Alcohol and seizures: few questions and their answers

One of the readers of my blog asked me a few very specific questions with respect to alcohol intake and seizures.  Many times your excellent questions and my answers to them get lost in the sea of information here. So I decided to post her questions and my reply to them as a main post. I feel many of you shall find them informative.  I have removed the reader’s name and email id.

T	35 y/o m with no significant medical hx has been a chronic binge drinker since the age of 20. Alcohol intake has increased more through the years (1-2 pints of whiskey 3-4 times/week including minimal beer intake). 3 years ago after a weekend of binging, which included cocaine, he had his first clonic-tonic seizure (that was witnessed). ER doc said it was d/t the cocaine. Since then he had stopped using cocaine but continued to have seizures after binging. It has been 3 years of multiple untreated gran mal, partial and/or focal seizures. It mostly happens a few days after stopping the liquor and/or when sleep deprived. One evening while driving and NOT drinking, he crashed his car and does not remember any of it. At this point he has stopped drinking. 20 days clean and has had 1-2 focal seizures during sleep. How long does AWS last? Do you think his brain is affected by having so many untreated seizures? Should he get on anti-epilectic meds? If these are provoked seizures will an EEG even be worth it? The family has no history of epilepsy. Will his driving be affected? As a physician, do you have to report to the state if someone has provoked seizures or would this be a HIPA violation? Does taking the recommended dose of Nyquil have any affect on provoking a seizure during withdrawal? Would he have a high risk of reoccurrance? Thank you for your time and advice. T
braindiseases	Dear T, thank you for writing in. You ask specific questions and hence I shall answer them likewise. Q: How long does AWS last? A: acute alcohol withdrawal seizures occur about 24 to 48 hours after the last drink. Delirium tremens (during which the patients may have a flurry of seizures) peaks 72 hours after the last drink. We usually like to put patients on Librium or Ativan (lorazepam) to prevent AWS till we see no signs of autonomic instability (such as variations in blood pressure and heart rate), tremors and so forth. Q: Do you think his brain is affected by having so many untreated seizures? Should he get on anti-epilectic meds? If these are provoked seizures will an EEG even be worth it? A: while there is no study which clearly shows that the brain is damaged by seizures permanently (and I do not mean status epilepticus–where in neuronal death does occur unless seizures are controlled quickly), ongoing untreated seizures certainly are not desirable. Whether he needs to be on long term anti-convulsant is a question that can only be answered after reviewing his history at length and after taking into consideration test results such as EEG and MRI brain. We are assuming his seizures are provoked. It is also possible that he has an inherent epileptogenicity and the alcohol brings it out. Also during this long history,. he may have fallen and now have a secondary seizure focus in the brain. So yes the EEG is worthwhile. Q: The family has no history of epilepsy. Will his driving be affected? As a physician, do you have to report to the state if someone has provoked seizures or would this be a HIPA violation? A: The laws with respect to driving and epilepsy vary from state to state. In the state of NY where I practice, I am NOT mandated by law to report to the DMV (department of motor vehicles) that my patient has a seizure disorder. All I have to do is tell the patient that the law in NY is that ” you have to be seizure free on medications for one year before you can drive”. I do this and I document in the chart that I told the patient about not driving. It is left to the patient’s own good judgement that they shall heed my advise and not drive. In the state of NJ, the physician is mandated by law to report this to the DMV. The duration of time you have to be seizure free before you can drive also varies from state to state. The DMV website or the American Epilepsy Society website are good resources for more information. Now suppose you come to know the patient is still driving (inspite of your advise). Moreover he is driving a school bus. What do you do then? Hmmm tricky and messy situation. Lives are at stake here. I shall confront (maybe not confront but approach) the patient with this information. If he still continues to drive, my responsibility to the public at large exceeds patient confidentality (HIPAA privacy rules). I can then approach the DMV directly. Q: Does taking the recommended dose of Nyquil have any affect on provoking a seizure during withdrawal? Would he have a high risk of reoccurrance. A: many medications can lower seizure threshold. I would double check on all his medications to see if he is taking anything which lowers his seizure threshold. The risk of recurrence can only be determined after a detailed history and taking tests like EEG and MRI brain into consideration. Hope this helps. Personal Regards, Nitin Sethi, MD

Early signs of Parkinson’s disease: making the diagnosis

Early signs of  Parkinson’s  disease: making the diagnosis

Nitin K Sethi, MD

Assistant Professor of Neurology

New York-Presbyterian Hospital

Weill Cornell Medical Center

New York, NY 10065

 

Well it is the start of a new year and a new decade. Welcome twenty ten. I wish all the readers of my blog a very happy new year. Recently I saw a patient in my office and he shall be the subject of my post. He came to see because of his tremor. Actually I should not say he came to see me, the patient infact felt there was nothing wrong with him.

“Dr. Sethi, I have noticed a tremor in my right hand for the past 3 months. It does not bother me. I feel fine. It is my wife who wants me to come and get this checked out” he said.

As I examined him I realised his ” hand shakes” problem was something more sinister as I found tell tale signs suggestive of Parkinson’s disease. That is what I shall discuss here, how does one go about making the diagnosis of Parkinson’s disease ? What are the points in the history and examination that make me as a doctor consider this diagnosis?

Parkinson’s disease may start off very innocuously. All my patient had noticed was that for the past3 months he had a tremor in his right hand. The tremor did not bother him and did not interfere with any activity of daily living such as writing, getting dressed, eating and so forth.  He in fact would not have sought a neurological consultation if his wife had not insisted.  That said and done, there are certain characteristics of the tremor which can aid in the diagnosis. The classical tremor described with Parkinson’s disease is what is called a resting tremor. Now pray what does that mean? Simple the tremor is most prominent when the hands are rest. Let me explain with the aid of an example. While I was talking to my patient and eliciting his medical history, my visual attention was focussed at his hands which were at rest on his lap. I noticed his right hand to have a tremor, the tremor became more prominent when he was distracted. If I asked him to look at his right hand, he could stop the tremor for a few seconds but then the tremor came back. He did not have  a tremor in his left hand or in his legs. When the arms were extended (held up in front of him), the tremor  abated.

So point number 1:  Sporadic Parkinson’s disease usually starts of in the sixth to seventh decade of life. The initial presentation may be quite subtle with only a mild tremor. The tremor initially is asymmetrical (that is it may only be in one hand) and classically it is a resting tremor (most prominent when the hands are completely at rest). The tremor becomes less prominent when the hands are doing something (in motion) and completely abates when the patient falls asleep. Remember the tremor at least initially during the disease course may not be bothersome for the patient and may not impair his quality of life. Hence the patient may not seek attention and the diagnosis may be delayed.

There are some other early signs of Parkinson’s disease. On close inspection I was able to document them in my patient too. When he spoke to me, his face lacked the usual emotions. What do I mean by that. Well when we speak our face show a variety of emotions, we frown, we roll our eyes, sometimes our eyes smile and so forth. A Parkinson’s disease patient has what is called a “mask-like” face-there is a paucity of normal facial expressions.

So point number 2.  Mask like face

Parkinson’s disease patients have a characteristic gait. For want of better words, they walk stiffly. The classical gait is described as bent forward, walking with short quick steps (as if they are going to topple over) and the arms are held by the side (they do not have the usual arm swing).

So point number 3. Gait (They walk funny!!!)

So if you or any of your loved ones show these signs, make sure you get a neurological opinion. Your doctor shall be able to elicit further points in the history and examination which shall help secure the diagnosis of sporadic Parkinson’s disease. Remember the diagnosis of Parkinson’s disease remains a clinical diagnosis (one made by a doctor after history and examination). There are no confirmatory tests (at least none that are used in the office setting).