New or different "spells" should always prompt a differential diagnosis. Cerebral ischemia is the single most common cause of first seizures after 60 years of age1. TIAs may be confused with seizures though a "negative" motor deficit, positional recovery, and the ancillary testing suggest ischemia as opposed to focal seizures. Extended-release levitiracetam was substituted for phenytoin to avoid drug-drug interactions, and to avert adverse effects (above) that are common in this age group with enzyme-inducing AEDs.
Carotid endarterectomy was performed to prevent recurrent stroke with EEG used to detect the dynamic effects of ischemia. Unilateral or bilateral loss of fast frequencies may occur. Scalp EEG demonstrated bilateral suppression (B) in our patient though he recovered without incident and was maintained on anti-platelet therapy.
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