Re: First time faint/seizure

Posted By CCF Neurology MD on September 28, 1997 at 01:52:02:

In Reply to: First time faint/seizure posted by Pat Kirby on September 25, 1997 at 16:51:24:







: Hello,
I have searched your archives and forum prior to posting this message.
I understand that the description below is a long-winded description.  
Please excuse me if I have included more than necessary.  I was careful
to include all info I thought may be necessary and helpful to answer my
questions.
Personal stats & info: female; 35 years old; 5' 7"; 135 lb.; current and
general health is very good; no meds; don't use over the counter drugs;
don't drink alcohol, coffee, soda or other caffeinated beverages; don't
smoke; rarely ingest sucrose or corn syrup; medical history--had a very
high fever and vomiting for many days at about age 3(?), tonsils out at
age 7, a car accident w/a major blow to the head at age 17 (10/79--concussion,
loss of consciousness for an unknown amount of time, 1 hour?), lots of
parental physical abuse that included contact with the head and shaking--
from toddler age (or younger?) through teen years, periodically some strange
headaches, light experiences of de ja vu perhaps a few times a year,
circulation to fingers and toes tends to be poor, started experiencing
hayfever in my late 20's; regular exercise--avid runner, daily stretch
routine, also biking, and other sports and high energy activities;
average 4-5 hours of sleep per night, feeling well rested every morning;
could stand to increase my food intake--food types are healthy, amount may
be on the scant side; a lot of stress, both personal and professional;
heavy eye work--lots of computer work, photography, videography; lots
of phone time--often cordless and cell phone.
*The situation: On 9/9/97 I experienced a loss of consciousness for the first
time--to my knowledge.  It took place in the mid afternoon.  I had been
feeling normal and had not been involved in any physical exertion that day.  
I was sitting in an office--comfortable room temperature--wearing loose
fitting clothing.  I had eaten a peanut butter & jelly sandwhich (no sucrose
or corn syrup) on natural whole wheat bread about an hour and a half prior to
losing consciousness (this was pretty much all I had to eat so far that day,
by 1 pm).  At the time I lost consciousness I was finishing up
an appointment with a hypnotherapist (my first visit).  The subject matter
was an emotional one, and I did get somewhat emotional a few minutes prior to
losing consciousness.  The therapist had done a general hypnotherapy session,
during which I *felt* completely cognizant of what was being said even though
the therapist instructed me to "zone" out--to not pay attention to what was
being said.
*The episode: I was sitting upright, posture fairly straight, on the edge of
the couch, pulled out my checkbook (some say this was the cause!) while
talking to the therapist, turned my head to the left and looked out the
window.  At that point I started to experience a strong sense of de ja vu, I
began to feel tingly in my head and shoulders, light-headed and dizzy.  I said,
"Wow!  I'm feeling a real strong sense of de ja vu." (or something to that
sentiment.)  I didn't feel anxiety about it--it was more like a feeling
of fascination about the sensations that were coming on.  The sensations
increased fairly quickly and it felt kind of like a faucet of sensations
being turned more to open the valve up--increase a sort of pressure in my
head--not a painful pressure however--maybe like a numbing pressure.
The last thing I remember before losing consciousness was that I was saying
the statement I quoted above.  Then, while I was coming to, I saw paramedics
coming into the room.  I felt fine.  They asked me the standard questions
and I was able to answer them correctly.  I remember answering them.  I
remembered things like my license plate number, phone numbers, etc.  
However, I didn't know that I had passed out.  So, in that sense I was
confused--about why the paramedics were there--and after they told me
what happend I still did not want to go into the ambulance.  
Also, there was no tenderness during paramedic's palpations.
*The witness's description of the episode: The therapist said a glazed look
came over my face. My body thrusted back into the couch.  Then it stiffened
up like a plank and gradually slid down to the floor and began to jitter,
quiver, shake (my limbs were not flying around).  My impression of the
description of convulsions was that it may have looked like I was shivering
or had a bad case of caffeine withdrawl (withdrawal) (again, I don't drink coffee, soda,
etc.).  My eyes were completely rolled up, no portion of the irises were
visible.  I was foaming at the mouth--no odor from the mouth was detectable.  
The duration of the episode was estimated at 4-5 minutes.
I was transferred to the ER without incident.  ECG was normal, "normal sinus
rhythm, rate 65."  Chemistry tests: CHEM 7 -- all stats fell within the
expected range.  Hematology: BCP -- all stats fell within the expected
range except RDW, which was 15.1% (printed "expected range" = 11.5-14.5). I
was told by an ER nurse that this was nothing to worry about if all else
was normal (that the increased percentage was very small).  The "Patient
Care Instruction" sheet I was given gave the diagnosis "Vasovayal Syncope."
Handwritten next to that was "Seizure."  I was instructed to see a
neurologist in 2-3 days.  I did NOT have an EEG, CT scan or MRI.
*Visit to the neurologist: The neurologist asked the standard questions,
performed palpation types of tests, and talked to the therapist who
witnessed the episode.  The neurologist has decided, all but "officially,"
that the episode was an epileptic seizure--decision was "Based on the
witness's description and that you have said you experience de ja vu a few
times a year... I STRONGLY suspect this was an epileptic seizure...I can't
officially diagnose epilepsy until you have some of the other tests done...
But I DO recommend that you begin taking medication now...even if you don't
have the other tests..."  
This neurologist informed me that, "Of course it's your decision as to
whether or not you take medication.  But if you choose not to, the DMV may
very well tell you you can't drive for at least six months."  This seemed
like a very premature statement to be making, at least in the way that he
presented it--as the total of the situation.
The neurologist has recommended that I do not drive until further information
is learned.  I have chosen not to drive for the safety of others, as well
as myself.  
The neurologist's statements and other indications lead me to believe that  
he may be predisposed to the idea that I definitely have epilepsy and that
it's enough of a case to warrant medication right off the bat.  There are
things about the neurologist's behavior and attitude that have me wondering
if he's not simply trying to cover his butt due to a previous negative
experience...call it intuition or whatever...but it's something I have not
been able to ignore.  I want a second opinion--which I am currently looking
into--however it will probably be a while before I can get one.
If possible I would like to know, sooner than the second opinion will come,
what a fellow neurologist thinks about putting someone on medication after
this degree of examination.  
I would also like to know if there are standard procedures required to be
followed in order to officially diagnose epilepsy and where I might
obtain such a list..  I am trying to learn all I can regarding how to go
about getting the proper diagnosis and care (if needed).  I am currently
a part time student, working part time and am without health insurance.  
So I do not have anyone like a primary health care provider to consult.  
I also do not qualify for any of the government assistant programs.
Any thoughts you have regarding this situation and how it's being handled
would be greatly appreciated!  Thank you for your time and for any input
you may give.
Sincerely,
Pat Kirby
***@****





Dear Pat:
I would like to complement you for the precise history.
Briefly:
1) While the episode is quite suspicious of a partial seizure (temporal lobe origin?) with generalization, there are some atypical features. I think the possibilities of syncope and pseudo-seizure do stand, and can not be ruled out with any confidence.
2) The matter of starting anti-epileptic medication after a first seizure is complex. The risk of recurrence of an unprovoked spontaneous seizure in an adult is about 50 percent over time (20-70% in different sudies); medication may delay this recurrence. The risk of recurrent seizures is significantly increased if the EEG is positive for epileptiform activity. While first seizures are often treated, this is not a routine recommendation. The situation is further complicated in your case by the uncertainty of the diagnosis. The risks and benefits of treating and not treating need to be fully understood by you from your physician before you decide about taking treatment.
3) The laws of driving and epilepsy differ in different states. The situation is more murky when the first event is not diagnosed with certainty. I suggest that you discuss this matter in depth with your neurologist(s).
If you live near Cleveland, I strongly recommend that you seek a second opinion from one of the epileptologists at the Cleveland Clinic. The epilepsy department at Clinic is one of the most renowned ones in the world. Dr. Hans Luders (the chairman) and other faculty (Drs. Morris, Dinner, Geller, and Foldvary) are internationally recognised authorities on the subject. Appointments can be made by calling [phone] toll free, or [phone] locally.
Good luck!