Case — 80-Year-Old Hypertensive, Diabetic Woman with CAD and Atrial Fibrillation, Admitted with Altered Sensorium Following GTCS

Frame the problem. A generalised tonic-clonic seizure at 80 years is an acute symptomatic (provoked) seizure until proved otherwise, not idiopathic epilepsy. Two features dominate the differential: she is on antithrombotic therapy for atrial fibrillation, so intracranial haemorrhage must be excluded first; and she is diabetic, so hypoglycaemia must be excluded immediately.

Immediate stabilisation (first 10 minutes). Airway, left lateral position, oxygen, suction, IV access, cardiac and SpO monitoring. Check capillary blood glucose at the bedside and give IV thiamine 100 mg before any 2 glucose. If seizures continue: IV lorazepam 0.1 mg/kg (maximum 4 mg per dose); if status persists, second-line IV levetiracetam 60 mg/kg, fosphenytoin 20 PE/kg or valproate 40 mg/kg — all equally effective; then anaesthesia with continuous EEG. Infuse slowly and watch blood pressure and respiration.

Focused history from attendants. The exact drug list — insulin or sulfonylurea, metformin, warfarin versus a DOAC, antiplatelets, beta-blocker, digoxin, amiodarone, statin, and pro-convulsant drugs such as tramadol or a quinolone; recent falls or head injury; fever; missed or doubled doses; alcohol; prior stroke, seizure or dementia; and her baseline cognition and functional status, which will shape every subsequent decision.

Examination. Vital signs and temperature, GCS, pupils, fundi, neck stiffness, and a search for lateralising signs and Todd’s paresis. Lateral tongue bite and urinary incontinence support a true GTCS. Look for scalp haematoma, periorbital bruising and other signs of head injury; examine the heart for atrial fibrillation, murmur and failure; and screen for a septic focus — chest, urine, skin and pressure areas.

Differential diagnosis to work through. Intracranial haemorrhage — anticoagulant-related intracerebral haemorrhage and chronic subdural haematoma; acute ischaemic stroke or cardioembolic infarct with seizure; hypoglycaemia; hyponatraemia; uraemic or hepatic encephalopathy; sepsis-associated encephalopathy; hypoxic-ischaemic injury after an arrhythmia; CNS infection (meningoencephalitis, tuberculoma, neurocysticercosis); drug toxicity or withdrawal; hypertensive encephalopathy/PRES; and non-convulsive status epilepticus.

Investigations — immediate. Capillary and laboratory glucose; serum sodium, calcium, magnesium; urea, creatinine and electrolytes; LFT; arterial blood gas; full blood count; CRP or procalcitonin; ECG and troponin (silent myocardial infarction or arrhythmia is a real possibility with her CAD and AF); coagulation profile and INR — mandatory given anticoagulation; blood and urine cultures; chest X-ray.

Investigations — neurological. Urgent non-contrast CT brain is the first imaging study, looking for haemorrhage, subdural collection, infarct or mass. If the CT is non-diagnostic, proceed to MRI with DWI ± MR angiography. Lumbar puncture after imaging if infection is suspected and there is no contraindication — noting that anticoagulation must be reversed first. EEG is essential if consciousness does not recover within 30–60 minutes, to exclude non-convulsive status epilepticus.

Managing the anticoagulated patient. If intracranial haemorrhage is confirmed: stop the anticoagulant and reverse it immediately — vitamin K plus 4-factor prothrombin complex concentrate for warfarin, idarucizumab for dabigatran, and andexanet alfa or PCC for a factor Xa inhibitor; lower systolic blood pressure to about 130–140 mmHg; obtain a neurosurgical opinion; and decide on the timing of restarting anticoagulation later with the cardiology team. If instead there is an ischaemic stroke, a seizure at onset does not by itself preclude thrombolysis when the deficit is clearly attributable to the stroke.

Antiseizure medication decision. An acute symptomatic seizure from a fully reversible metabolic cause does not require long-term antiseizure medication — correct the cause. If a structural lesion (haemorrhage, infarct, subdural, tumour) is found, start maintenance therapy: levetiracetam is the drug of choice — intravenous formulation, no CYP450 interactions with her anticoagulant, statin or antiarrhythmic, with the dose adjusted for creatinine clearance. Avoid phenytoin and carbamazepine, which interact with warfarin, DOACs, statins and amiodarone and cause hypotension and arrhythmia on rapid infusion.

Supportive and comprehensive geriatric care. Aspiration precautions with a formal swallow screen before oral intake; VTE prophylaxis; pressure-area care; a delirium prevention bundle (orientation, sleep, mobilisation, avoidance of restraints, catheters and anticholinergics); nutrition; early physiotherapy; glycaemic control that avoids hypoglycaemia; deprescribing of pro-convulsant and anticholinergic drugs; falls, driving and home-safety advice; and an early, explicit goals-of-care discussion with the family, followed by comprehensive geriatric assessment before discharge.

ANNEXA-I (NEJM 2024) — reversal of factor Xa inhibitor-associated intracerebral haemorrhage. In 530 patients (mean age 79 years) with ICH within 15 hours of a factor Xa inhibitor, andexanet alfa achieved better haemostatic efficacy than usual care (67.0% vs 53.1%, p=0.003) but caused more thrombotic events (10.3% vs 5.6%, p=0.048), including ischaemic stroke (6.5% vs 1.5%), with no difference in 30-day mortality or modified Rankin outcome. Because of this, plus cost and availability, 4-factor PCC remains the widely used option in Indian practice — a nuance worth writing.

AHA/ASA 2026 Acute Ischaemic Stroke Guideline. The approach to thrombolysis contraindications has been modified, and seizure at stroke onset is no longer treated as an absolute barrier when the deficit is attributable to the infarct. Tenecteplase 0.25 mg/kg (maximum 25 mg) as a single bolus is now a Class 1 recommendation alongside alteplase within 4.5 hours, thrombolysis should be given for disabling deficits regardless of NIHSS score, and thrombectomy eligibility has been broadened to ASPECTS 3–10 and up to 24 hours with mismatch imaging — all directly relevant to an 80-year-old whose first GTCS turns out to be a stroke.