Editors' Note: Clinical Reasoning: A 70-Year-Old Man With Right Arm and Leg Shaking

Seizure-like activity is a common neurologic complaint among patients evaluated in the emergency department, and it may be due to a broad spectrum of epileptic and nonepileptic conditions. Drs. Frey and Seachrist navigated the case of a 70-year-old man with unilateral shaking, impaired consciousness, and generalized upper motor neuron signs in their case report. The patient failed to improve with intravenous lorazepam and was later found to have acute bilateral anterior cerebral artery infarctions. The authors postulate that the patient’s anarthria and lethargy were a reflection of underlying akinetic mutism, although this is typically associated with preserved alertness in the setting of reduced speech output after frontal lobe injuries. Focal motor or complex partial seizures are also potential explanations for this patient’s shaking movements and impaired speech output, and these findings are not uncommon after cortical infarction. Drs. Freund and Tatum emphasize that the patient’s lack of response to lorazepam and unremarkable ictal/interictal EEG do not preclude the diagnosis of seizure. Ultimately, it is unclear if the patient’s “seizure-like” movements were epileptic in origin, but the data suggest the patient’s ongoing hypertonicity and mutism were more likely related to tissue injury rather than seizure. Early recognition (and treatment) of seizure in these cases is critical to prevent secondary brain injury.

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