Urinary Retention Following Epileptic Seizure with Pontine Microlesion

Case at a Glance

A 26-year-old female with known epilepsy developed complete urinary retention and treatment-resistant cluster seizures following a severe tonic-clonic seizure. MRI revealed a left pontine microlesion described as capillary ectasia/microvasculitis.

Patient's Story

The patient, a 26-year-old European female (height 173cm, weight 53kg) with a history of polymorphic epilepsy, presented with a 43-day history of complete urinary retention following a severe seizure on June 2nd. During this seizure, she experienced facial petechiae and conjunctival hemorrhages due to capillary rupture. Post-seizure, she completely lost the sensation of bladder fullness and urinary urgency. She described experiencing severe cephalic pain between her eyes, which she attributed to her body's inability to sense the need to urinate. Additionally, she developed cluster seizures that became resistant to her usual emergency medications including midazolam.

Initial Assessment

Current medications include zonisamide, levetiracetam, and intramuscular vitamin B12 1000 IU injections. The patient reported that her previously effective antiepileptic drugs and rescue medications had lost their efficacy since the onset of symptoms. She also complained of persistent headaches and neck pain unresponsive to analgesics.

The Diagnostic Journey

Neurological workup included electroencephalography (EEG) which demonstrated status epilepticus during a 40-minute seizure episode. Brain MRI with epilepsy protocol revealed a left pontine microlesion characterized as capillary ectasia/microvasculitis. Urological evaluation was performed, with all tests returning within normal limits, ruling out primary urological pathology.

Final Diagnosis

Primary diagnosis: Epilepsy with polymorphic seizures, currently refractory. Secondary findings: Left pontine capillary telangiectasia (microlesion), Post-ictal urinary retention of unclear etiology.

Treatment Plan

Continued antiepileptic therapy with zonisamide and levetiracetam, though with noted decreased efficacy. Vitamin B12 supplementation maintained. Urological management for retention symptoms. Neurology consultation recommended to evaluate the relationship between the pontine lesion and current symptoms, though surgical intervention is contraindicated due to the high-risk pontine location.

Outcome and Follow-up

The patient's urinary retention persisted at 43 days post-seizure. Seizure control remained suboptimal with development of treatment resistance. The pontine microlesion was deemed unlikely to be the primary cause of urological symptoms by consulting physicians, as such small capillary telangiectasias are typically benign. However, the temporal relationship between the severe seizure and symptom onset suggests a possible neurological etiology requiring ongoing neurological management and monitoring.