Should We Treat Electroencephalographic Discharges in the Clinic or in the Intensive Care Unit, and if so When and How?

Electrical Status Epilepticus in Sleep (ESES) in an Elderly Adult: A Case Report

Electrical status epilepticus in sleep (ESES) is a pattern of continuous spikes seen in electroencephalography (EEG) and may be associated with neuropsychological deficits in children. This EEG pattern has not previously been reported in older adults. In this case report, a 66-year-old woman with post-traumatic epilepsy presented to the emergency department following a breakthrough seizure. Her EEG exhibited a striking pattern of continuous spikes during sleep that stopped abruptly with wakefulness, which is characteristic of the ESES phenomenon. This patient had triggers for a breakthrough seizure including subtherapeutic seizure medication levels, exposure to flashing lights, and iatrogenic hyperthyroidism, but none of these triggers have been known to cause selectively continuous spikes during sleep on EEG. This finding suggests that the phenomenon of ESES may persist into older adulthood.

Electrical status epilepticus in sleep (ESES) - Treatment pattern and EEG outcome in children with very high spike-wave index

OBJECTIVE

The objective of the study was to determine electrical status epilepticus in sleep (ESES) outcome in children with very high spike-wave index (SWI; ≥85%), and assess treatment pattern.

METHODS

Medical records of children 1-17 years old with ESES were reviewed. In this study, ESES is defined as SWI in non-rapid eye movement (non-REM) sleep of ≥85%. Electrical status epilepticus in sleep resolution is defined as reduction of SWI to <50%.

RESULTS

Complete data were available in 33 children. Age at ESES diagnosis ranged from 32 to 165 months, median 76 months. The median duration of follow-up was 33 months. Two-thirds of the children were on one or more antiepileptic drugs (AED) at ESES diagnosis. Antiepileptic drugs were used as first treatment for ESES in 24/33 (73%). Electrical status epilepticus in sleep initially resolved in 76%, but 56% had subsequent relapse. The relapse rate was higher for steroids (89%) and benzodiazepines (60%) as compared with nonbenzodiazepine AEDs (29%). At last follow-up, ESES resolved in 21 children (64%). Electrical status epilepticus in sleep resolution was associated with seizure freedom (Fisher's exact, p < 0.05).

SIGNIFICANCE

Using electroencephalogram (EEG) criteria, ESES resolved in 64%. We found high failure rate of first-line AEDs in preventing ESES, and high relapse rate. Standardization of ESES management is urgently needed.