SEIZURES: III

Abstract

A 60‐year‐old African‐American man was admitted to the hospital in October 1991 with seizures and right hemiparesis. He had end‐stage renal disease (ESRD), presumed due to hypertension and/or analgesic nephropathy, and had been on maintenance hemodialysis since July 1987. Noncontrast CAT of the brain revealed mild cortical atrophy and non‐specific while matter ischemic changes. Contrast CAT showed a right hemisphere CVA, and magnetic resonance imaging (MRI) suggested a right frontal meningioma. Cerebral arteriogram was confirmatory, and he underwent resection of the fronto‐parietal tumor in early November 1991. Past medical history included over 20 years of hypertension, angina for five years, gout, and peptic ulcer disease. Cardiovascular evaluation of exertional dyspnea and bilateral calf weakness included a negative thallium stress test and minimal to moderate flow impairment of tibial‐peroneal vessels by Doppler. Low iron stores led to upper and lower endoscopy and a colonic polypectomy. There was a question of an allergic reaction to intravenous iron administration (the patient reported lip swelling), and erythropoietin therapy was started in December 1990 (starting hematocrit was 23%). Hemodialysis access was achieved via a Brescia‐Cimino arteriovenous fistula in his left arm, which developed extensive upper arm and shoulder collaterals, leading to a fistulogram and a diagnosis of subclavian stenosis in January 1989. Angioplasty was successful, and repeat fistulogram was unremarkable in February 1991. Blood pressure control was usually adequate, ranging from 140–180/80–100 on diltiazem, clonidine, and captopril. Occasional elevation to 210/120 were seen. In the months prior to the seizure, his treatments were adjusted because of low Kt/V (by increased dialyzer surface area and increased time). Hematocrit had risen to 30%‐33% with erythropoietin therapy (2000 Units thrice weekly). Hemodialysis was accomplished without heparin use, due to his gastrointestinal bleeding history. He was felt to be gaining “flesh” weight. In late March 1992, he had a tonic‐clonic seizure. Repeat CAT scan of the brain was unchanged. He was started on phenytoin thrice daily, but he discontinued therapy and had two more seizures (with negligible serum levels of phenytoin) in April 1992. In May, he was readmitted after another tonic‐clonic seizure. Phenytoin levels were in the therapeutic range, and CAT scan was again unchanged. Phenobarbital was added to his regimen. Drowsiness limited his compliance, and he had several additional seizures. In late July, he suffered a respiratory arrest shortly after a seizure.