Title: NonConvulsive Status Epilepticus: an example of the overlap between Neurology and Psychiatry
1Non-Convulsive Status Epilepticus an example of
the overlap between Neurology and Psychiatry
- Kristen Shirey, MD
- Duke University Medical Center
- Depts. of Internal Medicine Psychiatry
2Case 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).
3Case 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.
4Differential Diagnosis
5Med/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.
6Med/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
7Exam 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.
8Mental 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).
9Laboratory/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.
10Hospital 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.
11Differential Diagnosis
- Diagnostic Tests??
- Invasive Procedures??
12Psychiatric 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.
13Hospital 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.
14Diagnosis
- Nonconvulsive Status Epilepticus
15Hospital 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.
16Case 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.
17Nonconvulsive Status Epilepticus Presenting with
Auditory and Visual Hallucinations
18Nonconvulsive 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)
19Nonconvulsive Status Epilepticus
Meierkord. Lancet Neurology 20076329-39.
20Nonconvulsive 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
21EEG in NCSE
Beyendburg. Gerontology 200753388-396
22EEG 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.
23Nonconvulsive 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
24Nonconvulsive 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
25Nonconvulsive 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.
26Nonconvulsive 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
27Algorithm for Management of SE
Lowenstein. NEJM. 1998338(14).
28Nonconvulsive 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
29Antiepileptic Drug Therapy for SE
Lowenstein. NEJM. 1998338(14).
30References
- 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.
31Questions?
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