Seizure

HPI:

Seizure - 2.2cm rim-enhancing lesion in the right occipital lobe.

2.2cm rim-enhancing lesion in the right occipital lobe.

26M with a history of retroperitoneal embryonal carcinoma (IIIC, known liver/lung metastases) presenting with new-onset “seizures” for one week. The patient reports the first episode occurred 6 days ago, he noted progressive loss of vision on the left side (over 1-2min), followed by loss of consciousness and awoke in an ambulance. He denies any urinary/fecal incontinence, tongue biting, or post-spell confusion, and he awakes spontaneously and is able to get up under his own power. Episodes are not associated with palpitations, nausea or diaphoresis. An episode of identical character occurred 4 days later and triggered his presentation today. He otherwise denies fevers/chills, headaches, nausea/vomiting, changes in vision outside of episodes.

A witness, the father, described the patient reporting vision loss, followed by collapse and tensing of trunk and limb muscles for 1-2 minutes (without rhythmic shaking) during which the patient was unresponsive. The patient then awoke but was confused, unaware of what had happened and unable to recognize his father.

The patient was initially diagnosed with his malignancy several months ago, presenting with flank pain, weight loss and hemoptysis and recently completed a third cycle of chemotherapy (VIP: etoposide, ifosfamide, cisplatin).

PMH:

  • Retroperitoneal embryonal carcinoma. Stage IIIC

PSH:

  • None

FH:

  • Relative with testicular malignancy.

SHx:

  • No t/e/d use
  • Lives at home with family

Meds:

  • Norco 5/325mg p.o. q.4.h. p.r.n. pain

Allergies:

NKDA

Physical Exam:

VS: T 98.4 HR 67 RR 17 BP 116/67 O2 98% RA
Gen: Well-appearing, no acute distress
HEENT: PERRL, MMM, no lesions, discs sharp b/l
CV: RRR, normal S1/S2, no M/R/G
Lungs: CTAB, no crackles/wheezing, no focal consolidation
Abd: +BS, soft, NT/ND, no hepatosplenomegaly
GU: Testes descended b/l, no masses, non-tender
Ext: Warm, well-perfused, no rashes/ecchymoses
Neuro: AAOx4, CN II-XII intact, OS 20/40 OD 20/70, normal visual fields to confrontation, no dysmetria/dysdiadochokinesia, normal gait

Labs/Studies:

  • CBC: 7.8/14.4/43.3/179
  • BMP: 138/4.0/105/25/7/0.66/94
  • AFP: 3.5
  • B-hCG: 4222
  • MRI Brain: 2.2 cm rim-enhancing heterogeneous lesion in the right occipital lobe concerning for a metastatic focus.

Assessment/Plan:

26M w/hx retroperitoneal embryonal carcinoma with known liver/lung metastases presenting with syncope x1wk.

# Syncope: Likely neurogenic (seizure) given imaging findings of brain mass concerning for metastasis. Location of mass correlates with seizure characteristics as likely focus of complex partial seizure with apparent secondary generalization. Currently, no evidence of significant mass effect or increased intracranial pressure (no headaches, nausea/vomiting, papilledema). Patient discussed with neurosurgery who will evaluate the patient for surgical resection of mass.  Start levetiracetam for seizure prophylaxis.

# Retroperitoneal embryonal carcinoma: Stage IIIC with known liver/lung metastases, now with evidence of extension of disease. Consulted heme/onc who are familiar with the patient and do not plan for chemotherapy during this admission. Continue monitoring AFP, B-hCG levels which have remained stable.

Imaging:

CT Abdomen/Pelvis: Axial
CT Abdomen/Pelvis: Coronal
CT Abdomen/Pelvis: Sagittal
MRI Brain: Axial

Download: (.mp4)

Differentiating Seizure and Syncope:

The differential diagnosis of syncope is broad (and has been explored previously). This case explores the clinical features that have been shown to be most useful in differentiating syncope from seizure.1,2

Differentiating Seizure and Syncope

Questionnaire:

Feature Points
Tongue laceration 2
Déjà vu 1
Emotional stress associated with LOC 1
Head turning during spell 1
Unresponsive, unusual posture, limb movement, amnesia 1
Confusion 1
Lightheadedness -2
Sweating -2
Prolonged sitting/standing -2

Score: >1 likely seizure, <1 likely syncope

References:

  1. McKeon, A., Vaughan, C., & Delanty, N. (2006). Seizure versus syncope. Lancet neurology, 5(2), 171–180. doi:10.1016/S1474-4422(06)70350-7
  2. Sheldon, R., Rose, S., Ritchie, D., Connolly, S. J., Koshman, M.-L., Lee, M. A., Frenneaux, M., et al. (2002). Historical criteria that distinguish syncope from seizures. Journal of the American College of Cardiology, 40(1), 142–148.