Simple Focal Non-convulsive Status Epilepticus (NSCE) Masquerading as Acute Cerebrovascular Accident: A Case Study

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Journal of General Internal Medicine




supp 2

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LEARNING OBJECTIVE #1: - Recognize non-convulsive status epilepticus as a possible cause of unexplained focal neurological deficits. LEARNING OBJECTIVE #2: - EEG patterns can be uncertain in the diagnosis of NCSE. A trial of antiepileptics can help in making the diagnosis. CASE: Our patient is a 64-year-old female with no past medical history of seizures. She was brought to the hospital emergency room for an unwitnessed episode of loss of consciousness. On initial physical examination, she had a completely unremarkable neurological exam. She was admitted to the medicine floor for workup of her syncope. On hospital day two, the patient was found to have newly developed aphasia and right-sided body weakness in S614 ABSTRACTS JGIM addition to mild confusion. The patient was last witnessed without her symptoms more than 4 hours before, thus, no thrombolytic therapy was considered. An initial CT of the brain without contrast showed no acute pathological changes. This was followed by an MRI of the brain, which showed no evidence of acute cerebrovascular accident (CVA). Alternative diagnoses for the patient symptoms were sought and an urgent electroencephalogram (EEG) was performed. Initial EEG was characterized by multiple episodes of generalized 3-hertz spike and wave activity consistent with subclinical seizures. Immediate antiepileptic treatment was initiated with intravenous administration of Lorazepam which resulted in instant resolution of her symptoms. A repeat EEG showed no evidence of seizure activity. The patient was started on Phenytoin for long-term antiepileptic therapy. IMPACT: When the diagnosis of NCSE is suspected, an intravenous antiseizure drug trial is required, if the significance of uncertain EEG patterns is unclear. DISCUSSION: Status epilepticus is defined by the International League Against Epilepsy (ILAE) as a condition of abnormally prolonged seizures resulting either from the failure of mechanisms responsible for seizure termination or from the initiation of mechanisms. The temporal threshold that defines an abnormally prolonged seizure is based on the type of seizure. This duration is five minutes in convulsive status epilepticus. For status epilepticus without prominent motor symptoms or NCSE, the threshold is ten minutes. The clinical setting and etiology, EEG findings and the clinical status of the patient are several variables that may dictate the diagnosis and treatment of NCSE. Furthermore, the extent to which electrographic activity contributes to clinical impairment or ongoing neuronal injury is not always clear. Our patient was initially diagnosed with an acute cerebrovascular accident (CVA) due to clinical manifestation. However, an alternative diagnosis was sought after the MRI of the brain showed no evidence of acute CVA. Since clinical signs and symptoms are nonspecific in the diagnosis of NCSE, an EEG is required. Additionally, an intravenous anti-seizure drug trial is required in some cases if the significance of uncertain EEG patterns is uncleae.


Medicine and Health Sciences



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