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IM20.1-5 | Seizure Disorders — PBL Case

CLINICAL SETTING

Dr Ramesh, the medicine registrar on night duty at a government teaching hospital in Chennai, is called urgently to the on-call room at 2:15 am. He finds Kiran, a 21-year-old third-year MBBS student, being held steady by two of his batchmates. According to witnesses, Kiran was revising in the common room when, without warning, he suddenly became rigid, fell from his chair, and had generalised shaking of all four limbs for approximately 90 seconds. His face turned cyanosed briefly. He now lies on the floor, confused and sleepy, with a fresh lateral tongue laceration and urinary incontinence. His batchmates say he had been awake for 32 hours studying for his university exams. There is no family history of epilepsy. No prior similar episode was recalled. His blood pressure is 110/70 mmHg, pulse 96/min, temperature 37.1°C, SpO2 98% on room air, blood glucose by glucometer 88 mg/dL. Dr Ramesh takes a deep breath and begins his assessment. His first question to the batchmates: 'Tell me exactly what you saw — from the beginning.'

Trigger 1: The Witnessed Episode — What Exactly Happened?

The batchmates describe: 'He was typing notes. Then he made a strange sound and went stiff. Both legs straightened, both arms went out. Then the shaking started — all four limbs, rhythmically, for about 60–80 seconds. He bit his tongue. He wet himself. When it stopped, he was unresponsive for 2–3 minutes, then slowly became confused.' There was no warning aura. No eye deviation was noted. No one observed the left or right side being affected first. Kiran himself has no memory of the event. Dr Ramesh notes the lateral tongue laceration and post-ictal confusion and turns to the group: 'Based on what you have described, how would you classify this seizure type using the current ILAE framework? And does this single event make Kiran an epileptic?'

DISCUSSION POINTS

Using ILAE 2017 terminology, how would you classify this seizure? What features in the witness account support this classification?
What is the ILAE 2014 definition of epilepsy? Does a single episode like Kiran's satisfy those criteria? What additional information would change the answer?
What is the significance of the lateral tongue laceration compared with tip-of-tongue injury? What does post-ictal confusion tell you about the seizure type?

Click to reveal Trigger 2: The Investigation Sequence — What Must Be Done Tonight? (discuss previous trigger first!)

Trigger 2: The Investigation Sequence — What Must Be Done Tonight?

Dr Ramesh orders immediate investigations. Random blood glucose is 88 mg/dL (already confirmed). Blood results return: serum sodium 136 mEq/L, potassium 4.2 mEq/L, calcium 9.1 mg/dL, urea 18 mg/dL, creatinine 0.9 mg/dL, CBC normal, ECG normal sinus rhythm. CT brain without contrast shows no acute abnormality, no haemorrhage, no mass lesion. Kiran has now fully recovered, is conversant and oriented, and asks: 'Doctor, do I need an MRI? Do I need to start tablets now? Can I go back and write my exam tomorrow?' Dr Ramesh pauses. He knows the CT is normal — but does normal imaging rule out a structural cause? And when is the right time to start an antiepileptic drug after a first seizure?

DISCUSSION POINTS

What does a normal CT brain tell you in the context of a first seizure? What does MRI add, and is it urgently indicated tonight?
When is an EEG indicated, and what information does it provide that CT/MRI cannot?
Using ILAE guidelines, when should a long-term antiepileptic drug be started after a first unprovoked seizure? What risk factors for recurrence would prompt earlier treatment?

Click to reveal Trigger 3: Six Weeks Later — EEG Result and the AED Decision (discuss previous trigger first!)

Trigger 3: Six Weeks Later — EEG Result and the AED Decision

Kiran follows up with the neurology outpatient department six weeks later. He is well, back at college, and has had no further episode. His MRI brain (done electively) is normal. His EEG shows irregular polyspike-and-wave discharges maximal at awakening. When the neurologist reviews the history again, Kiran mentions something he had forgotten to say earlier: 'Actually, for the past year or so, every morning when I wake up, my hands jerk and I drop things — coffee cups, my phone. I thought it was just early morning clumsiness. It's worse after I pull an all-nighter.' The neurologist leans forward: 'That changes everything.' She explains the syndrome diagnosis and tells Kiran that an AED will be started. She adds: 'And I want to have a careful conversation about which drug, given your plans for the future.'

DISCUSSION POINTS

What epilepsy syndrome does this electroclinical constellation represent? State the diagnostic criteria and explain why the morning myoclonic jerks are the critical missing piece of the initial history.
Which antiepileptic drug is first-line for this syndrome? Name ONE AED that would be contraindicated and explain the pharmacological mechanism of the harm.
The neurologist mentions 'your plans for the future.' Kiran has a girlfriend and plans to marry in 3 years. If he were a woman of childbearing age with this syndrome, what would the key AED counselling points be regarding valproate?

Click to reveal Trigger 4: The Driving Question and the Safety Conversation (discuss previous trigger first!)

Trigger 4: The Driving Question and the Safety Conversation

Kiran is started on sodium valproate 500 mg twice daily. At his follow-up visit 3 months later, he is seizure-free (no GTCS, morning jerks markedly reduced). He is now in his clinical postings and will sit his university professional examination in 2 months. He tells the neurologist: 'I've been offered a rural health posting for my internship in a remote district. I plan to buy a motorbike to get to the primary health centre every day — it's 14 km. Also, I joined my friends for a weekend trip last month and had two late nights in a row — is that okay? And the last question: my father has epilepsy too — does that mean my kids could also have epilepsy?' The neurologist addresses each question carefully. She also notices Kiran has missed one tablet dose each week 'just to keep it in reserve', believing his AED supply from the hospital pharmacy is unreliable.

DISCUSSION POINTS

What does the Indian Motor Vehicles Act say about driving with epilepsy? Can Kiran ride a motorbike for his internship travel? What seizure-free period would be required before considering private driving?
Kiran has been missing one dose per week. What are the clinical consequences of irregular AED compliance in JME specifically? How would you counsel him about compliance and what to do if a dose is missed?
How would you counsel Kiran about: (a) sleep deprivation as a seizure trigger in JME, (b) alcohol, and (c) the genetics — what is the inheritance pattern of JME and what is the risk to his future children?

Group Task Assignments

Construct a one-page 'First Seizure Assessment Pathway' for a casualty officer: what history to take from the witness, what immediate investigations are mandatory, when to start an AED, and when to refer to neurology — based on ILAE 2014 criteria and evidence-based practice.
Draft a structured patient information leaflet for a newly diagnosed JME patient aged 18–25 covering: the syndrome name and what it means, first-line AED with how and when to take it, what to avoid (sleep deprivation, alcohol), driving regulations under Indian MV Act, water safety, and what to do if a seizure occurs.
Roleplay: one student is the neurologist, one is Kiran. The neurologist must disclose the diagnosis of JME, explain why valproate is being chosen, and counsel about one specific safety restriction (the student playing Kiran should push back — 'But I feel fine and I've only had one big seizure'). Debrief: what communication strategies did the neurologist use?
Using the SE management framework from your SDL, write a step-by-step protocol card for the first 40 minutes of generalised convulsive status epilepticus in an adult. Include drug names, doses, routes, and time triggers. Identify where you would escalate to ICU/anaesthesia.

Learning Issues

Research these questions and bring your findings to the discussion.

[IM20.1] What is the precise ILAE 2014 definition of epilepsy? How does it differ from the definition of a provoked seizure, and what clinical scenarios give a single unprovoked seizure a recurrence risk high enough to meet the definition?
[IM20.2] What are the ILAE 2017 seizure classification terms, and how does recognising an epilepsy syndrome (such as JME) change investigation priorities, treatment choice, and prognosis compared with classifying seizure type alone?
[IM20.3] For juvenile myoclonic epilepsy, what is the first-line AED, which drugs are absolutely contraindicated and why, and what are the teratogenicity risks and alternatives for women of childbearing potential?
[IM20.4] What are the specific safety restrictions for a young adult with epilepsy under Indian law and clinical guidelines — covering driving (private vs commercial), water activities, sleep, alcohol, and occupational considerations?
[IM20.5] What is the stepwise pharmacological management of generalised convulsive status epilepticus from the 5-minute threshold through first-line, second-line, and refractory phases, including drug names, doses, and time triggers?