Seizure Disorder Case Studies
A 12-year-old boy began to complain of frequent headaches 4 months before his hospital admission. On the day of his admission, he had a major motor seizure, which his parents observed. During the seizure he lost bladder and bowel control. On physical examination he appeared to be in deep postictal sleep. He had no focal neurologic signs. On examination of the optic fundi, no evidence of papilledema was found. Studies Results Routine laboratory work Within normal limits (WNL) Skull X-ray study, p. 1062 No evidence of skull fracture Lumbar puncture, p. 651 Opening pressure 250 cm H2O (normal: <200 cm H2O) Closing pressure 220 cm H2O (normal: <200 cm H2O) Cerebrospinal fluid (CSF) examination, p. 651 Blood Negative Color Clear Cells Lymphocytes 0-2/mm3 (normal: <5/mm3) Polymorphonuclear leukocytes None (normal: none) Protein 120 mg/dL (normal: 15-45 mg/dL) Glucose 50 mg/dL (normal: 50-75 mg/dL)
Questionably malignant cells Serologic test for venereal disease Negative (normal: negative) Electroencephalography (EEG), p. 549 Focal slowing of wave pattern in posterior aspect of the cerebrum (normal: regular, rhythmic. electrical waves) Brain scan, p. 785 Increase in radioactivity in the posterior aspect of the brain (normal: homogenous and minimal uptake of radioactive material) Cerebral angiography, p. 988 Neovascularity (tumor vessels) in the posterior aspect of the brain, involving the cerebellum and the occipital lobe of the cerebrum (normal: normal carotid vessels and terminal branches) Magnetic resonance imaging (MRI) of the brain, p. 1106 Tumor of the cerebellum extending into the posterior cerebrum Computed tomography (CT) scan of the brain, p. 1026 A soft tissue mass arising out of the cerebellum and invading the occipital lobe of the cerebrum
Diagnostic Analysis The skull X-ray study ruled out the possibility of a skull fracture as the cause of the boy’s problem. Lumbar puncture excluded the possibility of meningitis or subarachnoid hemorrhage: however, the high protein count and questionable positive cytology indicated a possible neoplasm. An EEG located an area of nonspecific abnormality in the posterior aspect of the brain. Brain scanning, cerebral angiography, and CT scanning indicated a posterior fossa tumor. These tests are mentioned in this case study mostly for historical interest. Under most circumstances, this young boy would have a MRI of the brain early in the diagnostic period. Because of these findings, the patient underwent a craniotomy. In many centers, this young boy would have a nonoperative stereotactic brain biopsy instead of a craniotomy. An invasive medulloblastoma was found to be arising from the patient’s cerebellum and involving the occipital lobe of the cerebrum. The tumor was unresectable. Postoperatively. the patient was given phenytoin (Dilantin) and radiation therapy to the involved area. A chemotherapy regimen was administered. The patient’s tumor did not respond to the therapy, and he died 4 months after the onset of disease. Critical Thinking Questions 1. What are the major assessments that the nurse should make during seizure activity? 2. Why is the EEG a priority study for patients with seizure disorders?