Subacute Encephalopathy With Seizures in Alcoholics (SESA) Presenting as Focal Nonconvulsive Status Epilepticus

PURPOSE

To acquaint readers with the underrecognized subacute encephalopathy with seizures in chronic alcoholics (SESA) that has more recently been associated with different types of status epilepticus.

METHODS

Case reports and review of the literature on SESA and nonconvulsive status epilepticus (NCSE).

RESULTS

Two cases: one with alternating bifrontoparietal NCSE, and one with focal, confusional NCSE, with imaging and EEG correlates.

CONCLUSION

Underrecognized SESA may present as NCSE with focal clinical, EEG and reversible diffusion-weighted MRI abnormalities, warranting expedited diagnosis and antiseizure treatment to minimize morbidity.

[Nonconvulsive status epilepticus in comatose adults]

INTRODUCTION

Nonconvulsive status epilepticus (SE) is a term used to denote a range of conditions in which electrographic seizure activity is prolonged and results in nonconvulsive clinical symptoms. Nowadays, some experts on nonconvulsive SE have emphasized the utility on the clinical practice to consider the classification taking in account both the clinical setting and the severity of consciousness impairment, differentiating between ambulatory patients (from almost normal mental state to stupor) which includes absence SE and complex partial SE; and nonconvulsive SE in coma.

AIM

To review the literature in relation to the diagnosis of nonconvulsive SE in comatose and/or critically ill patients.

DEVELOPMENT

Nonconvulsive SE has been reported with surprising frequency in a wide variety of acute neurological processes such as cerebrovascular disease, anoxia, subarachnoid hemorrhage, cranial trauma, encephalitis and following convulsive SE.

CONCLUSIONS

Nonconvulsive seizures and episodes of nonconvulsive SE in patients with severe impairment of consciousness are frequent and, therefore, continuous EEG monitoring is an essential neurophysiologic tool in the evaluation of comatose subjects. EEG interpretation in patients with nonconvulsive SE may be particularly difficult and problematic and, therefore, requires expert knowledge and a clinical and neurophysiologic specific training.

Nonconvulsive status epilepticus causing prolonged stupor after intraventricular hemorrhage: report of a case

We describe the case of an octogenarian woman who experienced a severe alteration of mental state due to non-convulsive status epilepticus (NCSE) complicating an intraventricular hemorrhage. Our report emphasizes that NCSE may be the cause of unexplained neurological deterioration in elderly patients with acute brain injury.

Necrotizing leukoencephalopathy associated with nonconvulsive status epilepticus and periodic short-interval diffuse discharges: a clinicopathological study

We describe the clinical, neuroimaging and neuropathological features of an immunocompromised patient diagnosed as having refractory nonconvulsive status epilepticus (NCSE), and whose consecutive electroencephalograms (EEGs) revealed persistent periodic short-interval diffuse discharges (PSIDDs). Prominent subcortical white matter lesions in keeping with the diagnosis of multifocal necrotizing leukoencephalopathy may be neuropathological substrate of NCSE with persistent PSIDDs.

Acute stimulus-sensitive postanoxic myoclonus: description of a case

We describe the clinical and electroencephalographic features of a comatose patient with severe anoxic encephalopathy who experienced acute reflex myoclonus precipitated by passive eye opening/closure and painful stimulation. Acute stimulus-sensitive postanoxic myoclonus is an underdiagnosed epileptic condition. Shortly after the anoxic insult, the diagnosis should be based on EEG evaluation and various types of stimulation. These should include passive eye opening/closure and painful stimuli.

Encephalopathy secondary to imipenem therapy

We describe the case of an 84-year-old woman who developed a confusional state and suffered from a generalized tonic-clonic seizure while she was treated with imipenem, a beta-lactam antibiotic. Focal and generalized epileptiform discharges and a photoparoxysmal response were prominent with transient changes on the EEG.

Creutzfeldt-Jakob disease and non-convulsive status epilepticus: a clinical and electroencephalographic follow-up study*1

OBJECTIVE

To describe the clinical and electroencephalographic findings from a confused elderly woman with Creutzfeldt-Jakob disease (CJD) that initially were compatible with the diagnosis of non-convulsive status epilepticus (NCSE).

METHODS AND RESULTS

A 75-year-old right-handed woman was admitted to our hospital because of confusion and alteration of mental status. The two first electroencephalograms (EEGs) showed continuous diffuse spikes, rhythmic sharp waves and sharp-and-slow wave complexes which were completely abolished after the administration of 10 mg of intravenous diazepam. Over the following days, the clinical state of the patient was unmodified despite aggressive antiepileptic therapy. A third EEG revealed pseudo-periodic negative or positive-negative slow waves localised in the right frontal region. Subsequently, two consecutive EEGs showed continuous periodic generalised bi-triphasic complexes at a rate of 1 Hz, compatible with the diagnosis of CJD. Finally, the patient died, and postmortem examination was diagnostic of the sporadic form of CJD.

CONCLUSIONS

Clinical and electroencephalographic features in the early stages of CJD may resemble NCSE. The administration of intravenous benzodiazepines and its clinical and electroencephalographic correlation, response to the antiepileptic therapy, and monitoring with serial EEG recordings may be helpful considerations in the differential diagnosis.

[Non-convulsive status epilepticus]

DEVELOPMENT

Non-convulsive status epilepticus (NCSE) is an epileptic condition lasting more than 30 minutes in which continuous or recurrent seizure activity on the electroencephalogram (EEG) is responsible for diverse clinical symptoms including alteration of mental state, abnormal behaviour, perception disturbances or consciousness impairment. Most authors recognize two types of NCSE depending on the ictal electroencephalographic changes: generalized (absence status epilepticus) and complex partial status epilepticus (CPSE). In addition, there is also a simple form of partial status which is likely underdiagnosed because of its frequent progression to CPSE, subtle and varied symptomatology and high proportion of normal electroencephalograms (EEG). Absence status epilepticus (ASE) may occur in different clinical situations including idiopathic generalized epilepsy (typical AS), symptomatic generalized epilepsy (atypical AS), and elderly subjects without antecedents of epilepsy on chronic treatment with psychotropic drugs (de novo AS of late onset). Furthermore, CPSE is more frequent than previously mentioned. Although initially was equated with temporal lobe status epilepticus, extratemporal cases of CPSE have been well-documented, and the electroclinical characteristics of two types (I and II) of frontal CPSE have been recently described. NCSE may occur in patients with diverse clinical diagnosis such as hypoxic-anoxic encephalopathy, cancer, drugs, autoimmune disorders, Creutzfeldt-Jakob disease, chromosomal alterations, peritoneal dialysis, infections, cerebral hamartomas or head trauma.

CONCLUSION

The identification of NCSE may be particularly arduous and, therefore, a high level of suspicion is essential to obtain an early diagnosis. An urgent EEG with administration of intravenous benzodiazepines is considered as the method of choice in the diagnostic evaluation of NCSE.

Complex partial status epilepticus of extratemporal origin in a patient with systemic lupus erythematosus

The purpose of this case report is to describe the clinical, electroencephalographic and neuroimaging findings from a woman with systemic lupus erythematosus presenting with complex partial status epilepticus (CPSE) of neocortical temporo-parieto-occipital origin. The patient experienced complex visual hallucinations that initially were attributed to treatment with corticosteroids; however, an electroencephalogram (EEG) demonstrated the epileptic aetiology of her symptoms. CPSE should be considered as a possible cause of altered mental status in lupus. An urgent EEG is essential to make an accurate diagnosis.

[Epileptic auras: classification, pathophysiology, practical usefulness, differential diagnosis and controversials]

OBJECTIVE

To examine those aspects of the epileptic auras that may contribute to improve our understanding of this epileptic manifestation.

DEVELOPMENT

Epileptic aura is that portion of the seizure which occurs before consciousness is loss and for which memory is retained afterwards. In the case of simple partial seizures, the aura is the entire seizure. This epileptic phenomenon is the consequence of the activation of functional cortex by abnormal, unilateral, circumscribed and brief neuronal discharge. Surface electroencephalogram frequently fails to detect any changes during an isolated aura. The incidence of auras in partial epilepsy remains imprecise and there are marked discrepancies among authors. Viscerosensorial and experiential auras are most often seen in temporal lobe epilepsy. Feeling of fear is the commonest affective symptom associated with epileptic discharges from mesial temporal origin. Special sensory auras including visual, gustatory and vertiginous are more frequently described in extratemporal epilepsy. Olfactory auras are rare, however, when they occur the most likely etiology is a tumor involving the amygdala and hippocampus. Somatosensory auras include sensations of tingling or numbness, electrical feeling or very occasionally, pain. There is not agreement with the classification of determined auras such as motor, cephalic and sexual. The differential diagnosis is enormously heterogeneous including vestibular disfunction, migraine, stroke, autonomic disturbances, drug intoxications and psychiatric disorders.

CONCLUSION

The clinical manifestations of the epileptic auras are extraordinarily diverses and, therefore, the knowledge of their pathophysiology, characteristics, incidence and association with differents types of focal epilepsy are the clue to obtain a precise diagnosis.

De novo absence status of late onset following withdrawal of lorazepam: a case report

The aim of this report is to describe the clinical and electroencephalographic findings seen in an elderly woman without previous history of seizures who developed a nonconvulsive generalized status epilepticus following acute withdrawal of lorazepam. Scalp video-EEG monitoring was obtained using the standard 10/20 system of electrode placement. Cognitive and speech functions were specifically tested during the evaluation. Continuous irregular rhythmic generalized 2.0-2.5 Hz sharp-and-slow wave complexes intermixed with spikes and polyspikes more prominent over the frontocentral areas were seen on the EEG. This epileptic activity was continuous and unmodified by sensory stimulation and eyes opening and closing. Intravenous injection of diazepam caused a rapid normalization of the EEG with disappearance of the clinical manifestations. De novo absence status is a specific epileptic condition that should be suspected in all elderly subjects on chronic treatment with psychotropic drugs presenting in a confusional state. An urgent EEG is essential to confirm the diagnosis.

[Nonconvulsive status epilepticus of frontal origin. A case report]

INTRODUCTION

Nonconvulsive status epilepticus (NCSE) of frontal origin is a form of partial status epilepticus which has rarely been well-documented. The inespecificity of the symptoms contribute frequently to its misinterpretation being the EEG the most useful tool to make an accurate diagnosis.

CLINICAL CASE

We report a 53-year-old woman who suffered from two generalized tonic-clonic seizures secondary to a left frontal hematoma in 1994. Onset of treatment with carbamazepine was followed by a complete control of seizures. After remaining seizure-free during four years, antiepileptic therapy was discontinued. By June 1999, she presented with a prolonged confusional state having a generalized tonic-clonic seizure at the emergency room. At that moment, a computed tomography (CT) scan was normal. Generalized seizures were controlled with phenytoin, however, the patient remained confused having occasionally episodes of turning of the head and eyes to the right side. Ictal EEG examination showed recurrent bilateral frontopolar, frontocentral and frontotemporal epileptiform discharges with a left frontal focal onset. The diagnosis of NCSE of frontal origin was made. Despite several anticonvulsant combinations, confusional state remained unchanged and she was transferred to the intensive care unit for sedation with propofol and mydazolam. On the following days, she experienced a marked improvement and EEG showed a few frontal spikes and sharp waves but without evidence of electrographic status epilepticus. The patient was finally discharged and remains seizure-free on phenytoin therapy.

CONCLUSIONS

Our clinical and EEG findings are in keeping with the diagnosis of NCSE of frontal origin. A severe confusional state was the most prominent symptom and EEG was essential for the diagnosis.

[Photogenic epilepsy]

INTRODUCTION

The commonest reflex seizures are those induced by visual stimuli, and amongst these, those provoked by intermittent luminous stimulus.

DEVELOPMENT

A directed anamnesis and suitable intermittent light stimulation are important during electroencephalographic studies for the confirmation of the diagnosis of photosensitive epilepsy. The photogenic epilepsies, that is those in which all the epileptic seizures are provoked by visual stimuli, form a small group of epilepsies within the idiopathic generalized epilepsies with their onset during adolescence. These seizures have had great social impact, since media diffusion of the possibility of their appearance whilst watching television or playing video games.

CONCLUSION

The correct diagnosis and preventive measures, together with the correct anti-epileptic treatment are in favour of a good prognosis in the great majority of patients.

Castleman's disease associated with chronic inflammatory demyelinating polyradiculoneuropathy: a clinical and electrophysiological follow-up study

Castleman's disease (CD), or angiofollicular lymph node hyperplasia, is a rare lymphoproliferative disorder that can be associated with peripheral neuropathy. We report the long-term follow-up of a patient with a chronic inflammatory demyelinating polyradiculoneuropathy complicating the mediastinal form of classic CD who improved notably with immunosuppressive therapy. Our findings suggest that serial electrophysiological studies may be useful for monitoring treatment efficacy.

Abdominal epilepsy in an adolescent with bilateral perisylvian polymicrogyria

PURPOSE

We report a patient with recurrent episodes of severe periumbilical pain accompanied by headache, pallor, dizziness, and visual hallucinations who was subsequently diagnosed as having abdominal epilepsy and a bilateral sylvian cortical malformation.

METHODS AND RESULTS

During an EEG examination, the patient had a simple partial seizure, manifested as intense abdominal pain. The ictal EEG showed a focal electrographic seizure arising from the left frontotemporal region. Computed tomography scan was normal; however, magnetic resonance imaging (MRI) revealed asymmetric lesions involving both sylvian fissures compatible with polymicrogyria. Onset of treatment with sodium valproate was followed by a significant reduction of seizures.

CONCLUSIONS

Abdominal epilepsy should be suspected in adolescents or adults with paroxysmal episodes of abdominal pain associated with migraine-like symptoms. EEG and MRI investigations are indicated. A developmental brain disorder should be considered as a possible etiology.

[Osterosclerotic myeloma and polyneuropathy]

INTRODUCTION

The peripheral neuropathy is a common complication in patients with osteosclerotic myeloma. The association with hepatosplenomegaly, lymphadenopathy and variable endocrine disturbances and skin changes constitute the POEMS syndrome. The pathogenesis of this syndrome is unclear, but the presence of M protein and elevated levels of interleukin-6 in the serum of patients, suggests an immunologic mechanism.

CASE

A 68 year old woman presented with a 2 year history of progressive weakness and paresthesias in both legs. Neurological examination revealed a sensorimotor polyneuropathy, involving predominantly the lower extremities. In addition to neurological findings, the patient had lymphadenopathy and skin hyperpigmentation. Serum protein immunoelectrophoresis revealed a peak of monoclonal IgA lambda paraprotein. Radiographic examination disclosed multiple osteosclerotic lesions. Electrophysiological evaluation showed a severe axonal and demyelinating sensorimotor polyneuropathy. Biopsy of sural nerve revealed demyelination and axonal degeneration. Axillary lymph node biopsy were consistent with giant lymph node hyperplasia. Interleukin-6 serum levels were normal.

CONCLUSIONS

The POEMS syndrome or Crow-Fusake syndrome is a rare multisystem disorder often associated with osteosclerotic myeloma. A severe demyelinating sensorimotor polyneuropathy frequently constitutes the chief complaint. These patients have a polyneu-ropathy which resembles idiopathic chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and the electrophysi-ological studies are essential in the diagnosis. The pathogenesis has not been explained. Presumably, the plasma cells secrete an immunoglobulin or another substance that is toxic to peripheral nerves. Interleukin-6 is implicated in the pathogenesis of this disease.