NonConvulsive Status Epilepticus: an example of the overlap between Neurology and Psychiatry - PowerPoint PPT Presentation

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NonConvulsive Status Epilepticus: an example of the overlap between Neurology and Psychiatry

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Title: NonConvulsive Status Epilepticus: an example of the overlap between Neurology and Psychiatry


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
Case Presentation
  • 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).

3
Case Presentation
  • 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.

4
Differential Diagnosis
5
Med/Psych History
  • PMH
  • Chronic Bronchitis with hx atypical mycobactrium
  • Breast Cancer s/p radical mastectomy
  • Idiopathic Polyneuropathy
  • Hypothyroidism
  • Hyperlipidemia
  • Past Psych Hx
  • Major Depression, Single Episode, no
    hospitalizations, suicidality, or psychotic
    symptoms in the past.
  • Social Hx
  • 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.

6
Med/Psych History
  • 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

7
Exam Findings
  • Vital Signs T 36.8, BP 120/55, P 98, RR 20
  • PE
  • 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.

8
Mental Status Exam
  • MSE
  • 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).

9
Laboratory/Radiographic Findings
  • Labs
  • 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
  • CXR PA/Lateral Normal cardiopulmonary findings.
  • CT Brain without contrast No acute intracranial
    process.

10
Hospital Course
  • 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.

11
Differential Diagnosis
  • Diagnostic Tests??
  • Invasive Procedures??

12
Psychiatric Consultation
  • 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.

13
Hospital Course
  • Emergent EEG performed with findings of
  • 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.

14
Diagnosis
  • Nonconvulsive Status Epilepticus

15
Hospital Course
  • Neurology Consult
  • Patient transferred to Neuro ICU and loaded on IV
    phenytoin and levetiracetam and underwent
    continuous video EEG.
  • MRI Brain
  • no acute findings and extensive white matter
    chronic small vessel ischemic disease.
  • Lumbar Puncture
  • One nucleated cell, 13 RBC, Protein 52, Glucose
    133, Gram Stain neg, VDRL PCR neg, HSV PCR neg.

16
Case Conclusion
  • 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.

17
Nonconvulsive Status Epilepticus Presenting with
Auditory and Visual Hallucinations
18
Nonconvulsive Status Epilepticus
  • 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.

The Mt Sinai J of Med Vol.73 No.7 Nov 2006
Gerontology 200753388-396 NEJM 1998.338(14)
19
Nonconvulsive Status Epilepticus
Meierkord. Lancet Neurology 20076329-39.
20
Nonconvulsive Status Epilepticus
  • Categories
  • Generalized or Absence NCSE
  • Focal or Complex Partial NCSE
  • 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 200753388-396
21
EEG in NCSE
Beyendburg. Gerontology 200753388-396
22
EEG in NCSE
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.
Meierkord. Lancet Neurology 20076329-39.
23
Nonconvulsive Status Epilepticus
  • Common Clinical Presentations
  • 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 200753388-396
24
Nonconvulsive Status Epilepticus
  • 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 (gt2 hours) post-ictal period after a
    generalized tonic-clonic seizure

The Mt Sinai J of Med Vol.73 No.7 Nov 2006
Gerontology 200753388-396
25
Nonconvulsive Status Epilepticus
  • 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

Meierkord. Lancet Neurology. 20076329-39.
26
Nonconvulsive Status Epilepticus
  • Diagnosis
  • 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 200374189-191
27
Algorithm for Management of SE
Lowenstein. NEJM. 1998338(14).
28
Nonconvulsive Status Epilepticus
  • 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).

NEJM. 1998338(14) The Mt Sinai J of Med Vol.73
No.7 Nov 2006 Gerontology 200753388-396
29
Antiepileptic Drug Therapy for SE
Lowenstein. NEJM. 1998338(14).
30
References
  • 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
    200753388-396
  • Husain, AM, Horn, GJ, Jacobson, MP.
    Non-convulsive status epilepticus usefullness of
    clinical features in selecting patients for
    urgent EEG. J Neurol Neurosurg Psychiatry
    200374189-191
  • 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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