What is the appropriate management for an elderly male patient presenting with generalized tonic-clonic seizures, bilateral Globus Pallidus infarcts, an old infarct in the left pons, and leukocytosis with neutrophilia?

Management of Elderly Male with GTCS, Bilateral Globus Pallidus Infarcts, and Leukocytosis

This patient requires immediate initiation of antiepileptic medication given the multiple GTCS episodes and structural brain disease (bilateral globus pallidus infarcts), along with urgent investigation of the marked leukocytosis to identify and treat any underlying infection or hematologic malignancy.

Immediate Antiepileptic Treatment

Emergency physicians may initiate antiepileptic medication in the ED for patients who experienced seizures with a remote history of brain disease or injury 1. This patient clearly falls into this category with documented bilateral infarcts and an old pontine infarct, which provide anatomic substrate for recurrent seizures 1.

First-Line Treatment Options

• Levetiracetam 30 mg/kg IV over 5 minutes is the preferred initial agent, with 68-73% efficacy and minimal cardiovascular effects, making it particularly suitable for elderly patients with stroke history 2
• Alternative: Valproate 20-30 mg/kg IV over 5-20 minutes demonstrates 88% efficacy with 0% hypotension risk 2
• Avoid phenytoin/fosphenytoin as first choice in this elderly stroke patient due to 12% hypotension risk and cardiovascular concerns 2

Rationale: Levetiracetam has minimal drug interactions, favorable safety profile in elderly patients, and no cardiovascular toxicity—critical considerations given this patient's cerebrovascular disease 3, 4. The history of CNS injury (stroke) increases seizure recurrence risk substantially, making immediate treatment appropriate after even a first seizure 1.

Critical Evaluation of Leukocytosis

The white blood cell count of 42,000 with neutrophil predominance requires immediate investigation to distinguish between seizure-induced inflammatory response versus serious underlying pathology 5.

Distinguishing Seizure-Induced Changes from Infection/Malignancy

• Seizure-induced leukocytosis typically shows WBC counts that are elevated but rarely exceed 20,000-25,000 5
• A WBC of 42,000 is highly concerning for acute leukemia, severe infection, or other hematologic malignancy 6
• Seizures with postictal hemiparesis due to cerebral infarction can be a rare manifestation of acute myeloid leukemia, where leukocytosis and cancer-induced coagulopathy cause thrombosis 6

Immediate Workup Required

• Peripheral blood smear to evaluate for blast cells (acute leukemia can present with seizures from cerebral infarction due to leukostasis and hypercoagulability) 6
• Blood cultures, urinalysis, chest X-ray to rule out severe bacterial infection 5
• C-reactive protein levels: if >6 mg/dL, this warrants close observation for concurrent infection rather than seizure-induced inflammation 5
• Body temperature monitoring: if >39°C or persisting >8 hours after consciousness recovery, consider infection rather than seizure-induced fever 5

Management of Underlying Stroke and Seizure Etiology

Precipitating medical conditions should be identified and treated 1. The bilateral globus pallidus infarcts suggest:

• Evaluate for hypoxic-ischemic injury, carbon monoxide poisoning, or metabolic causes (globus pallidus is particularly vulnerable to these insults)
• Check glucose, electrolytes (especially sodium), renal function to identify reversible causes 2
• Neurology consultation for stroke workup and long-term seizure management
• Hematology consultation urgently if peripheral smear shows blasts or if no clear infectious source identified for the extreme leukocytosis 6

If Seizures Continue Despite Initial Treatment

For refractory seizures (continuing despite benzodiazepines and one second-line agent), initiate continuous EEG monitoring and consider anesthetic agents 2:

• Midazolam infusion: 0.15-0.20 mg/kg IV load, then 1 mg/kg/min continuous infusion (80% efficacy, 30% hypotension risk) 2
• Valproate as second-line: 30 mg/kg IV if not already given (88% efficacy, minimal hypotension) 2

Critical Pitfalls to Avoid

• Do not attribute the extreme leukocytosis solely to seizures—a WBC of 42,000 demands investigation for leukemia or severe infection 5, 6
• Do not delay antiepileptic treatment in this patient with structural brain disease; the seizure recurrence rate is approximately 75% in patients with remote symptomatic seizures 1
• Do not use neuromuscular blockers alone, as they only mask motor manifestations while allowing continued electrical seizure activity and brain injury 2
• Monitor for acute leukemia presenting as stroke with seizures, particularly given the constellation of bilateral infarcts and marked leukocytosis 6

Admission and Monitoring

This patient requires hospital admission given:

• Multiple seizures (3 episodes of GTCS) 1
• Structural brain disease with acute bilateral infarcts 1
• Extreme leukocytosis requiring urgent investigation 5, 6
• Need for continuous monitoring and potential adjustment of antiepileptic therapy 2