Non-Convulsive Status Epilepticus: an example of the - Right ...


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Non-Convulsive Status Epilepticus: an example of the - Right ...

  1. 1. 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
  2. 2. Case Presentation <ul><li>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). </li></ul>
  3. 3. Case Presentation <ul><li>HPI: </li></ul><ul><ul><li>Reported 1 week of progressive confusion, headache, and new onset hyperglycemia documented at ALF. </li></ul></ul><ul><ul><li>Two weeks of “hearing a grinding sound, like a washing machine running” and reports seeing “crickets and large white bugs crawling on my sheets.” </li></ul></ul>
  4. 4. Differential Diagnosis
  5. 5. Med/Psych History <ul><li>PMH: </li></ul><ul><ul><ul><li>Chronic Bronchitis with hx atypical mycobactrium </li></ul></ul></ul><ul><ul><ul><li>Breast Cancer s/p radical mastectomy </li></ul></ul></ul><ul><ul><ul><li>Idiopathic Polyneuropathy </li></ul></ul></ul><ul><ul><ul><li>Hypothyroidism </li></ul></ul></ul><ul><ul><ul><li>Hyperlipidemia </li></ul></ul></ul><ul><li>Past Psych Hx: </li></ul><ul><ul><li>Major Depression, Single Episode, no hospitalizations, suicidality, or psychotic symptoms in the past. </li></ul></ul><ul><li>Social Hx: </li></ul><ul><ul><li>Lives in ALF alone, protestant, widowed 3 months ago, occasional glass of wine, no tobacco or illicit drug use. </li></ul></ul><ul><li>Family Hx: Non-Contributory, no family psych history. </li></ul>
  6. 6. Med/Psych History <ul><li>Medications: </li></ul><ul><ul><li>Calcium citrate + vitamin D 2 tabs po BID-CC </li></ul></ul><ul><ul><li>Docusate 100mg po daily </li></ul></ul><ul><ul><li>Levothyroxine 88mcg po daily </li></ul></ul><ul><ul><li>Omeprazole 20mg po daily </li></ul></ul><ul><ul><li>Simvastatin 20mg po qhs </li></ul></ul><ul><ul><li>Risperidone 1mg po qhs </li></ul></ul><ul><ul><li>Enoxaparin 40mg subQ daily </li></ul></ul><ul><ul><li>Insulin 4 units subQ TID-AC + SSI </li></ul></ul>
  7. 7. Exam Findings <ul><li>Vital Signs: T 36.8, BP 120/55, P 98, RR 20 </li></ul><ul><li>PE: </li></ul><ul><ul><li>Gen: WD/WN, Elderly female, NAD </li></ul></ul><ul><ul><li>Skin/Mucosa: No rashes/lesions, Membranes moist </li></ul></ul><ul><ul><li>HEENT: NC/AT, EOMI, PERRLA </li></ul></ul><ul><ul><li>Neck: Supple, No LAD, No thyromegaly, nl JVP </li></ul></ul><ul><ul><li>CV: RRR, S1/S2 nl, no m/r/g </li></ul></ul><ul><ul><li>Resp: CTAB, no wheezes </li></ul></ul><ul><ul><li>Abd: +BS, soft, NT/ND, no HSM, no rebound/guarding </li></ul></ul><ul><ul><li>Ext: No C/C/E </li></ul></ul><ul><ul><li>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. </li></ul></ul>
  8. 8. Mental Status Exam <ul><li>MSE: </li></ul><ul><ul><li>Fragile elderly female, anxious, cooperative yet guarded. Speech regular rate with normal intonation and tone with increased latency. </li></ul></ul><ul><ul><li>Mood was “confused,” and affect was blunted and congruent. </li></ul></ul><ul><ul><li>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.” </li></ul></ul><ul><ul><li>Insight was poor and judgement was impaired. Cognition was consistent with MMSE 27/30 (incorrect day, season and 2/3 on recall). </li></ul></ul>
  9. 9. Laboratory/Radiographic Findings <ul><li>Labs: </li></ul><ul><ul><li>WBC 10.6, Hgb 15.1, Hct 43, Plt 246 </li></ul></ul><ul><ul><li>Na 127, K 3.8, Cl 97, CO2 24, BUN 20, Cr 0.9, Glucose 404, Ca 9.1, Alb 3.4, AG 6 </li></ul></ul><ul><ul><li>TSH 4.01, fT4 1.19 </li></ul></ul><ul><ul><li>ESR 20 </li></ul></ul><ul><ul><li>UA – SG 1.031, 1+ Prot, 3+ Glucose, No ketones, 1+ blood, 6 RBC, normal WBC, no bacteria </li></ul></ul><ul><ul><li>Urine and Blood Toxicology Negative </li></ul></ul><ul><li>Radiographic: </li></ul><ul><ul><li>CXR PA/Lateral: Normal cardiopulmonary findings. </li></ul></ul><ul><ul><li>CT Brain without contrast: No acute intracranial process. </li></ul></ul>
  10. 10. Hospital Course <ul><li>Admitted to General Medicine Service/Geriatric Hospitalist </li></ul><ul><ul><li>Initial workup significant for hyperglycemia without evidence of acidosis as well as hyponatremia. </li></ul></ul><ul><ul><li>Blood glucose corrected with initiation of insulin and patient started on IV normal saline for correction of hyponatremia. </li></ul></ul><ul><ul><li>Psychiatry consult placed for new onset hallucinations and altered mental status. </li></ul></ul>
  11. 11. Differential Diagnosis Diagnostic Tests?? Invasive Procedures??
  12. 12. Psychiatric Consultation <ul><li>Psych ROS patient noted to have symptoms of low mood, insomnia, decreased energy and concentration in association with death of husband 3 months ago. </li></ul><ul><li>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.” </li></ul>
  13. 13. Hospital Course <ul><li>Emergent EEG performed with findings of: </li></ul><ul><ul><li>Background activity of predominantly intermixed theta and delta activity. </li></ul></ul><ul><ul><li>Frequent, rhythmic theta activity in right temporal region, T4, which evolves into spike and wave discharges consistent with seizures lasting 15-20 seconds. </li></ul></ul><ul><ul><li>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. </li></ul></ul>
  14. 14. Diagnosis : Nonconvulsive Status Epilepticus
  15. 15. Hospital Course <ul><li>Neurology Consult </li></ul><ul><ul><li>Patient transferred to Neuro ICU and loaded on IV phenytoin and levetiracetam and underwent continuous video EEG. </li></ul></ul><ul><li>MRI Brain: </li></ul><ul><ul><li>no acute findings and extensive white matter chronic small vessel ischemic disease. </li></ul></ul><ul><li>Lumbar Puncture: </li></ul><ul><ul><li>One nucleated cell, 13 RBC, Protein 52, Glucose 133, Gram Stain neg, VDRL PCR neg, HSV PCR neg. </li></ul></ul>
  16. 16. Case Conclusion <ul><li>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. </li></ul>
  17. 17. Nonconvulsive Status Epilepticus Presenting with Auditory and Visual Hallucinations
  18. 18. Nonconvulsive Status Epilepticus <ul><li>Definition </li></ul><ul><ul><li>Status Epilepticus defined as single seizure or series without recovery of consciousness between seizures lasting at least 20-30 minutes. </li></ul></ul><ul><ul><li>Historically Charcot described a patient in 1888 with ‘automatisme ambulatoire” </li></ul></ul><ul><ul><li>Epilepsy Research Foundation 2005 – “A range of conditions in which electrographic seizure activity is prolonged and results in nonconvulsive clinical symptoms.” </li></ul></ul>The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396; NEJM 1998.338(14)
  19. 19. Nonconvulsive Status Epilepticus Meierkord. Lancet Neurology 2007;6:329-39.
  20. 20. Nonconvulsive Status Epilepticus <ul><li>Categories </li></ul><ul><ul><li>Generalized or Absence NCSE </li></ul></ul><ul><ul><li>Focal or Complex Partial NCSE </li></ul></ul><ul><li>Electrographic Criteria (no pathognomonic EEG pattern) </li></ul><ul><ul><li>Frequent or continuous focal EEG seizures </li></ul></ul><ul><ul><li>Frequent or continuous generalized spike wave discharges without history of seizure </li></ul></ul><ul><ul><li>Periodic lateralized, or periodic bilateral, epileptiform discharges occurring in a patient with a coma after a generalized tonic clonic seizure </li></ul></ul>The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396
  21. 21. EEG in NCSE Beyendburg. Gerontology 2007;53:388-396
  22. 22. 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.
  23. 23. Nonconvulsive Status Epilepticus <ul><li>Common Clinical Presentations </li></ul><ul><ul><li>De novo somnolence, stupor, or coma of primary unknown origin </li></ul></ul><ul><ul><li>De novo neuropsychiatric or behavioral disturbances such as confusional states with agitation, bizarre behavior, mutism, hallucinations, speech disturbances and amnesia </li></ul></ul><ul><ul><li>Limited neurologic deficits such as cortical blindness or aphasia with clinical fluctuations </li></ul></ul><ul><ul><li>AMS with clinical signs of epileptic activity: subtle myoclonus, chewing, blinking, staring, nystagmus, etc. </li></ul></ul><ul><ul><li>Autonomic disturbances (e.g. belching, borborygmi, flatulence) </li></ul></ul><ul><ul><li>Prolonged post-ictal period </li></ul></ul>The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396
  24. 24. Nonconvulsive Status Epilepticus <ul><li>Clinical Situations when NCSE on DDx </li></ul><ul><ul><li>AMS associated with myoclonus or ocular symptoms and/or fluctuating mental status </li></ul></ul><ul><ul><li>AMS of unexplained etiology, especially in patient with a seizure history </li></ul></ul><ul><ul><li>Unexplained AMS in the elderly </li></ul></ul><ul><ul><li>Stroke patients who appear clinically worse than expected </li></ul></ul><ul><ul><li>Prolonged (>2 hours) post-ictal period after a generalized tonic-clonic seizure </li></ul></ul>The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396
  25. 25. Nonconvulsive Status Epilepticus <ul><li>Disorders Mimicking NCSE </li></ul><ul><ul><li>Metabolic encephalopathy </li></ul></ul><ul><ul><li>Migraine aura </li></ul></ul><ul><ul><li>Posttraumatic amnesia </li></ul></ul><ul><ul><li>Prolonged post-ictal confusion </li></ul></ul><ul><ul><li>Psychiatric disorders </li></ul></ul><ul><ul><li>Substance de- or intoxication </li></ul></ul><ul><ul><li>Transient global amnesia </li></ul></ul><ul><ul><li>Transient ischemic attack </li></ul></ul>Meierkord. Lancet Neurology. 2007;6:329-39.
  26. 26. Nonconvulsive Status Epilepticus <ul><li>Diagnosis </li></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>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. </li></ul></ul>J Neurol Neurosurg Psychiatry 2003;74:189-191
  27. 27. Algorithm for Management of SE Lowenstein. NEJM . 1998;338(14).
  28. 28. Nonconvulsive Status Epilepticus <ul><li>Treatment/Management </li></ul><ul><ul><li>Transfer to Neurologic Service or Neuro-ICU (if available) for monitoring (i.e. EEG, airway, etc.) </li></ul></ul><ul><ul><li>Benzodiazepines are the first-line treatment </li></ul></ul><ul><ul><li>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). </li></ul></ul>NEJM . 1998;338(14); The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396
  29. 29. Antiepileptic Drug Therapy for SE Lowenstein. NEJM . 1998;338(14).
  30. 30. References <ul><li>Lowenstein D.H., & Alldredge, B.K. Status Epilpeticus . NEJM . 338 (14); 970-76. </li></ul><ul><li>Riggio, Silvana. Psychiatric Manifestations of Nonconvulsive Status Epilepticus . The Mt Sinai J of Med Vol.73 No.7 Nov 2006 </li></ul><ul><li>Beyenburg, S, Elger, CE, & Reuber, M. Acute Confusion or Altered Mental State: Consider Nonconvulsive Status Epilepticus . Gerontology 2007;53:388-396 </li></ul><ul><li>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 </li></ul><ul><li>Takaya, S., et al. Frontal nonconvulsive status epilepticus manifesting somatic hallucinations . Journal of the Neurological Sciences 234 (2005)25-29 </li></ul><ul><li>Meierkord, H., & Holtkamp, M. Non-convulsive status epilepticus in adults: clinical forms and treatment . Lancet Neurology 2007; 6: 329-39. </li></ul>
  31. 31. Questions?