Jakob-Creutzfeldt disease. Modification of clinical and electroencephalographic activity with methylphenidate and diazepam

Stimulus-induced arousal with transient electroencephalographic improvement distinguishes nonictal from ictal generalized periodic discharges

In the case of suspicion of nonconvulsive status epilepticus (NCSE), reactivity on electroencephalograms (EEGs) can provide valuable diagnostic information. Reactivity refers to responses to auditory or somatosensory stimulation, with changes in amplitude and frequency of background activity. Because of self-perpetuating processes and the failure of self-terminating mechanisms, status epilepticus is unlikely to cease when patients spontaneously move, and it cannot typically be stopped by external stimulation (i.e., auditory and tactile stimuli). The defining EEG characteristic of absence status epilepticus is the presence of bilateral, synchronous, symmetric, rhythmic paroxysmal activity that shows little or no reactivity to sensory stimulation. On the other hand, in metabolic/toxic or multifactorial encephalopathies, triphasic waves (TWs) are influenced by the level of vigilance. TWs may be transiently abolished when patients increase their level of alertness from a drowsy/lethargic state to a state of wakefulness. This reactivity is only observed when patients can be aroused by a somatosensory or auditory stimulus. This reactivity tends to disappear with increasing severity of the disease and in comatose patients. In patients without preexisting developmental and epileptic encephalopathy, this pattern of stimulus-induced wakefulness with transient improvement of the EEG is a major criterion in determining that the EEG patterns are not ictal. This criterion of reactivity on EEGs, beyond the classical clinical/EEG criteria of NCSE (Salzburg criteria), should now be systematically added.

Addition of clobazam successfully treating drug resistant seizures in Heidenhain variant Creutzfeldt Jakob disease: A case report

Creutzfeldt Jakob Disease (CJD) is a rapidly progressive and fatal neurodegenerative disease that is uncommonly accompanied with seizures. In this case report, we describe a 63-year-old male patient who presented with a 3-week history of visual disturbances and clonic movement of his left arm. Additionally, the patient was reported to have developed erratic behaviors along with insomnia during this period. An EEG showed 4 electrographic seizures of bilateral temporo-occipital onset characterized by 1.5 Hz periodic discharges, lasting 2-13 min. Levetiracetam was started and titrated to the maximal dose however seizures continued so lacosamide and clonazepam were initiated. Despite these aggressive treatments, seizures continued, and oral clobazam 5 mg BID replaced clonazepam. Continued electrographic seizures warranted an increase in clobazam to 10 mg BID after which the seizures stopped; of note, lateralized periodic discharges (LPDs) remained. The patient's symptoms were consistent with the Heidenhain variant, along with probable CJD due to positive RT-QuIC assay, positive 14-3-3 protein, MRI FLAIR hyperintensities, and EEG findings. Although the patient passed away 3 weeks following admission as a result of CJD, we propose that there may be clinical benefit in the use of clobazam in suspected CJD patients presenting with seizures, and its use merits further investigation.

Stimulus-Induced Rhythmic or Periodic Intermittent Discharges (SIRPIDs) in patients with triphasic waves and Creutzfeldt-Jakob disease

Since the term Stimulus-Induced Rhythmic, Periodic, or Ictal Discharges (SIRPIDs) was introduced into the vocabulary of electrophysiologists/neurologists, there has been an ongoing debate about its significance, as well as its correlation with outcomes. SIRPIDs are frequently seen in patients who are critically ill from various causes. The literature reflects the findings of triphasic morphology, with the generalized periodic discharge (GPD) classification in many patients with SIRPIDs: toxic/metabolic encephalopathies, septic, and hypoxemic/hypercapnic encephalopathies, but also sharp periodic complexes in Creutzfeldt-Jakob disease and advanced Alzheimer's disease. In these settings, GPDs disappear when patients fall asleep and reappear when patients spontaneously wake up, or are awoken by an external stimulus, or sometimes because of a respiratory event, with the possibility of the appearance of GPDs with a cyclic alternating pattern. SIRPIDs may be seen as a transitional pattern between sleep and waking states, corresponding to a postarousal/awakening phenomenon. As SIRPIDs are a transient phenomenon and can usually be recorded repeatedly with each stimulation, the word "Ictal" could be replaced by "Intermittent": Stimulus-Induced Rhythmic or Periodic Intermittent Discharges. However, considering that SIRPIDs may be "potentially ictal" or on an "ictal-interictal continuum" in some situations, the "plus" modifier may be added: SIRPIDs-plus.

EEG Observations in Probable Sporadic CJD

INTRODUCTION

Sporadic Creutzfeldt Jakob Disease, the most common reported prion disease, is a fatal neurodegenerative disease caused by the misfolding of protein PrP^C to PrP^SC. EEG is the first in vivo test to support the clinical diagnosis of sporadic CJD (sCJD). This study is carried out to describe the comprehensive electroencephalography changes in a cohort of patients with probable sCJD from south India.

METHODOLOGY

This retrospective observational study is conducted by reviewing case records from 2013-2020. Demographic, clinical, imaging details were noted. Electroencephalogram (EEG) recordings were retrieved and reviewed independently by two qualified epileptologists and the findings were visually analyzed and correlated with clinical and imaging abnormalities.

RESULTS

Fifty patients with probable sCJD with the availability of artefact-free EEG were included in the study. The mean age was 59.76 ± 8.17 years and M: F was 31:19. Magnetic resonance imaging (MRI) brain showed abnormality defining CJD in 48/50, i.e., 96%patients. EEG showed specific and or nonspecific abnormalities in 88%. The specific abnormalities, i.e., periodic sharp wave complexes (PSWC), were noted 66%. PSWC were mostly asymmetric (90%) and more frequently seen in the right hemisphere (57.6%). Amplitude maximum in the occipital region was noted in 42.4% and in frontal region in 36.4%. The sensitivity of EEG specific abnormalities to diagnose probable sCJD according to CDC 2018 criteria with positive MRI findings was 68.75%.

CONCLUSION

This study showed that EEG is a relatively inexpensive and sensitive tool and assists in the diagnosis of sCJD. However, it can be normal or show nonspecific abnormalities in the early stages of the disease.

Creutzfeldt-Jakob disease and the eye. I. Background and patient management

This article attempts to summarise our current understanding of TSEs as they affect man. Specific aspects relevant to ophthalmological practice, in particular the management of patients in day-to-day clinical practice and with respect to corneal transplantation, have been discussed. In the companion article we discuss the specific ophthalmic and neuro-ophthalmic features of these diseases.

Creutzfeldt-Jakob disease with periodic lateralized discharge: case report

A case of CJD with PLD in the first EEG is reported. The PLD became bilateral in the next EEG. The subsequent EEGs showed shifting asymmetries. In this case, PSD reappeared after 5 months' absence. The PLD occasionally appeared over the hemisphere ipsilateral to the side of the myoclonic jerks. The clinical significance of the PLD and reappearance of PD, and the diagnostic importance of PLD are discussed.

Temporal evolution of electroencephalographic abnormalities in Creutzfeldt-Jakob disease

Frequent serial EEG investigations of three patients with neuropathologically confirmed Creutzfeldt-Jakob disease lasting 13, 24 and 68 weeks revealed typical periodic activity of short duration with stereotyped bilateral sharp waves at the 7th, 8th, and 12th week, respectively, after the onset of symptoms. During the later stages, there were several deviations from this typical pattern. However, periodic activity was preceded between the 3rd and 9th week by intermittent localized or lateralized delta rhythms, which gradually changed into periodic activity. This early temporal evolution of EEG abnormalities may be helpful in the early diagnosis of Creutzfeldt-Jakob disease when accompanied by other investigations to exclude other causes of intermittent delta rhythms.

Serial polysomnograms in Creutzfeldt-Jakob disease

This is a report of the case of a patient with Creutzfeldt-Jakob disease, whose electroencephalograms and polysomnograms were repeatedly recorded throughout the course of the illness with details of the alterations of periodic synchronous discharges. In the advanced stage of the disease, the appearance of peculiar paroxysms was noted, predominantly in the early morning. Furthermore, apnea of the central type was observed during the same time period. Discussions were held on the mechanisms inducing the EEG paroxysms and apneas.

Sleep apnea with unusual EEG changes in Jakob-Creutzfeldt disease

Disruption of the periodic pattern in the EEG was observed in a patient with Jakob-Creutzfeldt disease. Periods of apnea (during 'sleep') were associated with abrupt cessation of the periodic complexes and their replacement by 7-9 c/sec waves which persisted throughout the apneic episode. The periodic complexes reappeared on termination of the apnea. This close temporal association between disruption of the periodicity and apneic episodes suggests proximity of respiratory neurons and the deep subcortical pacemaker.

Periodic synchronous discharge and myoclonus in Creutzfeldt-Jakob disease: diagnostic application of jerk-locked averaging method

The technique of jerk-locked averaging was applied to two patients with pathologically proved Creutzfeldt-Jakob disease. Patient 1, whose brain contained numerous kuru plaques and severe cerebral white matter degeneration, did not show any periodic synchronous discharges in spite of frequently repeated EEG recordings. The technique of jerk-locked averaging, however, disclosed a negative sharp wave over the contralateral central area in close temporal association with myoclonus of an upper extremity. Patient 2 had classic periodic synchronous discharges on the EEG, and jerk-locked averaging delineated a fixed relationship in time and space between the periodic discharge and the myoclonus.

Analysis of clinical and electrophysiological findings in Jakob-Creutzfeldt disease

Serial EEG and EMG investigations were performed in the course of a histologically verified case of Jakob-Creutzfeldt disease. Some electrophysiologic data, including visual-evoked responses were analyzed using a computer. Correlations between clinical and EEG findings suggest that the generator of the periodic discharges may be localized in some circumscribed area of the upper brain stem, probably the thalamus. The inhibitory effect of various narcotics suggests that the pacemaker of the triphasic discharges has relations to the nonspecific activating system.

Electroencephalographic and clinicopathological studies on Creutzfeldt-Jakob syndrome

The correlation between the appearance of the characteristic electroencephalographic abnormality, cardinal clinical manifestations, and neuropathological features was studied in four cases of Creutzfeldt-Jakob syndrome consisting of subacute spongiform encephalopathy and classical Creutzfeldt-Jakob disease. Consideration is given to the differences in the electroencephalographic findings between these two subgroups of the syndrome and on the underlying pathological mechanism.

Cyclic EEG changes in subacute spongiform and anoxic encephalopathy

Polygraphic recordings of EEG, EMG, EKG and respiration were made on three patients with histologically verified subacute spongiform encephalopathy and one patient with anoxic encephalopathy both before and after intravenous diazepam. The records showed cyclical activity occurring about every half minute in which the EEG changes were correlated with myoclonus and cardio-respiratory changes. It is suggested that these cycles represent spontaneous cycles of arousal to which the 1/sec sharp waves are related wnd which result from the same mechanisms that produce other cyclical autonomic phenomena.