobulbar affect which is seen in patients with organic brain disease such as stroke. This is also referred to as LABILITY OF EMOTION where they can what appear to be swinging moods that go between laughing and crying for no apparent or obvious reason though we often attribute these spells to depressive mood disorder...that is not always the case. Pseudobulbar affect (PBA) can also be controlled and addressed with specific agents available.

Bottom line in this case is that in my current practice to provide the most benefit for this patient under her current circumstance I would recommend starting an appropriate antiepileptic medication with a plan to adjust and monitor levels in order to minimize side effects and other unwanted effects of the drug. I would be very uncomfortable NOT starting anything knowing that she has very viable brain substrate that could cause her to have a 2nd episode or worse (status epilepticus) which would clearly cause much more damage and set her back considerably in her rehabilitation progress from the stroke compared to the potential down sides of taking the medication. I think Keppra is a good choice as well as Tegretol or Lamotrigine as another option. Any of these drugs could have a positive effect as well on her possible PBA.

In the mean time I would also work her up with another 1 or 2 EEG's to see if you can't capture abnormal spike and wave activity from the right hemisphere (specifically where she had her stroke) and get a localization of the focus of that seizure as well as understanding the electrical stability or instability of her stroked hemisphere. I would also look for infections and other causes for epileptic triggers and address or correct those as soon as possible. I did look at her EEG recording and could not see anything that qualified as grossly epileptic. Since I am not an EPILEPTOLOGIST by specialization it would also be helpful if you could upload the report of the EEG by the reader so that I may check my own assertion that the EEG did not demonstrate XXXXXXX epileptic activity.

Antiepileptic medications as mentioned may also positively impact any diagnosis of fibromyalgia.

I hope this addresses your concerns. If so, may I ask for the favor of a HIGH STAR RATING on our interaction and some brief written feedback.

Write to me at: bit.ly/drdariushsaghafi for additional comments, concerns, or to upload information that you would like me to look at in the event you may have reports, imaging studies of the head, labs performed, or doctors' notes you'd like reviewed.

This query required 45 minutes to read, research, and compile an envoy to the patient

---

Brief Answer:
Thank you for your kind words

Detailed Answer:
The observation of the heaviness being felt over the right frontal area is not necessarily significant or indicative of any clinical correlation with the radiographic finding of GLIOTIC AREA IN LEFT PARIETAL REGION....." In other words, the presence of what may be either discomfort or headache in that territory does not have to always correlate with phenomenon which are occurring involving the opposite or nearly homologous area of brain. Cranial pain unfortunately, has no correlate to anatomy when it comes to those sorts of findings as well as motor or sensory deficits have. So the symptom is neither overly impressive or worrisome from a clinical perspective.

Funny you mention the antidepressant properties of Tegretol because in fact, when the medication was first developed and introduced in the 1960's its original purpose was exactly that...to treat depression. A little known fact is that this medication comes from the class known as TRICYCLIC ANTIDEPRESSANT. However, when it came out and was initially used for that purpose...especially in schizophrenic patients it was found that it had a POOR property of treating depression and as people began raising the dose and the frequency of dosing as they were trying to find a clinically relevant break point for its efficacy they serendipitously discovered that in patients who were DEPRESSED/SCHIZOPHRENIC and had convulsive disorders that the medication could dramatically correct the convulsive spells....but it was abysmal in terms of treating the actual mood disorder which is what people were looking for...and so its role very quickly shifted and its use as an antiepileptic began to rival that of one of the only effective treatments present at that time which was Dilantin! Bottom line is that I would not recommend nor do I ever use Tegretol to treat stroke patients for depressed mood disorder. Although, in patients who show mood INSTABILITY or ANGER DISORDERS such as rage, over the top fear or anxiety on a disproportionate scale to expected given the situation at hand TEGRETOL can and is used by psychiatry...but it is still rare since many generations of newer (and MORE EXPENSIVE) medications have made their way to the market and physician arsenal since that time.

In my opinion and by way of the experiences I have using Keppra and Tegretol I believe Keppra has many less side effects that are manifest compared to Tegretol. Particularly, symptoms of dizziness, cognitive blunting/slowing, slurred speech, etc. Keppra has a good point of efficacy at a fairly low dose of use compared to Tegretol which sometimes has to be pushed to serum levels that cause noticeable side effects to both patients as well as patients and also has to be constantly monitored by serum checks. Therefore, for those reasons I do like Keppra over Tegretol in treating partial seizure disorders. I believe also that Keppra possesses less medication interaction compared to Tegretol which interacts with just about everything (seemingly) and in addition has negative notoriety in one other thing which is somewhat pronounced and that is SALT WASTING. Tegretol can cause loss of sodium from the body more readily and without warning compared to Keppra although truth be told, virtually ALL antiepileptic medications from the older generations such as Tegretol (Dilantin, Depakote, Lamictal, etc.) cause sodium wasting through the kidneys. The newer AED's seem to be a bit more benign in that aspect of things.

I hesitate to give dosage initiatives since this is a topic which is very delicate when dealing with LONG DISTANCE PATIENTS. Dosing a patient with a particular drug is highly dependent upon many factors in patients including other medications being taken, constitutional aspects of the patients, their neurological examination, and also how committed nursing is in giving patients their ordered doses ON TIME every time....therefore, I would have to defer in giving specific dosing instructions unless I could physically examine the patient and have more first hand knowledge of the clinical situation. Your doctor, however, or neurologist is well versed in how to dose these 2 medications adequately so as to achieve good clinical results.

I'm afraid that I am not familiar with ACITROM since it is not manufactured or used in the U.S. I would say as a general rule of thumb the anticoagulants I am accustomed to working with here do not have any strong drug to drug reactions with most standard AED's, however, for precise and up to the minute assurances on the one being employed in your mom please once again consult the treating neurologist or the pharmacist who dispenses that particular medication.

The use of memantine and rivastigmine is commonly prescribed in patients with speech/language disturbances as a possible aid to recovery. I've never found either of those drugs useful for that purpose and even in treating the indicated diagnosis of dementia in patients for which they were designed I believe there is limited benefit and utility that I've witnessed in over 20 years of prescribing or seeing those medications prescribed. I think that's a point of style of each physician and in a case such as the present my decision point comes down to risks and benefits in terms of adding MORE MEDICATIONS to a person who is compromised with respect to full volume and functionality of the brain which can be definitely affected just by TAKING MORE MEDICATION which does not have any absolutely noticeable benefits vs. the hoped benefits of some type of language support or stimulation that could possibly occur as an adjunct to active speech therapy. My bias is to err on the side of not using such drugs if there is no clear cut benefit THAT I CAN SEE OR MEASURE..especially after 12 months or more since the index event.

Again, please check with your neurologist who would have a better understanding of the progress she is making in this arena since I would hate to see someone give up a potentially useful drug if in fact, there are signs of clinical improvement that your doctor can appreciate because of his presence in the situation vs. my opinions which are coming sans such an advantageous perspective.

You may look into some novel and interesting smart phone apps that can be downloaded from the Internet that are useful for patients with aphasia. I find these apps particularly useful as an aid to family or friends interested in providing OFF HOURS SPEECH THERAPY to their loved one since active professional speech/language therapy generally only occurs at most once or twice weekly. Therefore, anything that furthers that mission during off time or off hours, in my opinion and actively engages or forces the patient to use their skill of language is far superior and preferable to any drug or medication that can be prescribed.

Many thanks for your kind words of praise and confidence in what I've written previously. My hope is that your loved one fully recovers and that some small item I've provided in this writing is of importance in that puzzle of rehabilitation.

Cheers!

I hope this addresses your concerns and hope you will keep me in mind for future queries and questions regarding these or other neurological/medical issues that I may be able to help resolve.

Write to me at: bit.ly/drdariushsaghafi for additional comments, concerns, or to provide status updates if this possible. I like keeping track of my consult patients as they recover and move on to better places in their journeys back to health. I wish XXXXXXX AZ were a bit closer to XXXXXXX OH! I have a sister-in-law who lives in Mesa and occasionally go to Neurology meetings in XXXXXXX ..especially when the weather in the North starts to be a bit uninviting...such as NOW! LOL.

This query required 105 minutes to read, research, and compile an envoy to the patient.

---