Clinical Reasoning: An unusual cause of indeterminate spells

Abstract

A 38-year-old, right-handed woman presented to the epilepsy clinic for evaluation of recurrent spells. These spells are characterized by an aura of a "rushing" cephalic sensation and a sense of "spaciness" or "dizziness" followed by loss of awareness with subsequent amnesia for the event. During these events, the patient is observed by family to sit down and slump forward or fall, followed by hyperventilation and occasionally staring, for up to 3 minutes. There is no head turn, eye deviation, or abnormal body movements. Postictally, she reports generalized weakness without focality and confusion. The spells occurred sporadically for 8 years, but recently increased in frequency to 5 to 20 times per day. Triggers included lack of sleep, stress, and various food products. The patient reported some improvement with levetiracetam therapy at 1,500 mg twice daily.The patient was hospitalized for head injury from a motor vehicle accident at 16 years of age. She was amnestic for the event but was told that there were "contusions" in her brain. She endorses significant psychosocial stressors including a recent divorce and loss of her business. She reports a 10 pack-year history of smoking but denies excessive use of alcohol or illicit drugs. Neurologic examination at presentation was unremarkable. Basic laboratory tests including electrolytes, random blood glucose, and drug screening were normal. Likewise, ECG was normal. Outside EEGs reported left temporal slowing. Seizure protocol brain MRI showed multiple linear T2 hyperintensity, most prominent subcortically in the left frontal lobe, presumably posttraumatic (figure, A).

Malignant carotid body tumors: What we know, what we do, and what we need to achieve. A systematic review of the literature

“…Among these articles, 20 (158 patients) included 5 or more patients (Table 1) 18–39 and were considered for the proportion MA. The remaining 112 studies (179 patients), represented by case reports or case series with <5 patients, are reported in Table S1 3,40–152 …”

“…For proportion meta‐analysis (MA), only case series with at least five consecutive cases were considered (Table 1). 18–39 All the other case series describing less than five patients (including case reports) were considered only for the SR and detailed in Table S1 3,40–152 …”