Seizure-Like Episode in an 18-Year-Old Male: A Clinical Case Report

on

CLINICAL CASE 02

Suspected Seizure / Convulsive Syncope in an 18-Year-Old Male With Normal Follow-Up MRI and EEG

1. PATIENT PROFILE

  • Age: 18 years
  • Sex: Male
  • Setting: Emergency department
  • Relevant specialty: Neurology

2. CHIEF COMPLAINT

The patient presented with:

  • One episode of abnormal behavior associated with clenching of the hands
  • Dizziness
  • Pre-syncope

3. HISTORY OF PRESENTING ILLNESS

An 18-year-old male presented to the emergency department following an episode of abnormal behavior associated with clenching of the hands. The episode was accompanied by dizziness and a sensation of pre-syncope.

There was no reported tongue bite or upward rolling of the eyeballs. On initial evaluation, the patient was conscious and oriented.

The clinical presentation raised the possibility of a seizure-like event versus convulsive syncope or myoclonic jerks.

4. INITIAL CLINICAL EXAMINATION

General and Neurological Examination

  • Conscious and oriented
  • No tongue bite noted
  • No uprolling of eyeballs noted
  • No significant focal neurological deficit reported

Vital Signs

Parameter

Finding

Heart Rate

110–113 beats/min

Blood Pressure

150/80 mmHg

SpO₂

97% on room air

The patient was noted to have tachycardia.

5. EMERGENCY INVESTIGATIONS

Neuroimaging

NCCT Head:

Non-contrast CT of the head demonstrated a small, subtle, ill-defined hypodensity in the right temporal lobe.

MRI of the brain was recommended for further evaluation and clinical correlation.

Laboratory Investigations

Investigation

Finding

WBC count

14.08 × 10³/µL

Ionized calcium

0.99 mmol/L

Lactate

3.05 mmol/L

Serum creatinine

1.34 mg/dL

Total bilirubin

1.08 mg/dL

Direct bilirubin

0.43 mg/dL

Lymphocytosis was also noted.

Cardiac Evaluation

ECG: Sinus tachycardia.

6. INITIAL DIFFERENTIAL DIAGNOSIS

Based on the clinical presentation and emergency evaluation, the following possibilities were considered:

  1. Convulsive syncope, including vasovagal or orthostatic syncope
  2. Myoclonic jerks
  3. Seizure disorder

The absence of certain typical seizure-associated features, such as tongue biting and eye deviation, was considered during the initial assessment.

7. ACUTE MANAGEMENT

The patient was admitted for observation and medical management.

Treatment included:

  • IV Ringer's Lactate: 75 mL/hour
  • Inj. Emset: As prescribed
  • Inj. Pantop: As prescribed
  • Inj. Optineuron Forte: As prescribed
  • Tab. Petril-MD 0.5 mg (clonazepam): SOS, as prescribed

The patient remained clinically stable and was subsequently discharged with advice for neurological follow-up.

8. SPECIALIST EVALUATION AND FOLLOW-UP INVESTIGATIONS

8.1 Echocardiography

A 2D echocardiogram was performed as part of the evaluation for a possible cardiac cause of the pre-syncopal/ syncopal event.

Findings:

  • Normal cardiac chambers
  • Left ventricular ejection fraction (LVEF): 67%

No significant structural cardiac abnormality was reported.

8.2 Neurology Evaluation

On subsequent neurological evaluation, Idiopathic Generalized Epilepsy (IGE) was considered as a working diagnosis.

The patient was prescribed:

Brivaracetam 50 mg twice daily

Further neurological investigations were advised.

8.3 Electroencephalography (EEG)

EEG was performed during follow-up.

Findings:

  • Background activity: approximately 8–9 Hz
  • No epileptiform discharges
  • No ictal rhythm observed during the recording

Impression: Normal EEG.

8.4 Contrast-Enhanced MRI Brain

A contrast-enhanced MRI of the brain was subsequently performed.

Findings:

  • No significant intracranial abnormality
  • Normal brain morphology
  • No significant focal lesion identified

Importantly, the subtle right temporal hypodensity described on the initial non-contrast CT was not confirmed on MRI.

9. FINAL CLINICAL ASSESSMENT

The patient experienced a seizure-like episode characterized by abnormal behavior and hand clenching, associated with dizziness and pre-syncope.

The initial CT scan demonstrated a subtle, ill-defined right temporal hypodensity; however, subsequent high-resolution contrast-enhanced MRI of the brain showed no corresponding significant abnormality.

The follow-up EEG was also normal, with no epileptiform discharges or ictal activity during the recording.

A neurological working diagnosis of Idiopathic Generalized Epilepsy (IGE) was considered, and the patient was started on brivaracetam.

10. CLINICAL COURSE AND OUTCOME

The patient was stabilized following emergency evaluation and was discharged with neurological follow-up.

Subsequent cardiac evaluation showed normal cardiac structure and preserved left ventricular systolic function.

Neurological investigations, including EEG and contrast-enhanced MRI of the brain, did not demonstrate significant abnormalities.

The patient remained under neurological follow-up and was advised regarding activity and posture precautions as clinically appropriate.

11. DISCUSSION

Seizure-like episodes can present with a variety of motor and behavioral manifestations and may sometimes be difficult to distinguish from convulsive syncope.

In this case, the episode of abnormal behavior and hand clenching was associated with dizziness and pre-syncope. The absence of tongue biting and eye rolling, together with the clinical history, prompted consideration of convulsive syncope and myoclonic jerks in the differential diagnosis.

The initial CT finding of a subtle right temporal hypodensity raised the possibility of a structural intracranial abnormality. However, subsequent contrast-enhanced MRI showed no significant abnormality and did not confirm the CT finding.

Similarly, a normal EEG does not by itself exclude epilepsy, particularly when the clinical history remains suggestive. Therefore, interpretation of EEG and neuroimaging should always be integrated with the complete clinical history and neurological examination.

The case highlights the importance of correlating an initial imaging abnormality with higher-resolution imaging and the overall clinical picture before attributing a seizure-like event to a structural brain lesion.

12. KEY LEARNING POINTS

  • Clinical history and examination remain essential in distinguishing seizure from convulsive syncope.
  • A subtle abnormality on an initial CT scan may require further evaluation with MRI.
  • Normal MRI findings can help exclude a suspected structural brain lesion.
  • A normal routine EEG does not necessarily exclude epilepsy.
  • Diagnosis and treatment should be based on the overall clinical picture rather than a single investigation.
  • Cardiac evaluation may be appropriate when syncope or pre-syncope is part of the presentation.

13. CONCLUSION

While the initial emergency CT scan suggested a potential right temporal lobe issue, subsequent high-resolution MRI and EEG were both normal. The patient was managed for a suspected seizure/convulsive syncope and remains under neurological care with anti-epileptic medication (Brivaracetam) while being advised to avoid heavy exertion and sudden changes in posture.

REFERENCES

1. National Institute for Health and Care Excellence (NICE). Epilepsies in children, young people and adults: diagnosis and management NICE.

2.Fisher RS, Acevedo C, Arzimanoglou A, et al. ILAE Official Report: A practical clinical definition of epilepsy. Epilepsy. 201;55(4):475–482.

3. ILAE classification of the epilepsies: Position paper of the ILAE Commission for Classification and Terminology. Epilepsy. 2017

4. International League Against Epilepsy (ILAE). Classification and Definition of Epilepsy Syndromes. ILAE.

5. International League Against Epilepsy (ILAE). ILAE Definition of the Idiopathic Generalized Epilepsy Syndromes: Position Statement. Epilepsy. 2022.


PATIENT CONFIDENTIALITY

All personally identifying information has been excluded from this case presentation. The patient's name, hospital identification details, contact information, address, and other unnecessary identifying information have not been included.


Medical Disclaimer: The information provided in this article is strictly for educational, study, and exam-preparation purposes. It does not constitute professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider for clinical decisions.

Comments

Post a Comment