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).
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.
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
Electrographic Criteria (no pathognomonic EEG pattern)
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.
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).