What is the management plan for a 45-year-old male patient with a history of chronic alcoholism, presenting with generalized tonic-clonic seizures (GTCS) and subsequent left hemiparesis?

Management of a 45-Year-Old Chronic Alcoholic with GTCS and Left Hemiparesis

Immediate Priorities

This patient requires emergent neuroimaging (CT head without contrast) to rule out intracranial hemorrhage, stroke, or structural lesion causing the hemiparesis, followed by seizure management and treatment of underlying alcohol-related complications. 1

Initial Assessment and Stabilization

• Assess airway, breathing, and circulation (ABCs) with high-flow oxygen to prevent hypoxia, which worsens seizures 2
• Establish IV access immediately for medication administration and fluid resuscitation 2
• Check fingerstick glucose immediately to rule out hypoglycemia as a seizure trigger, which is common in alcoholics 1, 2
• Obtain vital signs including temperature to identify potential infectious causes (meningitis, encephalitis) 2

Emergent Neuroimaging

CT head without contrast is mandatory in this patient given the combination of new focal neurologic deficit (left hemiparesis) and seizures in the setting of chronic alcoholism [1, @29@]. The American College of Emergency Physicians guidelines classify this as requiring emergent CT due to: new focal deficits, recent trauma (fall 3 days ago), and altered mental status [@29@].

Key differential diagnoses to evaluate:

• Subdural hematoma (24.8% of chronic alcoholics with neurological problems have head injury) 3
• Intracerebral hemorrhage (15.2% of chronic alcoholics present with stroke) 3
• Cerebral venous thrombosis (can present with seizures and hemiparesis) 1
• Structural lesions (tumors, abscesses)
• Marchiafava-Bignami disease (rare demyelinating disorder in chronic alcoholics presenting with hemiparesis and seizures) 4

Laboratory Evaluation

Obtain comprehensive laboratory studies immediately 1, 2:

• Electrolytes (especially sodium) - hyponatremia is a common cause of seizures in alcoholics 1
• Glucose - hypoglycemia occurs in alcoholics and can cause seizures 1
• Calcium and magnesium - hypocalcemia and hypomagnesemia (8 of 18 alcohol-related seizure patients had magnesium <1.5 mEq/L) 1
• Complete blood count - to assess for infection or anemia 2
• Liver function tests - elevated gamma-glutamyltranspeptidase is common 5
• Toxicology screen and blood alcohol level 2
• Anticonvulsant drug levels if patient was on any antiepileptic medications 2

Seizure Management

If the patient is actively seizing or has recurrent seizures:

• Administer lorazepam 0.1 mg/kg IV (maximum 4 mg) at 2 mg/min as first-line treatment, may repeat once after 5-10 minutes if seizures continue 2, 6

If seizures persist after benzodiazepines, administer second-line agent 2, 6:

• Fosphenytoin 20 mg/kg PE IV at 150 mg/min, OR
• Levetiracetam 40 mg/kg IV (maximum 2,500 mg), OR
• Valproate 30 mg/kg IV at 6 mg/kg/hour

Note: Phenytoin/fosphenytoin causes hypotension in 12% of cases versus 0% with valproate 6. Levetiracetam has demonstrated 67-73% efficacy and may be preferred given better side effect profile 6, 7.

Thiamine Administration

Administer thiamine 500 mg IV immediately before any glucose-containing fluids to prevent precipitating Wernicke encephalopathy 4. Chronic alcoholics are at high risk for:

• Wernicke encephalopathy (15.2% of chronic alcoholics) 3
• Marchiafava-Bignami disease (thiamine deficiency-related demyelinating disorder) 4

Administration of thiamine within 14 days of symptom onset demonstrates statistically better outcomes 4.

Alcohol Withdrawal Management

Assess for alcohol withdrawal syndrome given the 3-day timeline since last drink 1:

• Withdrawal seizures occur in 18.1% of chronic alcoholics 3
• Consider benzodiazepine protocol (e.g., CIWA protocol with lorazepam or diazepam) for withdrawal prophylaxis
• Correct magnesium deficiency if present (common in alcohol-related seizures) 1

Decision on Antiepileptic Medication Initiation

Do NOT routinely initiate long-term antiepileptic medication in the ED for alcohol-related provoked seizures 1. The American College of Emergency Physicians states that emergency physicians need not initiate antiepileptic medication for patients who have had a provoked seizure; precipitating medical conditions should be identified and treated 1.

However, if CT reveals structural brain disease (hemorrhage, infarct, mass), initiate antiepileptic medication as this represents a remote symptomatic seizure with higher recurrence risk 1.

Advanced Imaging Considerations

If CT is negative but clinical suspicion remains high, obtain MRI brain with and without contrast 1, 8:

• MRI is superior for detecting:
  • Marchiafava-Bignami disease (corpus callosum hyperintensity on T2/FLAIR) 4
  • SESA syndrome (subacute encephalopathy with seizures in alcoholics - shows reversible T2/DWI abnormalities) 5, 9
  • Cerebral venous thrombosis 1
  • Subtle structural lesions missed on CT 8

Admission Criteria

This patient requires hospital admission given 1:

• Persistent focal neurologic deficit (left hemiparesis) that has not returned to baseline
• Recent fall with potential head trauma 3 days ago
• Multiple seizures (3 episodes)
• Chronic alcoholism requiring withdrawal monitoring

The American College of Emergency Physicians states that patients who have NOT returned to clinical baseline should be admitted 1.

Monitoring and Follow-up

• Continuous cardiac monitoring for QT prolongation (can occur with hypocalcemia in alcoholics) 1
• Neurologic checks every 2-4 hours to monitor for deterioration
• Consider EEG if altered mental status persists to rule out nonconvulsive status epilepticus 2, 6
• Repeat neuroimaging in 24-48 hours if clinical deterioration occurs or if initial imaging showed evolving pathology 1

Common Pitfalls to Avoid

• Never give glucose before thiamine in chronic alcoholics - this can precipitate Wernicke encephalopathy 4
• Do not assume seizures are simply "alcohol withdrawal" without imaging - 34-41% of patients have abnormal CT findings, and structural lesions are common 1
• Do not discharge patients with persistent focal deficits - the hemiparesis indicates structural pathology until proven otherwise 1
• Do not overlook subdural hematoma - extremely common in alcoholics with falls (24.8% incidence) 3