Nonconvulsive Status Epilepticus in Adults: Thirty-Two Consecutive Patients from a General Hospital Population

We studied all adult patients who between 1984 and 1989 were initially diagnosed at our hospital as having nonconvulsive status epilepticus. Thirty-two patients fulfilled the criteria, which included ictal EEG recordings. The annual incidence was 1.5 in 100,000 inhabitants. The median age at onset of status was 51 years. Ten patients had status as their first epileptic manifestation, but most patients had a previous history of epilepsy. Median duration of epilepsy at onset of status was 4 years. Fourteen patients had focal ictal seizure activity on EEG and thus met the criteria for complex partial status. Eighteen patients had generalized seizure activity on EEG, but only 6 of these had a history of absence epilepsy or juvenile myoclonic epilepsy. None had Lennox-Gastaut syndrome. The clinical features of status in the remaining 12 patients were in some respects similar to those of the patients with complex partial status. We hypothesize that the EEG seizure activity in these patients may have been generalized from an initial focus.     

Topiramate and status epilepticus: report of three cases

OBJECTIVE: The goal of this study was to report the effectiveness of topiramate in treating status epilepticus. METHODS: Three patients with status epilepticus were treated with topiramate 500 mg twice daily for 2-5 days, with the dose gradually tapered thereafter to 200 mg twice daily. The patients' clinical status and EEG recordings were followed. RESULTS: Patient 1 was admitted for subacute encephalopathy that was complicated by secondarily generalized status epilepticus resistant to lorazepam, fosphenytoin, and pentobarbital coma. Topiramate was added and, 2 days later, pentobarbital was tapered with no recurrence of ictal discharges as the patient improved clinically. Patient 2 had end-stage liver disease and was hospitalized for peritonitis, and his course was complicated by partial status epilepticus. Topiramate was started and, 2 days later, his mental status improved as repeat EEG showed no further ictal discharges although periodic epileptiform discharges were seen in the left centroparietal area. The patient later died from complications of variceal bleeding. Patient 3 suffered cardiopulmonary arrest, and developed postanoxic seizures, which did not respond to lorazepam, fosphenytoin, valproate, and propofol coma as continuous EEG recordings showed recurrent generalized ictal discharges. Two days after topiramate was started, propofol was tapered and discontinued and EEG showed generalized slow wave activity and no ictal discharges. The patient was discharged to another facility 12 days later. CONCLUSIONS: Topiramate was effective in treating two patients with refractory generalized status epilepticus and one with complex partial status epilepticus. It should therefore be considered as an option in these situations, especially when other medications cannot be used.     

Two Cases of Nonconvulsive Status Epilepticus in Association with Tiagabine Therapy

We report two patients with intractable partial seizures who developed generalized nonconvulsive status epilepticus (NCSE) after receiving tiagabine (TGB). Neither had a history of absence seizures or generalized epileptic discharges on prior EEG monitoring. Clinicians need to be aware of a possible association between TGB and NCSE.     

Absence status associated with focal activity and polydipsia-induced hyponatremia

We report a case of de novo absence status associated with focal discharge and polydipsia-induced hyponatremia. Nonconvulsive status epilepticus (NCSE) is classified as absence status or complex partial status. Absence status is characterized by bilateral synchronized spike and wave complex bursts and a variety of conscious disturbances. Possible precipitating factors for NCSE include benzodiazepine withdrawal, excessive use of psychotropic drugs, and electrolyte imbalances. Hyponatremia is a rare precipitating factor. In this case, the patient was 59 years old and had suffered from primary insomnia but had no history of epilepsy. NCSE improved by means of saline infusion. However after recovery from NCSE EEG revealed some spikes in the left frontal area. Absence seizures can also show generalized spike and slow waves, and cases of focal lesion-associated absence seizures have been reported. Although absence seizures and absence status are two distinct conditions, they should not be considered together. We assumed that hyponatremia induced by polydipsia precipitated epileptogenicity in the left frontal area, and then focal activity secondarily generalized and resulted in absence status.     

Persistent Nonconvulsive Status Epilepticus After the Control of Convulsive Status Epilepticus

Summary: Purpose: Convulsive status epilepticus (CSE) is a major medical and neurological emergency that is associated with significant morbidity and mortality. Despite this high morbidity and mortality, most acute care facilities in the United States cannot evaluate patients with EEG monitoring during or immediately after SE. The present study was initiated to determine whether control of CSE by standard treatment protocols was sufficient to terminate electrographic seizures. Methods: One hundred sixty-four prospective patients were evaluated at the Medical College of Virginia/VCU Status Epilepticus Program. Continuous EEG monitoring was performed for a minimum of 24 h after clinical control of CSE. SE and seizure types were defined as described previously. A standardized data form entry system was compiled for each patient and used to evaluate the data collected. Results: After CSE was controlled, continuous EEG monitoring demonstrated that 52% of the patients had no after-SE ictal discharges (ASIDS) and manifested EEG patterns of generalized slowing, attenuation, periodic lateralizing epileptiform discharges (PLEDS), focal slowing, and/or burst suppression. The remaining 48% demonstrated persistent electrographic seizures. More than 14% of the patients manifested nonconvulsive SE (NCSE) predominantly of the complex partial NCSE seizure (CPS) type (2). These patients were comatose and showed no overt clinical signs of convulsive activity. Clinical detection of NCSE in these patients would not have been possible with routine neurological evaluations without use of EEG monitoring. The clinical presentation, mortality, morbidity, and demographic information on this population are reported. Conclusions: Our results demonstrate that EEG monitoring after treatment of CSE is essential to recognition of persistent electrographic seizures and NCSE unresponsive to routine therapeutic management of CSE. These findings also suggest that EEG monitoring immediately after control of CSE is an important diagnostic test to guide treatment plans and to evaluate prognosis in the management of SE.     

Complex Partial Status Epilepticus of Frontal Lobe Origin

Abstract: Nonconvulsive status epilepticus may be subdivided into generalized (absence) status and complex partial status. The latter is generally considered as a rare condition, whereas the former is fairly common to have been reported in many articles. We have reported here a case of complex partial status epilepticus in which the seizure origin was thought to be located in the frontal but not temporal lobe. After looking over the relevant literatures we commented that the incidence of complex partial status of extratemporal origin does not seem to be as rare as it has been believed to be. The main reason for this is the frequency with which it is misdiagnosed. The diagnostic errors are due to a failure to recognize the epileptic cause of the attacks or to appreciate localizing the clinical seizure characteristics and misleading scalp EEG findings. By making a closer observation of clinical manifestations, the likelihood that a correct diagnosis can be made will be increased.     

"Obtundation Status (Dravet)" Caused by Complex Partial Status Epilepticus in a Patient with Severe Myoclonic Epilepsy in Infancy

Summary: Purpose : We report a 1-year 7-month-old boy with severe myoclonic epilepsy in infancy (SME) who exhibited complex partial status epilepticus (CPSE), which was confirmed by ictal video-EEG analysis. This boy first had a hemi-convulsion in a hot bath at age 3 months. Thereafter, he exhibited both partial and generalized seizures that were extremely intractable. At age 9 months, he had a prolonged episode of impaired consciousness that fit the "obtundation status in SME" defined by Dravet et al.
Methods and Results : Ictal EEG revealed persisting irregular spike-and-wave complexes over the left hemisphere, predominantly in the occipitotemporal area, and confirmed CPSE. The EEG abnormalities with decreased level of the consciousness continued -6 h after onset of the symptoms even with AED administration.
Conclusions : Because SME features both generalized and focal seizures, both types of nonconvulsive status may be seen in SME. Although Dravet et al. already reported long-lasting atypical absences in patients with SME as "obtundation status," we demonstrated CPSE in an infant with SME who exhibited a prolonged stuporous state.     

Can absence status epilepticus be of frontal lobe origin?

Five women with an unclassifiable nonconvulsive status epilepticus (NCSE) characterized by young age at onset, prolonged confusions, focal motor seizures, and both generalized spike-and-wave discharges and focal epileptic discharges on the EEG were studied with video-EEG monitoring. Electrographically, the NCSE originated from the left frontal lobe in 4 patients, and the left hemisphere with multifocal seizure discharges in 1 patient. Focal motor seizures seemed to originate from the left hemisphere in all 5 patients, particularly from its anterior part in 3 of them. Results show that the NCSE is complex partial status epilepticus of frontal lobe origin electroclinically mimicking absence status epilepticus once it reaches a full-blown phase.     

Epileptic prodromes: Are they nonconvulsive status epilepticus?

PurposeThe aim of this study was to assess how frequently prodromes occur in an adult patient group from a tertiary referral epilepsy centre and to investigate the EEG changes during the prodromes.Methods578 consecutive patients were interviewed on subjective phenomena, experiences heralding the seizures, for at least 30 min before the start of the seizure. EEGs were recorded during the prodromes.ResultsTen out of 490 included patients had prodromes (2%). We were able to record EEG during prodromes in 6 patients. Three patients had EEG changes corresponding to nonconvulsive status epilepticus. Three patients had unrevealing EEG recordings during prodromes.ConclusionOur results suggest that at least in a part of the patients, the prodromes are actually ictal phenomena, and should be treated as nonconvulsive status epilepticus.     

Non-convulsive status epilepticus associated with tiagabine therapy in children

A case of a 7-year-old male with epilepsy who developed non-convulsive status epilepticus (NCSE) with electroclinical features consistent with those of atypical absence seizures after adjunctive antiepileptic therapy of tiagabine (TGB) is reported. The patient had frequent generalised and rare partial seizures with generalised epileptic discharges on prior electroencephalogram (EEG) recordings. NCSE was developed when rapid dosage increase and high dose of TGB was given. This case emphasises the need for close monitoring of children with epilepsy taking TGB for exacerbation of seizures or development of NCSE.     

Periodic febrile confusion as a presentation of complex partial status epilepticus

A 75-year-old woman was evaluated for recurrent episodes of fever she experienced periodically every 4-5 weeks over the last 12 months, lasting 2-3 days each. The fever was associated with continuous complex partial seizures, paralleled the seizure activity and returned to normal after the seizures had ceased. The ictal EEG recordings showed rhythmic bitemporal 3-4 Hz activity; the interictal recordings showed a spike and wave discharge over the right fronto-temporal region. Carbamazepine effectively controlled both the seizures and the fever; the latter was presumed to be an inherent manifestation of the seizure activity.     

Unilateral Limbic Epileptic Status Activity: Stereo EEG, Behavioral, and Cognitive Data

We report data from four patients with unilateral epileptiform status activity within different structures of the temporal lobe, recorded during stereoelectroencephalographic presurgical evaluation. The ictal clinical symptoms accompanying neocortical and mesiobasal limbic discharges (two patients with complex partial status epilepticus) consisted of various psychosensory and vegetative signs, which can be understood on the basis of the spatiotemporal analysis of the discharges. The other two patients with circumscribed long-lasting mesiobasal limbic epileptiform activity represent unilateral pure limbic status epilepticus and were characterized by a marked behavioral syndrome (with stickiness, aggressivity, etc.) and a monomorphic gustatory aura continua, respectively. The latter patient, with left hippocampal discharges of nearly continuous epileptiform character, was also assessed with tachistoscopic tasks. Performance revealed cognitive impairment only in the epileptically discharging hemisphere and in dependence on the quality of the EEG pattern. After unilateral selective amygdalohippocampectomy, the two patients with limbic status epilepticus were seizure free and had markedly improved behavior and cognitive functions. Thus, patients with nonconvulsive status epilepticus represent an ideal model, although rare, to correlate behavior alterations and brain dysfunction.     

癫痫持续状态及其治疗──附168例报告

本文报告168例癫痫持续状态．年龄13～72岁，平均47．64±17．83岁。男性119例，女性49例．其中强直一阵挛持续状态117例，阵挛－强宜－阵挛持续状态39例，强直持续状态10例及复杂性部份型癫痫持续状态－精神运动癫痫持续状态2例。本组治疗分为苯巴比妥钠肌注组132例，安定静脉注射组66例．两组在控制癫痫持续状态时为27．48±11．36分钟对31．93±10．47分钟，t＝2．21，P＜0．05。本病诊断正确，处理及时，预后良好。     

Status epilepticus with confusional symptomatology]

Non-convulsive confusional status epilepticus (NCSE) is classically separated into two forms on the basis of the ictal EEG, i.e., absence status (AS) and complex partial status epilepticus (CPSE). The diagnosis is difficult on the basis of clinical semiology alone, and requires emergency EEG investigation. Absence status, or 'petit mal' status, is a polymorphic condition that can complicate many epileptic syndromes, and is the most frequently encountered form of NCSE. It is characterized by confusion of varying intensity, associated in 50% of cases with bilateral periocular myoclonias. The EEG shows ictal generalized paroximal activity; normalization is obtained after benzodiazepine injection. In AS, there is a significant nosographic heterogeneity. Four groups can be distinguished: i) typical AS occurs in the context of a generalized idiopathic epilepsy; ii) atypical AS occurs in patients with symptomatic or cryptogenic generalized epilepsies; iii) 'de novo' AS (of late onset) is characterized by toxic or metabolic precipitating factors in middle-aged subjects with no previous history of epilepsy; iv) AS with focal characteristics occurs in subjects with a pre-existing or newly diagnosed partial epilepsy, mostly of extra-temporal origin. The majority of cases are in fact transitional forms between these four groups. CPSE is characterized by continuous or rapidly recurring complex partial seizures which may involve temporal and/or extratemporal regions. Cyclic disturbance of consciousness is characteristic of CPSE of temporal lobe origin, which requires vigorous treatment to prevent recurrence or cognitive sequelae. CPSE of frontal lobe origin is a diagnostic challenge: it is rare, the symptoms are unusual, and the patients should be documented extensively. A focal frontal lesion is revealed in one-third of cases.     

Status Epilepticus Characterized by Repetitive Asymmetrical Atonia: Two Cases Accompanied by Partial Seizures

Two cases of discontinuous status epilepticus (SE) characterized by repetitive asymmetrical atonic episodes associated with diffuse but asymmetrical spike waves are reported. Both patients also had partial seizures and interictal rolandic discharges. Dynamic EEG topography was performed to investigate the location or propagation of each ictal discharge overlying the scalp during status and showed immediate bilateral spread of discharges originating from a primary epileptogenic focus from a rolandic area.     

Frontal nonconvulsive status epilepticus associated with high-dose tiagabine therapy in a child with familial bilateral perisylvian polymicrogyria

PURPOSE: Antiepileptic drugs are known to exacerbate absence and myoclonic seizures, especially in patients with idiopathic generalized epilepsies. Exacerbation of nonconvulsive generalized seizures in patients with partial epilepsy is less common. Recently, however, a number of cases of putative generalized nonconvulsive status epilepticus (NCSE) or NCSE without further specification have been reported in patients with chronic partial epilepsy treated with the gamma-aminobutyric acid reuptake inhibitor tiagabine. Although complex partial status epilepticus during tiagabine therapy has also been reported, possible precipitation of NCSE specifically associated with frontal lobe discharges does not appear to have been recognized. In this communication, we describe the case of a boy with familial bilateral perisylvian polymicrogyria who developed frontal NCSE after being stabilized on high-dose tiagabine METHODS: A 12-year-old boy with familial bilateral perisylvian polymicrogyria, mental retardation, and refractory partial seizures was administered tiagabine in addition to sodium valproate. The tiagabine dosage was increased gradually up to 10 mg t.i.d. (1 mg/kg per day), resulting in complete seizure control. RESULTS: After 1 week on maintenance treatment, seizures were completely controlled, but the child developed hypoactivity, decreased reactivity, and affective detachment. An EEG recording revealed subcontinuous sharp-wave discharges with irregular runs of atypical spike-wave complexes over the anterior regions of both hemispheres, consistent with a diagnosis of frontal NCSE. A reduction in tiagabine dosage to 15 mg/day led to complete regression of the behavioral and affective changes and to disappearance of the subcontinuous EEG discharges. CONCLUSIONS: Although tiagabine-induced NCSE has been described previously, particularly in patients with preexisting spike-wave abnormalities, this is the first report that identifies its potential role in the precipitation of frontal NCSE.     

De Novo Aphasic Status Epilepticus

: The literature contains only a handful of reports of patients with aphasia as the principal or only obvious manifestation of partial status epilepticus. Even fewer patients of this type have been well documented both clinically and by ictal EEG monitoring. We studied an otherwise healthy woman with abrupt onset of aphasia initially thought to be the result of an infarct of the left temporoparietal area. We were able to document partial status epilepticus involving the left temporoparieta1 area with EEG/video monitoring and showed rapid reversal of the aphasic disorder with antiepileptic drug (AED) treatment. The case is presented with a review of previous reports to underscore the importance of considering this diagnosis in patients with abrupt onset of aphasia.     

Focal Status Epilepticus: Clinical Features and Significance of Different EEG Patterns

PURPOSE: Focal status epilepticus is typically diagnosed by the observation of continuous jerking motor activity, but many other manifestations have been described. EEG evidence of focal status may take several forms, and their interpretation is controversial. We detailed the clinical spectrum of focal status in patients diagnosed by both clinical deficit and EEG criteria and contrasted clinical manifestations in patients with different EEG patterns. METHODS: Patients were diagnosed with a neurologic deficit and discrete recurrent focal electrographic seizures or rapid, continuous focal epileptiform discharges on EEG. Clinical findings were determined by chart review. RESULTS: Of 41 patients with focal status, acute vascular disease was the cause in 21; 10 of 41 had exacerbations of prior epilepsy. A variety of clinical seizure types occurred, both before and after the EEG diagnosis, but the diagnosis was not expected in 28 patients before the EEG. Three had no obvious clinical seizures. Focal motor seizures and an abnormal mental status were the most common manifestations at the time of the EEG. With antiepileptic drugs, almost all had control of clinical seizures, and most improved in mental status. Patients with rapid continuous focal epileptiform discharges were nearly identical in presentation, likelihood of diagnosis, subsequent seizures, response to medication, and outcome to those with discrete seizures on EEG. CONCLUSIONS: Focal status epilepticus may be seen with a wide variety of clinical seizure types or without obvious clinical seizures. The diagnosis is often delayed or missed and should be considered after strokes or clinical seizures when patients do not stabilize or improve as expected. The diagnosis should be made equally whether patients have discrete electrographic seizures or continuous rapid focal epileptiform discharges on the EEG, and the same response to medications and outcome should be anticipated for the two groups.     

Beta activity in status epilepticus

Focal beta activity on scalp EEG is a rare seizure pattern that has most extensively been studied in patients undergoing evaluation for epilepsy surgery. However, ictal beta activity is uncommon beyond this population and has not been reported in human status epilepticus. We observed ictal focal beta activity as the predominant seizure pattern in a patient with refractory status epilepticus. Continuous left temporal beta activity clinically correlated with complex partial semiology on video-EEG.     

Three Epileptic Patients Suffering from Periods of Frequent Complex Partial Seizures and Diagnostic Criteria for Epileptic Status

Abstract: Presented here are three epileptic patients suffering from periods of frequent complex partial seizures. The importance of the following two points for the diagnosis of epileptic status of complex partial seizure is stressed. The first is the importance of EEG examination for differentiation of such epileptic status from psychogenic attack and absence status. The second is the importance of disturbed consciousness lasting between seizures. Based on EEG and clinical findings in our three patients, it was concluded that two of the three patients suffered from epileptic status of complex partial seizure and that the condition in the remaining one patient could not be judged as epileptic status of complex partial seizure. Detailed clinical and electroencephalographic findings in previously reported seven patients suffering from status epilepticus of complex partial seizure were compared with those of our two patients. The seven cases out of nine patients had epileptiform EEG activities beginning with localized rhythmic activities. All of the nine patients showed marked motor manifestations during the complex partial seizure such as adversive movement and automatic behaviors. Such motor manifestations of complex partial seizure are very useful for confirming the initiation and termination of the seizure. When the frequency of complex partial seizure is markedly increased, it becomes difficult to detect the initiation and termination of each seizure, and the discontinuous form of status epilepticus of complex partial seizure passes into its continuous form.