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

Non-Convulsive Status Non-Convulsive Status Epilepticus: an example of the Epilepticus: an example of the overlap between Neurology and overlap between Neurology and

PsychiatryPsychiatryKristen Shirey, MDKristen Shirey, MD

Duke University Medical CenterDuke University Medical Center

Depts. of Internal Medicine & PsychiatryDepts. of Internal Medicine & Psychiatry

Case PresentationCase Presentation

87 y/o Caucasian female who presented to the 87 y/o Caucasian female who presented to the ED (casualty) with altered mental status and new ED (casualty) with altered mental status and new onset auditory and visual hallucinations from her onset auditory and visual hallucinations from her Assisted Living Facility (ALF).Assisted Living Facility (ALF).

Case PresentationCase Presentation

HPI: HPI: Reported 1 week of progressive confusion, Reported 1 week of progressive confusion,

headache, and new onset hyperglycemia documented headache, and new onset hyperglycemia documented at ALF.at ALF.

Two weeks of “hearing a grinding sound, like a Two weeks of “hearing a grinding sound, like a washing machine running” and reports seeing washing machine running” and reports seeing “crickets and large white bugs crawling on my “crickets and large white bugs crawling on my sheets.”sheets.”

Differential DiagnosisDifferential Diagnosis

Med/Psych HistoryMed/Psych History

PMH:PMH: Chronic Bronchitis with hx atypical mycobactriumChronic Bronchitis with hx atypical mycobactrium Breast Cancer s/p radical mastectomy Breast Cancer s/p radical mastectomy Idiopathic PolyneuropathyIdiopathic Polyneuropathy HypothyroidismHypothyroidism HyperlipidemiaHyperlipidemia

Past Psych Hx: Past Psych Hx: Major Depression, Single Episode, no hospitalizations, suicidality, or Major Depression, Single Episode, no hospitalizations, suicidality, or

psychotic symptoms in the past.psychotic symptoms in the past. Social Hx: Social Hx:

Lives in ALF alone, protestant, widowed 3 months ago, occasional glass Lives in ALF alone, protestant, widowed 3 months ago, occasional glass of wine, no tobacco or illicit drug use.of wine, no tobacco or illicit drug use.

Family Hx: Non-Contributory, no family psych history.Family Hx: Non-Contributory, no family psych history.

Med/Psych HistoryMed/Psych History

Medications:Medications: Calcium citrate + vitamin D 2 tabs po BID-CCCalcium citrate + vitamin D 2 tabs po BID-CC Docusate 100mg po dailyDocusate 100mg po daily Levothyroxine 88mcg po dailyLevothyroxine 88mcg po daily Omeprazole 20mg po dailyOmeprazole 20mg po daily Simvastatin 20mg po qhsSimvastatin 20mg po qhs Risperidone 1mg po qhsRisperidone 1mg po qhs Enoxaparin 40mg subQ dailyEnoxaparin 40mg subQ daily Insulin 4 units subQ TID-AC + SSIInsulin 4 units subQ TID-AC + SSI

Exam FindingsExam Findings

Vital Signs: T 36.8, BP 120/55, P 98, RR 20Vital Signs: T 36.8, BP 120/55, P 98, RR 20 PE:PE:

Gen: WD/WN, Elderly female, NADGen: WD/WN, Elderly female, NAD Skin/Mucosa: No rashes/lesions, Membranes moistSkin/Mucosa: No rashes/lesions, Membranes moist HEENT: NC/AT, EOMI, PERRLAHEENT: NC/AT, EOMI, PERRLA Neck: Supple, No LAD, No thyromegaly, nl JVPNeck: Supple, No LAD, No thyromegaly, nl JVP CV: RRR, S1/S2 nl, no m/r/gCV: RRR, S1/S2 nl, no m/r/g Resp: CTAB, no wheezesResp: CTAB, no wheezes Abd: +BS, soft, NT/ND, no HSM, no rebound/guardingAbd: +BS, soft, NT/ND, no HSM, no rebound/guarding Ext: No C/C/EExt: No C/C/E Neuro: AAOx3, MMSE 27/30, NL bulk and tone, Motor 5/5 bilaterally, Neuro: AAOx3, MMSE 27/30, NL bulk and tone, Motor 5/5 bilaterally,

Sensation intact to light touch and vibration, DTR 1+ and symmetric, Sensation intact to light touch and vibration, DTR 1+ and symmetric, coordination nl FTN and HTS, gait normal no ataxia.coordination nl FTN and HTS, gait normal no ataxia.

Mental Status ExamMental Status Exam

MSE:MSE: Fragile elderly female, anxious, cooperative yet guarded. Fragile elderly female, anxious, cooperative yet guarded.

Speech regular rate with normal intonation and tone with Speech regular rate with normal intonation and tone with increased latency. increased latency.

Mood was “confused,” and affect was blunted and congruent. Mood was “confused,” and affect was blunted and congruent. Her thought process was tangential and she was confused Her thought process was tangential and she was confused

though she denied any paranoia, thought insertion/blocking, though she denied any paranoia, thought insertion/blocking, ideas of reference. Endorsed AH of “a running washing ideas of reference. Endorsed AH of “a running washing machine” and VH “of crickets and white bugs on my machine” and VH “of crickets and white bugs on my blanket.” blanket.”

Insight was poor and judgement was impaired. Cognition was Insight was poor and judgement was impaired. Cognition was consistent with MMSE 27/30 (incorrect day, season and 2/3 consistent with MMSE 27/30 (incorrect day, season and 2/3 on recall).on recall).

Laboratory/Radiographic FindingsLaboratory/Radiographic Findings

Labs:Labs: WBC 10.6, Hgb 15.1, Hct 43, Plt 246WBC 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, Na 127, K 3.8, Cl 97, CO2 24, BUN 20, Cr 0.9, Glucose 404,

Ca 9.1, Alb 3.4, AG 6Ca 9.1, Alb 3.4, AG 6 TSH 4.01, fT4 1.19TSH 4.01, fT4 1.19 ESR 20ESR 20 UA – SG 1.031, 1+ Prot, 3+ Glucose, No ketones, 1+ blood, UA – SG 1.031, 1+ Prot, 3+ Glucose, No ketones, 1+ blood,

6 RBC, normal WBC, no bacteria6 RBC, normal WBC, no bacteria Urine and Blood Toxicology NegativeUrine and Blood Toxicology Negative

Radiographic:Radiographic: CXR PA/Lateral: Normal cardiopulmonary findings.CXR PA/Lateral: Normal cardiopulmonary findings. CT Brain without contrast: No acute intracranial process.CT Brain without contrast: No acute intracranial process.

Hospital CourseHospital Course

Admitted to General Medicine Service/Geriatric Admitted to General Medicine Service/Geriatric HospitalistHospitalist Initial workup significant for hyperglycemia without Initial workup significant for hyperglycemia without

evidence of acidosis as well as hyponatremia.evidence of acidosis as well as hyponatremia. Blood glucose corrected with initiation of insulin and Blood glucose corrected with initiation of insulin and

patient started on IV normal saline for correction of patient started on IV normal saline for correction of hyponatremia.hyponatremia.

Psychiatry consult placed for new onset Psychiatry consult placed for new onset hallucinations and altered mental status. hallucinations and altered mental status.

Differential DiagnosisDifferential Diagnosis

Diagnostic Tests??Diagnostic Tests??

Invasive Procedures??Invasive Procedures??

Psychiatric ConsultationPsychiatric Consultation

Psych ROS patient noted to have symptoms of Psych ROS patient noted to have symptoms of low mood, insomnia, decreased energy and low mood, insomnia, decreased energy and concentration in association with death of concentration in association with death of husband 3 months ago.husband 3 months ago.

During assessment patient had 2 separate staring During assessment patient had 2 separate staring spells where she was unresponsive, noted to spells where she was unresponsive, noted to have right facial myoclonic jerks, and noted have right facial myoclonic jerks, and noted hearing a “grinding sound like a washing hearing a “grinding sound like a washing machine.”machine.”


Emergent EEG performed with findings of:Emergent EEG performed with findings of: Background activity of predominantly intermixed theta and Background activity of predominantly intermixed theta and

delta activity. delta activity. Frequent, rhythmic theta activity in right temporal region, T4, Frequent, rhythmic theta activity in right temporal region, T4,

which evolves into spike and wave discharges consistent with which evolves into spike and wave discharges consistent with seizures lasting 15-20 seconds. seizures lasting 15-20 seconds.

Rarely seizures spread bilaterally and during one seizure Rarely seizures spread bilaterally and during one seizure with spread from right temporal to bitemporal with spread from right temporal to bitemporal distribution, the patient described hearing a washing distribution, the patient described hearing a washing machine, and was intermittently unresponsive.machine, and was intermittently unresponsive.

DiagnosisDiagnosis: :

Nonconvulsive Status EpilepticusNonconvulsive Status Epilepticus


Neurology ConsultNeurology Consult Patient transferred to Neuro ICU and loaded on IV Patient transferred to Neuro ICU and loaded on IV

phenytoin and levetiracetam and underwent continuous video phenytoin and levetiracetam and underwent continuous video EEG.EEG.

MRI Brain:MRI Brain: no acute findings and extensive white matter chronic small no acute findings and extensive white matter chronic small

vessel ischemic disease.vessel ischemic disease.

Lumbar Puncture: Lumbar Puncture: One nucleated cell, 13 RBC, Protein 52, Glucose 133, Gram One nucleated cell, 13 RBC, Protein 52, Glucose 133, Gram

Stain neg, VDRL PCR neg, HSV PCR neg.Stain neg, VDRL PCR neg, HSV PCR neg.

Case ConclusionCase Conclusion

87 year old Caucasian female with 2 week 87 year old Caucasian female with 2 week history of progressive altered mental status and history of progressive altered mental status and new onset auditory and visual hallucinations due new onset auditory and visual hallucinations due to to right temporal nonconvulsive status right temporal nonconvulsive status epilepticusepilepticus assumed to be secondary to assumed to be secondary to hyperglycemia and hyponatremia after negative hyperglycemia and hyponatremia after negative workup for intracranial abnormalities or workup for intracranial abnormalities or infection, in an elderly patient with no prior infection, in an elderly patient with no prior history of epilepsy.history of epilepsy.

Nonconvulsive Status Nonconvulsive Status Epilepticus Presenting Epilepticus Presenting

with Auditory and Visual with Auditory and Visual HallucinationsHallucinations


DefinitionDefinition Status Epilepticus defined as single seizure or series Status Epilepticus defined as single seizure or series

without recovery of consciousness between seizures without recovery of consciousness between seizures lasting at least 20-30 minutes.lasting at least 20-30 minutes.

Historically Charcot described a patient in 1888 with Historically Charcot described a patient in 1888 with ‘automatisme ambulatoire”‘automatisme ambulatoire”

Epilepsy Research Foundation 2005 – “A range of Epilepsy Research Foundation 2005 – “A range of conditions in which electrographic seizure activity is conditions in which electrographic seizure activity is prolonged and results in nonconvulsive clinical prolonged and results in nonconvulsive clinical symptoms.”symptoms.”

The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396; NEJM 1998.338(14)


Meierkord. Lancet Neurology 2007;6:329-39.


CategoriesCategories Generalized or Absence NCSEGeneralized or Absence NCSE Focal or Complex Partial NCSEFocal or Complex Partial NCSE

Electrographic Criteria (no pathognomonic EEG Electrographic Criteria (no pathognomonic EEG pattern)pattern) Frequent or continuous focal EEG seizuresFrequent or continuous focal EEG seizures Frequent or continuous generalized spike wave discharges Frequent or continuous generalized spike wave discharges

without history of seizurewithout history of seizure Periodic lateralized, or periodic bilateral, epileptiform Periodic lateralized, or periodic bilateral, epileptiform

discharges occurring in a patient with a coma after a discharges occurring in a patient with a coma after a generalized tonic clonic seizuregeneralized 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 EEG in in

NCSENCSE

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.


Common Clinical Presentations Common Clinical Presentations De novo somnolence, stupor, or coma of primary unknown De novo somnolence, stupor, or coma of primary unknown

originorigin De novo neuropsychiatric or behavioral disturbances such as De novo neuropsychiatric or behavioral disturbances such as

confusional states with agitation, bizarre behavior, mutism, confusional states with agitation, bizarre behavior, mutism, hallucinations, speech disturbances and amnesiahallucinations, speech disturbances and amnesia

Limited neurologic deficits such as cortical blindness or Limited neurologic deficits such as cortical blindness or aphasia with clinical fluctuationsaphasia with clinical fluctuations

AMS with clinical signs of epileptic activity: subtle AMS with clinical signs of epileptic activity: subtle myoclonus, chewing, blinking, staring, nystagmus, etc.myoclonus, chewing, blinking, staring, nystagmus, etc.

Autonomic disturbances (e.g. belching, borborygmi, Autonomic disturbances (e.g. belching, borborygmi, flatulence)flatulence)

Prolonged post-ictal periodProlonged post-ictal period



Clinical Situations when NCSE on DDxClinical Situations when NCSE on DDx AMS associated with myoclonus or ocular symptoms AMS associated with myoclonus or ocular symptoms

and/or fluctuating mental statusand/or fluctuating mental status AMS of unexplained etiology, especially in patient AMS of unexplained etiology, especially in patient

with a seizure historywith a seizure history Unexplained AMS in the elderlyUnexplained AMS in the elderly Stroke patients who appear clinically worse than Stroke patients who appear clinically worse than

expectedexpected Prolonged (>2 hours) post-ictal period after a Prolonged (>2 hours) post-ictal period after a

generalized tonic-clonic seizuregeneralized tonic-clonic seizure



Disorders Mimicking NCSEDisorders Mimicking NCSE Metabolic encephalopathyMetabolic encephalopathy Migraine auraMigraine aura Posttraumatic amnesiaPosttraumatic amnesia Prolonged post-ictal confusionProlonged post-ictal confusion Psychiatric disordersPsychiatric disorders Substance de- or intoxicationSubstance de- or intoxication Transient global amnesiaTransient global amnesia Transient ischemic attackTransient ischemic attack

Meierkord. Lancet Neurology. 2007;6:329-39.


DiagnosisDiagnosis No clear criteria for deciding when to request an EEG, No clear criteria for deciding when to request an EEG,

however when NCSE is suspected on clinical grounds and however when NCSE is suspected on clinical grounds and EEG is indicated to confirm diagnosis.EEG is indicated to confirm diagnosis.

NCSE is a neurologic emergency and needs to be treated NCSE is a neurologic emergency and needs to be treated promptly to avoid neuronal damage, thus expedited promptly to avoid neuronal damage, thus expedited neurologic consultation and EEG are require to confirm the neurologic consultation and EEG are require to confirm the diagnosis.diagnosis.

According to an observational study in 2003 by Husain et al. According to an observational study in 2003 by Husain et al. suggested that history of remote seizure and ocular suggested that history of remote seizure and ocular movements were observed significantly more often in NCSE movements were observed significantly more often in NCSE and may help selecting patients for EEG evaluation.and may help selecting patients for EEG evaluation.

J Neurol Neurosurg Psychiatry 2003;74:189-191

Algorithm for Management of SEAlgorithm for Management of SE

Lowenstein. NEJM. 1998;338(14).


Treatment/ManagementTreatment/Management Transfer to Neurologic Service or Neuro-ICU (if Transfer to Neurologic Service or Neuro-ICU (if

available) for monitoring (i.e. EEG, airway, etc.)available) for monitoring (i.e. EEG, airway, etc.) Benzodiazepines are the first-line treatmentBenzodiazepines are the first-line treatment After BZD, further AED treatment may be required After BZD, further AED treatment may be required

for control of seizure activity and patient may for control of seizure activity and patient may require IV loading of AED (i.e. phenytoin, require IV loading of AED (i.e. phenytoin, fosphenytoin, valproate, and levetiracetam).fosphenytoin, valproate, and levetiracetam).

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 SEAntiepileptic Drug Therapy for SE

Lowenstein. NEJM. 1998;338(14).

ReferencesReferences

Lowenstein D.H., & Alldredge, B.K. Status Epilpeticus. NEJM. 338 (14); 970-76.

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.

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