A middle age male with history of HTN, smoking, and seizures presenting with “mini seizures” since last night. History of a TBI and subsequent seizure disorder back in 1998. Takes phenytoin for it, used to be on phenobarb as well but was taken off of it 1.5 months prior. His seizures have been of the generalized, tonic/clonic variety in the past. Since last night he has had L sided numbness on his face/arm. They have been episodic, coming every 10 min, and they last 2 min. He feels some “clumsiness” in that arm during these episodes but no reported weakness. No difficulty in speech/vision/swallowing. No fevers/chills/LOC/convulsive activity noted.

Phenytoin Level: 14.7
Labwork unremarkable
CT head: negative for acute pathology

Stroke or seizure? I wasn’t sure and I had the attending meet the patient as well. Both of us felt like these were probably seizures. Now I very rarely call neurology about seizures but you can make the argument that this is status so I called them. However, they informed me that isolated sensory symptoms for a seizure is VERY rare and that you are dealing with a possible stroke until proven otherwise. That was news to me, but to his point this was the first case I’ve seen. Anyways, we got the MRI/MRA and they were negative. His EEG showed multiple R sided epileptiform discharges. Loaded him with keppra in the ER, and a repeat EEG improved the seizure activity noted symptomatically and on the EEG. So yay, no stroke!

Main reason I point this out there is to avoid the pitfall of missing a stroke, as Neurology themselves were highly suspicious. Our initial thought process ended up being right, but in order to get there, the point here is to rule out stroke first! Same thing with a Todd’s paralysis BTW. Rule out stroke before you start making that assumption!