Bad Behavior, or Something More? > None Case Presentations UCSF - - PowerPoint PPT Presentation

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Nilika Shah Singhal, MD

February 2015

UCSF

DEPARTMENT OF NEUROLOGY Division of Epilepsy

Bad Behavior,

• r Something More?

Case Presentations

> Disclosures

> None

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Case 1: 10 year old boy with spells

• One month of spells

– Head shaking + head/eye version + behavioral arrests limb shaking

• Diagnosed with PNES

– Negative MRI, EEG – Failure of OXC to control limb shaking events

• Gait Disturbance

– Diagnosed with conversion disorder by neurology

• Mood Disturbance

– Withdrawn, anxious, dysphoric – Diagnosed with generalized anxiety disorder by psychiatry

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Case 1: continued

• Examination: vital signs within normal limits
• Alert, oriented. Blunted affect. Tearful, asking “please help.”
• Face symmetric, EOMI, no drooling. Dysarthria.
• Normal muscle bulk throughout. Normal tone in arms, Paratonia

in both legs. Left pronator drift.

• Tendon reflexes 2+/symmetric in arms; 3+ left>right patella, 5

beats clonus left ankle, 2 beats clonus right ankle

• No ataxia, dysmetria
• Sensation intact to light touch

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Case 1: continued

• Several typical spells seen during the

evaluation: feeling of “ about to have one”

• Hypermotor legs
• Erratic clonic jerking + tonic stiffening of left leg

with left arm stiffening and right arm flexion.

• Duration <30 seconds, no impaired awareness

during the episode, no post-ictal state.

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Case 1: continued

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Case 1: Q1: How would you characterize this event with bilateral motor symptoms but preserved awareness?

• A. Psychogenic non-epileptic seizure
• B. Supplementary Motor Area seizure
• C. Movement Disorder (dyskinesia)
• D. Behavioral disturbance

P s y c h

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e n i c n

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p i l e p t i . . . S u p p l e m e n t a r y M

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d e r ( d y s . . . B e h a v i

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a l d i s t u r b a n c e

9% 4% 13% 74%

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Case 1: continued

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Case 1: Q2: What would you predict would be the next diagnostic step?

• A. Another MRI
• B. Blood tests to search for vasculitis
• C. Psychiatry referral for a frustrated

patient and neurologist

• D. Lumbar puncture to search for

inflammation

A n

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h e r M R I B l

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53% 28% 1% 18%

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Case 1: Diagnosis: Anti-NMDAr Encephalitis

• Psychiatric episodes can occur at presentation, in

isolation, in children

– Delusional thinking, mood disturbances, aggression

• A wide variety of movement disorders are seen in

children

– Patients commonly present with more than one movement disorder – Gait impairment, chorea, stereotypic movements, ataxia, dystonia, limb monorhythmia, athetosis, tremor, blepharospasm > Next case

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Case 2: 5 year old boy with episodes of anxiety

• Two weeks of spells

– Sudden-onset crying, seeming anxious and fearful; makes eye contact with grandmother and reaches out for her – He may ‘thrash about’ seem generally tremulous. – Self-resolving in <30 seconds. – Afterwards, he resumes what he was doing. – Patient seems scared in even trying to describe his experience

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Case 2: continued

• Occurred from wakefulness initially; started to occur

from sleep

• Three hospital visits

– Toxicology screen, head CT, EEG obtained

• Diagnosed with psychosis; placed on a psychiatric

hold – Received Risperdal, Benadryl, Valium

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Case 2: Q1: What do you think is the next most useful diagnostic test to perform?

• A. Brain MRI
• B. Lumbar Puncture
• C. Extended video EEG monitoring
• D. Serum tests for metabolic diseases

B r a i n M R I L u m b a r P u n c t u r e E x t e n d e d v i d e

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. . . S e r u m t e s t s f

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m e t a b

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16% 5% 73% 7%

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Case 2

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Case 2: Further work-up

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Case 2: Features of cingulate gyrus seizures

• Hypermotor
• Ictal Vocalization
• Infrequent generalization
• Presence of emotionality: fear, laughter
• Presence of personality changes

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Case 2: Q2: What are advantages of epilepsy surgery compared to medical management of medically-refractory focal cortical dysplasia?

• A. Improved life expectancy
• B. Seizure-free rates higher than medical

management

• C. Improved IQ
• D. Answers 1 and 2
• E. All of the above

I m p r

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0% 10% 68% 21% 0%

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Referring and Provider consultation, Access Center: Phone: (855)-PBC-UCSF

> Thank you!

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