Transcript Right Temporal Nonconvulsive Status Epilepticus Presenting

Non-Convulsive Status
Epilepticus: an example of the
overlap between Neurology and
Psychiatry
Kristen Shirey, MD
Duke University Medical Center
Depts. of Internal Medicine & Psychiatry
Case Presentation
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87 y/o Caucasian female who presented to the
ED (casualty) with altered mental status and new
onset auditory and visual hallucinations from
her Assisted Living Facility (ALF).
Case Presentation
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HPI:
Reported 1 week of progressive confusion,
headache, and new onset hyperglycemia documented
at ALF.
 Two weeks of “hearing a grinding sound, like a
washing machine running” and reports seeing
“crickets and large white bugs crawling on my
sheets.”
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Differential Diagnosis
Med/Psych History
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PMH:
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Past Psych Hx:
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Major Depression, Single Episode, no hospitalizations, suicidality, or
psychotic symptoms in the past.
Social Hx:
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Chronic Bronchitis with hx atypical mycobactrium
Breast Cancer s/p radical mastectomy
Idiopathic Polyneuropathy
Hypothyroidism
Hyperlipidemia
Lives in ALF alone, protestant, widowed 3 months ago, occasional glass
of wine, no tobacco or illicit drug use.
Family Hx: Non-Contributory, no family psych history.
Med/Psych History
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Medications:
Calcium citrate + vitamin D 2 tabs po BID-CC
 Docusate 100mg po daily
 Levothyroxine 88mcg po daily
 Omeprazole 20mg po daily
 Simvastatin 20mg po qhs
 Risperidone 1mg po qhs
 Enoxaparin 40mg subQ daily
 Insulin 4 units subQ TID-AC + SSI
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Exam Findings
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Vital Signs: T 36.8, BP 120/55, P 98, RR 20
PE:
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Gen: WD/WN, Elderly female, NAD
Skin/Mucosa: No rashes/lesions, Membranes moist
HEENT: NC/AT, EOMI, PERRLA
Neck: Supple, No LAD, No thyromegaly, nl JVP
CV: RRR, S1/S2 nl, no m/r/g
Resp: CTAB, no wheezes
Abd: +BS, soft, NT/ND, no HSM, no rebound/guarding
Ext: No C/C/E
Neuro: AAOx3, MMSE 27/30, NL bulk and tone, Motor 5/5 bilaterally,
Sensation intact to light touch and vibration, DTR 1+ and symmetric,
coordination nl FTN and HTS, gait normal no ataxia.
Mental Status Exam
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MSE:
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Fragile elderly female, anxious, cooperative yet guarded.
Speech regular rate with normal intonation and tone with
increased latency.
Mood was “confused,” and affect was blunted and
congruent.
Her thought process was tangential and she was confused
though she denied any paranoia, thought insertion/blocking,
ideas of reference. Endorsed AH of “a running washing
machine” and VH “of crickets and white bugs on my
blanket.”
Insight was poor and judgement was impaired. Cognition was
consistent with MMSE 27/30 (incorrect day, season and 2/3
on recall).
Laboratory/Radiographic Findings
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Labs:
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WBC 10.6, Hgb 15.1, Hct 43, Plt 246
Na 127, K 3.8, Cl 97, CO2 24, BUN 20, Cr 0.9, Glucose 404,
Ca 9.1, Alb 3.4, AG 6
TSH 4.01, fT4 1.19
ESR 20
UA – SG 1.031, 1+ Prot, 3+ Glucose, No ketones, 1+ blood,
6 RBC, normal WBC, no bacteria
Urine and Blood Toxicology Negative
Radiographic:
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CXR PA/Lateral: Normal cardiopulmonary findings.
CT Brain without contrast: No acute intracranial process.
Hospital Course
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Admitted to General Medicine Service/Geriatric
Hospitalist
Initial workup significant for hyperglycemia without
evidence of acidosis as well as hyponatremia.
 Blood glucose corrected with initiation of insulin
and patient started on IV normal saline for
correction of hyponatremia.
 Psychiatry consult placed for new onset
hallucinations and altered mental status.
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Differential Diagnosis
Diagnostic Tests??
Invasive Procedures??
Psychiatric Consultation
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Psych ROS patient noted to have symptoms of
low mood, insomnia, decreased energy and
concentration in association with death of
husband 3 months ago.
During assessment patient had 2 separate staring
spells where she was unresponsive, noted to
have right facial myoclonic jerks, and noted
hearing a “grinding sound like a washing
machine.”
Hospital Course
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Emergent EEG performed with findings of:
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Background activity of predominantly intermixed theta and
delta activity.
Frequent, rhythmic theta activity in right temporal region, T4,
which evolves into spike and wave discharges consistent with
seizures lasting 15-20 seconds.
Rarely seizures spread bilaterally and during one seizure
with spread from right temporal to bitemporal
distribution, the patient described hearing a washing
machine, and was intermittently unresponsive.
Diagnosis:
Nonconvulsive Status Epilepticus
Hospital Course
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Neurology Consult
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MRI Brain:
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Patient transferred to Neuro ICU and loaded on IV
phenytoin and levetiracetam and underwent continuous video
EEG.
no acute findings and extensive white matter chronic small
vessel ischemic disease.
Lumbar Puncture:
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One nucleated cell, 13 RBC, Protein 52, Glucose 133, Gram
Stain neg, VDRL PCR neg, HSV PCR neg.
Case Conclusion
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87 year old Caucasian female with 2 week
history of progressive altered mental status and
new onset auditory and visual hallucinations due
to right temporal nonconvulsive status
epilepticus assumed to be secondary to
hyperglycemia and hyponatremia after negative
workup for intracranial abnormalities or
infection, in an elderly patient with no prior
history of epilepsy.
Nonconvulsive Status
Epilepticus Presenting
with Auditory and Visual
Hallucinations
Nonconvulsive Status Epilepticus
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Definition
Status Epilepticus defined as single seizure or series
without recovery of consciousness between seizures
lasting at least 20-30 minutes.
 Historically Charcot described a patient in 1888 with
‘automatisme ambulatoire”
 Epilepsy Research Foundation 2005 – “A range of
conditions in which electrographic seizure activity is
prolonged and results in nonconvulsive clinical
symptoms.”
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The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396; NEJM
1998.338(14)
Nonconvulsive Status Epilepticus
Meierkord. Lancet Neurology 2007;6:329-39.
Nonconvulsive Status Epilepticus
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Categories
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Generalized or Absence NCSE
Focal or Complex Partial NCSE
Electrographic Criteria (no pathognomonic EEG
pattern)
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Frequent or continuous focal EEG seizures
Frequent or continuous generalized spike wave discharges
without history of seizure
Periodic lateralized, or periodic bilateral, epileptiform
discharges occurring in a patient with a coma after a
generalized tonic clonic seizure
The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396
EEG
in
NCSE
Beyendburg.
Gerontology
2007;53:388-396
EEG
in
NCSE
Meierkord. Lancet
Neurology
2007;6:329-39.
Top: 18 yo with
juvenile absence
epilepsy with
medication
noncomplaince.
Shown 3 Hz spike
wave discharges.
Middle: 63 yo
with mesial
temporal lobe
epilepsy, EEG
during partial
complex status.
Bottom: 39 yo
with acute viral
encephalitis with
subtle NCSE.
Nonconvulsive Status Epilepticus
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Common Clinical Presentations
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De novo somnolence, stupor, or coma of primary unknown
origin
De novo neuropsychiatric or behavioral disturbances such as
confusional states with agitation, bizarre behavior, mutism,
hallucinations, speech disturbances and amnesia
Limited neurologic deficits such as cortical blindness or
aphasia with clinical fluctuations
AMS with clinical signs of epileptic activity: subtle
myoclonus, chewing, blinking, staring, nystagmus, etc.
Autonomic disturbances (e.g. belching, borborygmi,
flatulence)
Prolonged post-ictal period
The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396
Nonconvulsive Status Epilepticus
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Clinical Situations when NCSE on DDx
AMS associated with myoclonus or ocular symptoms
and/or fluctuating mental status
 AMS of unexplained etiology, especially in patient
with a seizure history
 Unexplained AMS in the elderly
 Stroke patients who appear clinically worse than
expected
 Prolonged (>2 hours) post-ictal period after a
generalized tonic-clonic seizure
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The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396
Nonconvulsive Status Epilepticus
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Disorders Mimicking NCSE
Metabolic encephalopathy
 Migraine aura
 Posttraumatic amnesia
 Prolonged post-ictal confusion
 Psychiatric disorders
 Substance de- or intoxication
 Transient global amnesia
 Transient ischemic attack
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Meierkord. Lancet Neurology. 2007;6:329-39.
Nonconvulsive Status Epilepticus
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Diagnosis
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No clear criteria for deciding when to request an EEG,
however when NCSE is suspected on clinical grounds and
EEG is indicated to confirm diagnosis.
NCSE is a neurologic emergency and needs to be treated
promptly to avoid neuronal damage, thus expedited
neurologic consultation and EEG are require to confirm the
diagnosis.
According to an observational study in 2003 by Husain et al.
suggested that history of remote seizure and ocular
movements were observed significantly more often in NCSE
and may help selecting patients for EEG evaluation.
J Neurol Neurosurg Psychiatry 2003;74:189-191
Algorithm for Management of SE
Lowenstein.
NEJM.
1998;338(14).
Nonconvulsive Status Epilepticus
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Treatment/Management
Transfer to Neurologic Service or Neuro-ICU (if
available) for monitoring (i.e. EEG, airway, etc.)
 Benzodiazepines are the first-line treatment
 After BZD, further AED treatment may be required
for control of seizure activity and patient may
require IV loading of AED (i.e. phenytoin,
fosphenytoin, valproate, and levetiracetam).
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NEJM. 1998;338(14); The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396
Antiepileptic Drug Therapy for SE
Lowenstein.
NEJM.
1998;338(14).
References
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Lowenstein D.H., & Alldredge, B.K. Status Epilpeticus. NEJM. 338 (14); 97076.
Riggio, Silvana. Psychiatric Manifestations of Nonconvulsive Status
Epilepticus. The Mt Sinai J of Med Vol.73 No.7 Nov 2006
Beyenburg, S, Elger, CE, & Reuber, M. Acute Confusion or Altered Mental
State: Consider Nonconvulsive Status Epilepticus. Gerontology 2007;53:388-396
Husain, AM, Horn, GJ, & Jacobson, MP. Non-convulsive status epilepticus:
usefullness of clinical features in selecting patients for urgent EEG. J Neurol
Neurosurg Psychiatry 2003;74:189-191
Takaya, S., et al. Frontal nonconvulsive status epilepticus manifesting somatic
hallucinations. Journal of the Neurological Sciences 234 (2005)25-29
Meierkord, H., & Holtkamp, M. Non-convulsive status epilepticus in adults:
clinical forms and treatment. Lancet Neurology 2007; 6: 329-39.
Questions?