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What Do These EEG And MRI Reports For Seizures Indicate?
Question: Can you please tell what type of epillepsy my son is having and if Keppra is a good choice of medicine?
His Symptoms:
1. He Starts Off with a Stare / Absence (for 10 secs)
2. Then Proceeds to Cry (for 10secs)
3. Then Progress to Tonic Phase (~20 seconds)
4. Most of the times, it ends with Clonic Phase (Arms and legs jerking)
5. Post Ictal - he sleeps for ~ 1.5 hours.
Video:
=====
My Son's Seizure looks as follows:
https://www.youtube.com/watch?v=KV4N5Yi8IhE
The Stare begins @ 16:46:34 and ends @ 16:46:45.
Cry/Shout begins @ 16:46:45 and ends @ 16:46:55
Tonic Phase begins @ 16:46:56 and ends @ 16:47:18
Other details/questions:
1. His seizure frequency has been increasing recently - Any known triggers for his kind of epillepsy?
2. His EEGs show Generalized Epileptic discharges during sleep (nothing when awake) - What does it mean in the context of his seizure video.
3. His MRI seems to be normal.
4. What is suggested medication for his presentation of seizure.
Thanks, XXXXXXX
His Symptoms:
1. He Starts Off with a Stare / Absence (for 10 secs)
2. Then Proceeds to Cry (for 10secs)
3. Then Progress to Tonic Phase (~20 seconds)
4. Most of the times, it ends with Clonic Phase (Arms and legs jerking)
5. Post Ictal - he sleeps for ~ 1.5 hours.
Video:
=====
My Son's Seizure looks as follows:
https://www.youtube.com/watch?v=KV4N5Yi8IhE
The Stare begins @ 16:46:34 and ends @ 16:46:45.
Cry/Shout begins @ 16:46:45 and ends @ 16:46:55
Tonic Phase begins @ 16:46:56 and ends @ 16:47:18
Other details/questions:
1. His seizure frequency has been increasing recently - Any known triggers for his kind of epillepsy?
2. His EEGs show Generalized Epileptic discharges during sleep (nothing when awake) - What does it mean in the context of his seizure video.
3. His MRI seems to be normal.
4. What is suggested medication for his presentation of seizure.
Thanks, XXXXXXX
Brief Answer:
Take steps as advised and consult pediatric epileptologist/neurologist
Detailed Answer:
Hello XXXXX,
I have gone through your question and video and understand your concerns.
The seizure semiology is asymmetrical with formation of figure of 4 posture, suggestive of focal onset of seizure.
In view of both febrile and afebrile seizures, secondary pathology is to be suspected.
MRI if normal should be repeated with epilepsy protocol.
The seizure type can best be described as localization related epilepsy either partial or complex partial with secondary generalization.
1) The trigger for seizures are fever, decreased or disturbed sleep, flashing lights, loud sound(in some cases)
2) The EEG in children is done either in sleep or with sedation and thus interpreted in sleep condition of patient.
3) Mri needs to be reevaluated or repeated if seizures are not controlled.
4) For treatment levetiracetam is a good drug and dose can be increased according to weight of child till side effects apparent. Other useful drugs may be valproate, oxcarbazepine, lacosamide.
For time being clobazam can be added to current treatment regimen.
Consultation with a pediatric neurologist or epileptologist will be helpful.
Hope you found the answer useful.
Wishing good health for the child.
Regards
Dr N Kumar
neurologist
Take steps as advised and consult pediatric epileptologist/neurologist
Detailed Answer:
Hello XXXXX,
I have gone through your question and video and understand your concerns.
The seizure semiology is asymmetrical with formation of figure of 4 posture, suggestive of focal onset of seizure.
In view of both febrile and afebrile seizures, secondary pathology is to be suspected.
MRI if normal should be repeated with epilepsy protocol.
The seizure type can best be described as localization related epilepsy either partial or complex partial with secondary generalization.
1) The trigger for seizures are fever, decreased or disturbed sleep, flashing lights, loud sound(in some cases)
2) The EEG in children is done either in sleep or with sedation and thus interpreted in sleep condition of patient.
3) Mri needs to be reevaluated or repeated if seizures are not controlled.
4) For treatment levetiracetam is a good drug and dose can be increased according to weight of child till side effects apparent. Other useful drugs may be valproate, oxcarbazepine, lacosamide.
For time being clobazam can be added to current treatment regimen.
Consultation with a pediatric neurologist or epileptologist will be helpful.
Hope you found the answer useful.
Wishing good health for the child.
Regards
Dr N Kumar
neurologist
Above answer was peer-reviewed by :
Dr. Deepak
Hi Dr. N XXXXXXX
Thanks for your reply. Sorry for the long email, But please bare with me and help us understand it better so that we can discuss with doctors here.
Could you please take a few more minutes looking at the video and help us understand what parts of the video corresponds to your diagnosis. We will be grateful if you dissect the video and point to which seizure category each of them fall into. (I believe he starts off with one (Want to know if it focal or Generalized) and then it extends into a Generic Tonic Clonic Seizure)
Here are our major questions:
1. At what point do you feel it was a 4 posture - could it be because of the way we lifted him? Please see his previous seizure in this video, where we just let him lie on the floor.
https://www.youtube.com/watch?v=oszyHszgzws
We believe all his seizures are exact replicas of each other. Even in this video, we think he probably stared before starting to scream.
Can you please let us know if you are seeing 4 posture?
2. Now, we clearly know it starts with a "Stare / Freeze" - What kind of epilepsy is it? - Focal or Generalized? He also tends to move his head gradually towards his right during the freeze period.
3. And then he screams / Crys - Is that a different Seizure? I don't believe it is the cry associated with a GTC, because it lasts for a good 10 seconds. What sort of seizures can lead to producing a cry sound?
4. I think his cry also marks some stiffening of body - Is it when the Tonic phase is beginning or is it after the scream ends?
5. You mentioned MRI repeat with Epilepsy protocol. Can you please elaborate or provide some more references so that I can approach Neurologists here?
Thanks, XXXXXXX
Thanks for your reply. Sorry for the long email, But please bare with me and help us understand it better so that we can discuss with doctors here.
Could you please take a few more minutes looking at the video and help us understand what parts of the video corresponds to your diagnosis. We will be grateful if you dissect the video and point to which seizure category each of them fall into. (I believe he starts off with one (Want to know if it focal or Generalized) and then it extends into a Generic Tonic Clonic Seizure)
Here are our major questions:
1. At what point do you feel it was a 4 posture - could it be because of the way we lifted him? Please see his previous seizure in this video, where we just let him lie on the floor.
https://www.youtube.com/watch?v=oszyHszgzws
We believe all his seizures are exact replicas of each other. Even in this video, we think he probably stared before starting to scream.
Can you please let us know if you are seeing 4 posture?
2. Now, we clearly know it starts with a "Stare / Freeze" - What kind of epilepsy is it? - Focal or Generalized? He also tends to move his head gradually towards his right during the freeze period.
3. And then he screams / Crys - Is that a different Seizure? I don't believe it is the cry associated with a GTC, because it lasts for a good 10 seconds. What sort of seizures can lead to producing a cry sound?
4. I think his cry also marks some stiffening of body - Is it when the Tonic phase is beginning or is it after the scream ends?
5. You mentioned MRI repeat with Epilepsy protocol. Can you please elaborate or provide some more references so that I can approach Neurologists here?
Thanks, XXXXXXX
Brief Answer:
Take treatment as advised and get investigated too
Detailed Answer:
Hello XXXXXXX
I have gone through both your videos and is replying question wise.
1. At what point do you feel it was a 4 posture - could it be because of the way we lifted him? Please see his previous seizure in this video, where we just let him lie on the floor.
https://www.youtube.com/watch?v=oszyHszgzws
Answer: The figure of 4 formation is visible from 16:47:25 onwards in video dated 31/03/2016. In figure of 4 formation, the right upper limb is extended at elbow and left arm is flexed at elbow. Head and neck turning to right. These features are suggestive of primary focus in the left brain hemisphere probably temporal lobe.
Previous video is not showing clearly such a posture.
We believe all his seizures are exact replicas of each other. Even in this video, we think he probably stared before starting to scream.
Can you please let us know if you are seeing 4 posture?
2. Now, we clearly know it starts with a "Stare / Freeze" - What kind of epilepsy is it? - Focal or Generalized? He also tends to move his head gradually towards his right during the freeze period.
Answer : Possibility of focal onset with secondary generalization type of seizure is more likely. Staring may be present in any seizure type, though more common and longer in complex partial or absence seizures.
3. And then he screams / Crys - Is that a different Seizure? I don't believe it is the cry associated with a GTC, because it lasts for a good 10 seconds. What sort of seizures can lead to producing a cry sound?
Answer: Loud noise or ictal cry is a part of tonic phase of generalized seizure.
4. I think his cry also marks some stiffening of body - Is it when the Tonic phase is beginning or is it after the scream ends?
Answer: Tonic phase has ictal cry followed by tonic posturing followed by clonic phase.
5. You mentioned MRI repeat with Epilepsy protocol. Can you please elaborate or provide some more references so that I can approach Neurologists here?
Answer; In view of previous febrile seizure possibility of damage to hippocampal area of temporal lobe is there. MRI epilepsy protocol has thin sections at hippocampus for higher detection.
You should follow the advice and treatment as advised by neurologist and discuss all doubts with him too.
Hope you found the answer helpful.
Do get back with further queries.
Regards
Dr N Kumar
Take treatment as advised and get investigated too
Detailed Answer:
Hello XXXXXXX
I have gone through both your videos and is replying question wise.
1. At what point do you feel it was a 4 posture - could it be because of the way we lifted him? Please see his previous seizure in this video, where we just let him lie on the floor.
https://www.youtube.com/watch?v=oszyHszgzws
Answer: The figure of 4 formation is visible from 16:47:25 onwards in video dated 31/03/2016. In figure of 4 formation, the right upper limb is extended at elbow and left arm is flexed at elbow. Head and neck turning to right. These features are suggestive of primary focus in the left brain hemisphere probably temporal lobe.
Previous video is not showing clearly such a posture.
We believe all his seizures are exact replicas of each other. Even in this video, we think he probably stared before starting to scream.
Can you please let us know if you are seeing 4 posture?
2. Now, we clearly know it starts with a "Stare / Freeze" - What kind of epilepsy is it? - Focal or Generalized? He also tends to move his head gradually towards his right during the freeze period.
Answer : Possibility of focal onset with secondary generalization type of seizure is more likely. Staring may be present in any seizure type, though more common and longer in complex partial or absence seizures.
3. And then he screams / Crys - Is that a different Seizure? I don't believe it is the cry associated with a GTC, because it lasts for a good 10 seconds. What sort of seizures can lead to producing a cry sound?
Answer: Loud noise or ictal cry is a part of tonic phase of generalized seizure.
4. I think his cry also marks some stiffening of body - Is it when the Tonic phase is beginning or is it after the scream ends?
Answer: Tonic phase has ictal cry followed by tonic posturing followed by clonic phase.
5. You mentioned MRI repeat with Epilepsy protocol. Can you please elaborate or provide some more references so that I can approach Neurologists here?
Answer; In view of previous febrile seizure possibility of damage to hippocampal area of temporal lobe is there. MRI epilepsy protocol has thin sections at hippocampus for higher detection.
You should follow the advice and treatment as advised by neurologist and discuss all doubts with him too.
Hope you found the answer helpful.
Do get back with further queries.
Regards
Dr N Kumar
Above answer was peer-reviewed by :
Dr. Naveen Kumar
Thanks for the detailed answer Dr. XXXXXXX XXXXXXX
I was told that the MRI was taken with Epi protocol.
I am attaching the MRI report and the latest EEG report. (Unfortunately, I was unable to get the raw results from the lab).
Please take a look and let me know if you find anything else that is interesting.
Based on EEG, Doctors here are inclined to classifying it as Generalized Epilepsy and started him on Keppra and now considering adding 'Zonisamide' - Any comments?
Thanks Again!
Sincerely, XXXXXXX
I was told that the MRI was taken with Epi protocol.
I am attaching the MRI report and the latest EEG report. (Unfortunately, I was unable to get the raw results from the lab).
Please take a look and let me know if you find anything else that is interesting.
Based on EEG, Doctors here are inclined to classifying it as Generalized Epilepsy and started him on Keppra and now considering adding 'Zonisamide' - Any comments?
Thanks Again!
Sincerely, XXXXXXX
Brief Answer:
Start zonisamide if seizures are not controlled on keppra alone
Detailed Answer:
Hello,
I have gone through Mri and eeg reports.
The only abnormality in Mri is left frontal tiny hyperintensity. This may be a focus for discharge and seizure but eeg is showing bilateral spikes suggestive of multi focality.
For treatment the drugs are increased gradually and other drug is added if maximum tolerable dose of first drug has been reached.
Zonisamide can be added if not responsive to keppra alone.
Hope you found the answer helpful.
Regards
Dr N Kumar
Neurologist
Start zonisamide if seizures are not controlled on keppra alone
Detailed Answer:
Hello,
I have gone through Mri and eeg reports.
The only abnormality in Mri is left frontal tiny hyperintensity. This may be a focus for discharge and seizure but eeg is showing bilateral spikes suggestive of multi focality.
For treatment the drugs are increased gradually and other drug is added if maximum tolerable dose of first drug has been reached.
Zonisamide can be added if not responsive to keppra alone.
Hope you found the answer helpful.
Regards
Dr N Kumar
Neurologist
Above answer was peer-reviewed by :
Dr. Yogesh D
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