A 65-Year-Old Woman With Possible Seizures

Selim R. Benbadis, MD

Disclosures

January 12, 2010

Case History

A 65-year-old woman is self-referred for a second opinion regarding possible seizures. For 3-4 months, she has had episodes of dizziness lasting 1-3 minutes, which occur 2-3 times daily. During these episodes, her family describes her as slow to respond, but she has no abnormal movements. The patient herself describes them as feeling like she is "about to pass out" and she states that they always occur upon standing. Her neurologist performed electroencephalography (EEG), which was read as showing temporal epileptiform abnormalities, and concluded that she was having seizures. She was placed on levetiracetam, but symptoms did not improve. She also had driving restrictions because of the diagnosis of seizures.

Medical history includes hypertension, coronary artery disease, depression, chronic low back pain, chronic tension-type headaches, and insomnia. Medications are atenolol 100 mg daily, amytriptiline 25 mg twice daily, oxycodone 10 mg every 6 hours, and lorazepam 1 mg at bedtime.

On examination, blood pressure, 105/54 mm Hg; pulse, 55 beats per minute; with no significant orthostatic changes on the day of the visit. Neurologic examination was completely normal.

Initial Impression

The patient's symptoms are not at all suggestive of seizures. Vague dizziness is extremely nonspecific and much more suggestive of presyncopal symptoms, while vertigo is almost never a manifestation of seizures. The diagnosis of seizures, therefore, is based exclusively on the abnormal EEG.

Next Steps

An ambulatory EEG was obtained for 48 hours to record the patient's episodes because they occur daily; 4 episodes were recorded in which she described her usual symptoms of dizziness. The EEG was completely normal between and during the episodes.

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