CME INDIA Presentation by Admin.
Dr Purvi Chawla, Diabetologist, Mumbai asks….
Had a patient recently who experienced Hypoglycemia and probably had a seizure related to that. The speech had not recovered completely in 2 days as the patient seemed to have bitten her tongue and there were ulcers.
- MRI brain was done too and is normal.
- How can we be sure it is only related to Hypoglycemia and not epilepsy?
CME INDIA Discussion
Dr Meena Chhabra, Diabetologist Delhi:
- Also, do an EEG.
- Is the Hypoglycemia documented confirmed?
- I have a similar scenario in a Type 1 Diabetic. She is type 1 on an insulin pump. Not documented hypo as no sugar level known that time. Mother suspended the pump and put honey in the mouth.
Dr N K Singh: Any similar history before?
Dr Meena Chhabra, Diabetologist, Delhi: Yes, Neurophysician says start Levetiracetam.
Dr N K Singh: Then, why it is not seizure? Epileptic seizures in relation to Hypoglycemia are rare.
Dr Meena Chhabra, Diabetologist, Delhi: I have seen. Previous episode documented low sugar.
Dr N K Singh: It is difficult to establish a clear cause-and-effect relationship between Hypoglycemia and seizures in the diabetic population Dr Purvi’s case looks hypo induced seizure with neuronal damage.
Dr Venkatesh Molio, Maregoan, Goa: Can get an EEG done.
Dr Premchand Singh, Internist Physician, Imphal: Any past history of head injuries and seizures. Needs complete work up on blood tests e.g., CBC, glucose, electrolytes, LFT, KFT etc. Is she a known patient of diabetes? What was the cause of hypo – OHA? Insulin?
Dr Purvi Chawla, Mumbai: Patient was going into repeated lows. At the time, her mouth twisted, they gave her sugar syrup first and then checked. It was 83.
Dr N K Singh: Epileptic seizures in relation to Hypoglycemia are rare.
Dr Meena Chhabra: I have seen. In type 1 patients.
Dr Premchand Singh, Imphal: Responding with sugar goes in favour of hypo induced seizure. What seems to be cause of hypo. Two or more seizures as the result of blood-sugar changes is not enough to diagnose someone with epilepsy, because these are considered “provoked” epileptic seizures as opposed to the “unprovoked” seizures associated with epilepsy -as per literature.
Dr Sudhir Ranjan DM, Neuro, Ranchi: Electrolyte imbalance, derangement in metabolic profiles may induce generalized tonic-clonic, myoclonic convulsions. continuous Partial seizure may be a feature of hypoglycaemia. Normal neurological examinations, normal imaging, absent of significant neurological illness justify seizure due to metabolic insult.
Dr Abhishek Singh, Neuro, Patna:
- Tongue bite is more in favour of seizure.
- Now whether it’s epilepsy or symptomatic seizure?
- If only one event, documented hypoglycaemia then most probably symptomatic seizure.
- Levetiracetam use is??? No proper guideline but If he is diabetic and drug induced hypoglycaemia then no need for anti-epileptic.
- If no aetiology known for hypoglycaemia then it’s better to give AED. Same time try to find out the cause…
- That’s the most practical way I think 🤔
Dr Ujjwal Roy, DM, Neuro, Ranchi: Ek number👌🏻👌🏻
Dr Ashok Kumar DM Neuro Ranchi:
- Remember that in past — rarely of course — Hypoglycemia had been tried as Activation procedure during EEG. Hypoglycemia can precipitate seizures in an epileptic patient or it can provoke Seizures on its own.
- Hypoglycemia with ” twisted mouth”/face and tongue bite (especially if marginal) suggest seizures — provoked/precipitated by Hypoglycemia. Transient focal deficits can occur with or without seizures.
- One would like to know the kind of speech problem in this patient. Is it just Dysarthria/slurred speech? If without Facial asymmetry, it may due to tongue bite. Ask her to repeat consonants — T, L, R, P, F. She should be able to utter Labial consonants P and F clearly if only tongue injury is the culprit.
- Next, if Facial asymmetry is present, note if the speech is laboured and non-fluent. Also, if she can follow verbal commands.
- For prognosis and further management — specifically Anti-epileptic medications (AED’s) — MRI Scan Brain (epilepsy protocol, Plain and Contrast) and EEG are must. FCD’s are frequently missed. Therefore, examine the MRI film as if it is a histopathology slide. Calcified granulomas are better seen in CT Scan Only plain CT should be done.
- History of seizures in past especially Febrile seizures during childhood strongly go in favour of Epilepsy.
- Recent deterioration in academic performance may be due to recurrent seizures or Hypoglycemia. But, old problems with school performance more likely have their origin in brain, hence epilepsy.
- Hypoglycemia can cause transient focal / lateralised deficits. And the patient should come clean. But persistent deficits hint at permanent brain injury or a pre-existing lesion.
- In all such cases with any clue of previous seizures or any cerebral lesion or neurological deficit, AED’s should have started. But Sometimes, one doesn’t get any clue regarding epilepsy despite all workup. In that case
- Taper off AED’s over next few weeks and
- Ask the patient to take precautions as in Epilepsy — avoid driving, swimming, riding 2-wheelers etc.
- Wait for Second seizure.
Dr D P Khaitan, Sr Consultant Physician, Gaya: If a diabetic person on drugs presents with generalised tonic clonic seizure with documented hypoglycaemia and normal MRI, his MRI should be repeated later on if there is associated signal of deteriorating personality or newly emerging neurological deficit.
Dr Harish Darla, Diabetologist, Mysore: Any diabetic patient who is not an know epileptic and if develops an episode of seizures… most likely cause could be Hypoglycemia, as there are no structural abnormalities and with 1st episode of seizure it’s waits and watch policy, but that patient should be warned about driving (if she is) not to drive for at least 4 weeks (if not wrong as per DVLA UK). No need for any anti-epileptic for now unless there is another episode? Is there any role for CGMS at all?
Dr Vinay Dhandhania, Diabetologist, Ranchi: EEG can be of some help.
CME INDIA Learning Points
IAH(Impaired awareness of hypoglycemia)
- When Hypoglycemia is deep and repeated, it can induce various neurological disorders, including epileptic seizures.
- The link between Hypoglycemia and epileptic phenomena is complex and poorly explained.
- A number of pathophysiologic processes may lead to seizures:
- Alterations in the integrity of the blood–brain barrier
- Electrolyte abnormalities
- Changes in neuronal permeability,
- ephaptic (non-synaptic) contact between neurons in the setting of oedema or infiltrative processes, and haemorrhage or mass effects caused by tumours or infections.
- During Hypoglycemia, multiple metabolic derangements occur. In particular, the excitatory amino acids glutamate and aspartate increase out of proportion to a slight rise in extracellular GABA. The resulting brain excitatory milieu may account for seizure activity
- In most of the studies a low frequency of seizures has noticed. This indicates that the risk of seizures in association with low blood glucose levels seems to be low. This is a finding of potentially great clinical relevance, since seizures in the presence of Hypoglycemia are often presumed to be acute symptomatic.
- Clinically the biggest difference is that a seizure caused by Hypoglycemia can cause a diabetic patient to fall into a coma if not treated immediately. Some people with epilepsy recover immediately after a seizure, while others may take minutes to hours to feel as they did before the seizure.
- The deep Hypoglycemia can induce convulsive crises as far as it can predisposes to the development of epileptogenic foci. The induced seizures are mainly generalized and tonic-clinic and the described abnormalities predominate in the frontal and temporal lobes.
- Hypoglycaemic brain death preferentially affects neurons, whereas ischemia tends to affect glial and endothelial cells as well.
- Hypoglycemia generally spares axons while damage from ischemia affects all parts of the neuron.
- The clinical syndrome of hypoglycaemic hemiplegia has been recognized for over 50 years.52, 53 It appears to be rare, with case series reporting an incidence of 2% among those admitted with Hypoglycemia.
CME INDIA Tail Piece
- The landmark Diabetes Control and Complications Trial
It found 16 episodes of coma or seizure per 100 patient-years in the aggressive glucose control group, compared to 5 in the moderate control group.74 Another prospective study had a rate of severe events (the combination of seizure or coma) at 4.8/100 patient-years. Most of the severe events were seizures, and risk factors were age under 6 and glycosylated haemoglobin <7%
- How to know that headache is due to Hypoglycemia?
Diagnostic criteria for headache attributed to fasting:
A. Headache with at least one of the following characteristics and fulfilling criteria:
- Frontal location
- Diffuse pain
- Non-pulsating quality
- Mild or moderate intensity
B. The patient has fasted for >16h.
C. Headache develops during fasting.
D. Headache resolves within 72h after resumption of food intake.
(International HA classification)
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Seizure associated with tongue bite and incontinenece of urine or stool should be in favour of Seizure disorder. Along with EEG correlation.
In our area a third dimension is added to confuse the clinician. Very comment scenario – a diabetic & Chronic alcoholic patient falls sick with reduced food intake & vomiting. Misses his quota of alcohol but continues taking medicines. Then he lands in the ER or OPD with hypoglycemia & seizure & at times focal weakness. The third dimension is Rum Fits.