DIAGNOSIS

DIAGNOSIS
Cardiology diagnosis was systole, secondary to enhanced vagary tone form the left temporal lobe-onset seizures.

TREATMENT and Outcome
The patient underwent implantation of a dual-chamber pacemaker. Since then, she has continued to have both type of seizures but has not fallen to the ground in association with the second type. She has elected to defer epilepsy surgery at this time.

Discussion
Ictal-indeed changes in heart rate and rhythm are among the many possible autonomic manifestations of seizures. Sinus tachycardia is the most frequent disturbance of cardiac rate that accompanies seizures.In one series of consecutive patients with temporal lobe seizures, ictal tachycardia was associated with left-sided seizure onset onset in four patients and right temporal lobe onset in eight patients.

Bradyarrhythmias, including bradycardia, sinus arrest, atrioventricular block, and a systole occurs less frequently than tachyarrhythmias. In some patients with ictal-indude bradyarrthmia, less of consciousness may be due to sync Ope and not to the seizure. In this patient, a chance in heart rate, although it is likely that falls were associated with cardiac asystole.

Recognition of the cardiovascular manifestation of seizures requires a high index of suspicion. This case illustrates that patients with abrupt falls following the onset of typical complex partial seizures should be evaluated for possible ictal-related cardiac conduction disturbances with simultaneous ECG and EEG monitoring.

In this particular case the patient had medically refractory simple partial and complex partial seizures. The latter was often associated with abrupt falling to the ground if she was standing during the seizure. Over the years, it was assumed that the patient's falls to the ground were a direct effect of the seizures on the strength and tone of her lower extremities. Only when she underwent ictal EEG monitoring did it becomes apparent that there was an alternative explanation-cardiac asystole. This is supported by the fact that she has not fallen since implantation of a cardiac pacemaker even though she continues to have the other typical manifestation of her seizures. Independent of her seizures, the patient had no other clinical evidence of cardiac arrhythmia's.


References
1. Schachter SC. Autonomic epilepsy. Se min Neurol 1995;15;158-66
2. Devin sky O, Price BH, Cohen SI. Cardiac manifesting of complex partial seizures. Am J Med 1986;56;443-46.

Epileptic Falls

Epileptic Falls

The case
A 35 years-old woman with a history of convulsions from 2 years of age was presented. Due to the history of recurrent febrile convulsions, she was started on mephobarbital at the age of 4 years.

History

her past medical history was significant for an occipital hemorrhage secondary to a seizure-related head injury at the age of 26, ovarian cysts and a transiently positive antinuclear antibody that was thought to be secondary to phenytoin. Family history was negative for epilepsy. Her father died from a myocardial infarction.

She reported of first menstrual period at the age of 13 and also her first febrile seizure. Over the ensuing years, she experienced two different types of seizures at an average frequency of times a month. The first type consisted of the feelings that she is forced or pushed down.

The second type began without a warning- she lost consciousness and the then was observed to stare for up to 330 seconds and to fall abruptly to the ground, usually with no apparent rhythmic or tonic motor movements.Positionally, she was tired, hungry and frustrated.

Previous evaluation consisted of an EEG(which showed left temporal interact epilepsy form discharges) and a normal routine magnetic resonance imaging scan.

Examination and Investigations
The patient was examined on three basis and the investigations attained as per these examinations were as follows:
1. General Health-Normal
2. Cardiologist examinations-Normal
3. Neurological examinations- Remarkable

Her anti epileptic medications were tapered and several seizures of the second type ascribed above were recorded while she was in bed. The ital EEG recordings demonstrated electrocardiograph seizure activity confined to the left anterior to mid-temporal region in addition, electrocardiography (ECG) monitoring showed progressive bradycardia leading to complete a systole for up to 14 seconds before a normal heart rate was resumed. The change in cardiac rhythm began after the initial clinical manifestations of the seizures(starting and unresponsiveness). The ECG finding prompted a consultation.

INTRODUCTION Of Migraine & Epilepsy

1. Neurological chronic disorders with manifestations (CDEM) are characterized by recurrent attacks of nervous system dysfunction with a return to baseline between attacks. Among the CDEM treated by neurologists, headaches (including migraine) and epilepsy are the most common, each compressing nearly 20% of out patient neurological visits.

2. Both migraine and epilepsy represent dist inch families of neurological disorders with typical constellations of symptoms. Migraine is characterized by recurrent attacks of pain and associated symptoms.

3. Epilepsy is characterized by recurrent attacks of positive neurological symptoms, often progressing to altered of lost consciousness, and at times
convulsive features.

4. The physician while treating these disorders face many challenges. The sensory, motor and cognitive characteristics of migraine and epilepsy often overlap. Both disorders presents with headache.

5. Furthermore, as migraine and epilepsy are highly co morbid, many individuals have both disorders, further complicating accurate diagnosis.Additionally, the therapeutic options for the disorders overlap.

6. Migraine may be co morbid with several other neuralgic and psychiatric conditions, including mood disorders (eg, depression, anxiety and panic disorders), epilepsy, stork and essential tremor. Co morbidity presents physicians with opportunities and and challenges for both and treatment.

"Both Migraine and epilepsy are heterogeneous families of chronic disorders with highly variable clinical features,natural histories, and patterns of treatment response. Both are characterized by episodes of
neurology's dysfunction, sometimes accompanied by
headache as well as gastrointestinal,
autonomic and psychological
features."

all diseases must be considered, and therapeutic strategics may need to be modified to avoid potential drug interactions. Commodities also may provide clues to the parapsychology's and any shared mechanisms of two disorders.

Longitudinal studies have demonstrated a bi-directional influence between migraine and major depression, but not between migraine and other severe headache. Migraine is strongly and consistently associated with panic disorder. The risk of migraine in epilepsy is increased particularly in individuals with head trauma, partial seizures, and a positive family history of migraine. The influence is bidirectional.

There is also growing evidence of an association between migraine and stroke, particularly among women of child-bearing age and individuals who experience migraine with aura. Lastly, a bidirectional association between migraine and essential tremor also exists. These findings suggests that migraine, major depression, epilepsy,and essential tremor shares one or common etiologies.