Assadollahi Marjan, Ramezani Mahtab, Karimialavijeh Ehsan, Mirfazaelian HadiNeurology Department, Shahid Beheshti University of Medical Sciences, Tehran, IranEmergency Medicine Department, Tehran University of Medical Sciences, Tehran 47-337, Iran

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Generalized seizure, the only manifestation of a small ischemic atherothrombotic infarction

Assadollahi Marjan1, Ramezani Mahtab1, Karimialavijeh Ehsan2, Mirfazaelian Hadi21Neurology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2Emergency Medicine Department, Tehran University of Medical Sciences, Tehran 14117-13137, Iran

KEY WORDS:Small ischemic atherothrombotic infarction; Seizure; Neurological defi cit

World J Emerg Med 2015;7(1):71–73

IN TRODUCTION

Seizure as the presentin g symptom of stroke has been reported previously.[1]Multivariate analysis of the reports revealed that cortical location was the only risk factor after either types of stroke.[1]Seizure as the presenting sign of a small atherothrombotic infarct is very rare and it was reported to be associated with a focal neurological defi cit.[2]

CASE REPORT

A 67-year-old man admitted to our emergency medicine department with an episode of generalized tonic-clonic seizure.This was the first seizure he had ever experienced in his life, which was accompanied by 2 minutes of tonic-clonic movements, upward gaze, urine incontinency, tongue biting and post-ichtal confusion.He had a history of hypertension and he used amelodipine for it.The patient smoked cigarettes but did not drink alcohol or use illicit drugs.He did not have any history for trauma.His familial history for epilepsy was negative.The classic presentation of the generalized tonic-clonic seizure excluded other differential diagnoses such as limb shaking.

On physical examination, the patient was righthanded, appeared arouse and conscious.Vital signs were normal except for his blood pressure which was 170/90 mmHg.While systemic physical examinations were within normal limits; neurological examination after post-ictal phase of seizure showed that he was alert, oriented and obeyed orders (Glasgow Coma Scale 15).Cranial nerves, motor examination, sensory and cerebellar tests were within normal limits with no focal neurological defi cit.

Laboratory tests were significant for hyperglycemia (FBS 220 mg/dL with normal range of 60–159 mg/dL), HbA1C 9.1 g/dL, hypercholesterolemia (cholesterol 256 normal<200, HDL 28 normal>40, LDL 195normal<150).Brain computed tomography (CT) did not show any significant abnormality.Then the patient was subjected to brain magnetic resonance imaging (MRI) and MR venography (MRV), showing multiple acute atherothrombotic infarcts of the subcortical and deep white matter in the right hemisphere on diffusion weighted imaging (DWI) sequence (Figure 1).The result of MRV was normal.

The electroencephalogram (EEG) and Doppler sonogram of the neck carotid arteries were nothing abnormal.Holter monitor test and echocardiography did not show arrhythmia or significant structural heart disease, but left ventricular hypertrophy.Brain CT angiography showed mild narrowing of left M1 and M2 segments of the middle cerebral artery.The basilar artery had a short segment of moderate to severe stenosis and both common carotid bulbs and proximal parts of internal carotid arteries had mild stenosis (Figure 2A, B).

Figure 1.Brain MRI without GAD (DWI sequence) demonstrating multiple acute lacunar infarcts of the subcortical and deep white matter in the right hemisphere.

Figure 2.Brain CT angiography of the patient.A and B: Mild narrowing of left M1 and M2 segments of the middle cerebral artery.The basilar artery had a short segment of moderate to severe stenosis and both common carotid bulbs and proximal parts of internal carotid arteries had mild stenosis.

The seizure did not recur during the proper antiepileptic therapy and the patient was discharged after the administration of oral phenytoin 100 mg TDS, aspirin 80 mg daily, and atorvastatin 40 mg daily.

DISCUSSION

Previous studies[3,4]have reported that the presence of seizures predicted the involvement of the anterior circulation and cortical structures.Studies[5,6]on adults with lacunar infarcts have demonstrated that additional lesions may be responsible for seizure presentation in addition to the subcortical lesion of lacunar infarcts.Kilpatrick et al[7]found early seizures in 24 (4%) of 604 patients with ischemic stroke (or 4.4%, excluding brain stem and cerebellar strokes, as did Bladin et al[8]).All 24 patients with early seizures had cortical infarcts of the anterior circulation.So et al[9]reported that lacunar infarction was associated with seizures in 2.6% of their cases, although the relationship between seizure and lacunar infarcts was questioned.However, risk factors for lacunar diseases, including hypertension, serum hypercholesterolemia, and left ventricular hypertrophy,[10-12]were associated with the development of seizures or epilepsy, even in those without overt stroke.Avrahami et al[13]reported generalized epileptic seizure in 5 elderly hypertensive patients who had lacunar infarcts on their follow-up brain CT scans.Three patients developed hemiparesis after seizure.Arboix et al[14]reported 8 patients with small atherothrombotic infarcts who were identified as having pure sensory stroke.There was a report about the increased inhospital mortality of patients with atherothromboticstrokes which were associated with early (within 48 hours) seizures.[15]

In conclusion, generalized seizure as a presenting sign of stroke is rare and in the reported cases it was accompanied by a focal neurological deficit.But our patient had a small ischemic atherothrombotic infarct only presenting with a seizure without any focal neurological defi cit.

Funding: None.

Ethical approval: Not needed.

Confl icts of interest: The authors have no competing interests.

Contributors: All authors contributed to the design and interpretation of the results and to further drafts.

REFERENCES

1 Myint PK, Staufenberg EFA, Sabanathan K.Post-stroke seizure and post-strokeepilepsyPostgrad Med J 2006; 82; 971: 568–572.2 Nicholas S Abend, Lauren A Beslow, Sabrina E Smith: Seizures as a presenting symptom of acute arterial ischemic stroke in childhood.J Pediatr 2011; 159: 479–483.

3 Lee JC, Lin KL, Wang HS, Chou ML, Hung PC, Hsieh MY, et al.Seizures in childhood ischemic stroke in Taiwan.Brain Dev 2009; 31: 294–299.

4 Delsing BJ, Catsman-Berrevoets CE, Appel IM.Early prognostic indicators of outcome in ischemic childhood stroke.Pediatr Neurol 2001; 24: 283–289.

5 Bladin CF, Alexandrov AV, Bellavance A, Bornstein N, Chambers B, Cote R, et al.Seizures after stroke: a prospective multicenter study.Arch Neurol 2000; 57: 1617–1622, 2000.

6 Giroud M, Dumas R.Role of associated cortical lesions in motor partial seizures and lenticulostriate infarcts.Epilepsia 1995; 36: 465–470.

7 Kilpatrick CJ, Davis SM, Tress BM, Rossiter SC, Hopper JL, Vandendriesen ML.Epileptic seizures in acute stroke.Arch Neurol 1990; 47: 157–160.

8 Bladin CF, Alexandrov AV, Bellavance A, et al.Seizures after stroke: a prospective multicenter study.Arch Neurol 2000; 57: 1617–1622.

9 So EL, Annegers JF, Hauser WA, O'Brien PC, Whisnant JP.Population-based study of seizure disorders after cerebral infarction.Neurology 1996; 42: 350–355.

10 Li X, Breteler MM, deBruyne MC, Meinardi H, Hauser WA, Hofman A.Vascular determinants of epilepsy: the Rotterdam study.Epilepsia 1997; 38: 1216–1220.

11 Ng SK, Hauser WA, Brust, JC, Susser M.Hypertension and the risk of new-onset unprovoked seizures.Neurology 1993; 43: 425–428.

12 Hesdorffer DC, Hauser WA, Annegers JF, Rocca WA.Severe, uncontrolled hypertension and adult-onset seizures: a casecontrol study in Rochester, Minnesota.Epilepsia 1996; 37: 736–741.

13 Avrahami E, Drory VE, Cohn DF.Generalized epileptic seizures as the presenting symptom of lacunar infarction of the brain.J Neurol 1988; 235: 472–474, 1988.

14 Arboix A, Garcia-Plata C, Garsia-Eroles L, Massons J, Comes E, Oliveres M, et al.clinical study of 99 patients with pure sensory stroke.J Neurol 2005; 252: 156–162.

15 Arboix A, Comes E, García-Eroles L, Massons JB, Oliveres M, Balcells M.Prognostic value of very early seizures for inhospital mortality in atherothrombotic infarction.Eur Neurol 2003; 50: 78–84.

Received July 20, 2015

Accepted after revision December 16, 2015

BACKGROUND: According to the literature, generalized seizure as a presenting sign of stroke is rare, and in the reported cases it was accompanied by a focal neurological defi cit.Presentation of a small ischemic atherothrombotic brain infarction with convulsive generalized seizure is very rare.

METHODS: We reported a patient with acute small ischemic atherothrombotic infarction associated with an episode of generalized tonic-clonic seizure, a rare clinical manifestation in this type of stroke.The patient was treated with anti-epileptic therapy after admission.

RESULTS: The patient was discharged with oral administration of phenytoin 100 mg TDS, aspirin 80 mg daily, and atorvastatin 40 mg daily.

CONCLUSION: Small ischemic atherothrombotic infarction can present only with a seizure without any focal neurological defi cit.

Corresponding Author:Karimialavijeh Ehsan, Email: e-karimi@sina.tums.ac.ir

DOI:10.5847/wjem.j.1920–8642.2016.01.014