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Non-Convulsive Status Epilepticus: an example of the overlap between Neurology and Psychiatry Kristen Shirey, MD Duke University Medical Center Depts.

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Presentation on theme: "Non-Convulsive Status Epilepticus: an example of the overlap between Neurology and Psychiatry Kristen Shirey, MD Duke University Medical Center Depts."— Presentation transcript:

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). 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: HPI: Reported 1 week of progressive confusion, headache, and new onset hyperglycemia documented at ALF. 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.” 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: PMH: Chronic Bronchitis with hx atypical mycobactrium Chronic Bronchitis with hx atypical mycobactrium Breast Cancer s/p radical mastectomy Breast Cancer s/p radical mastectomy Idiopathic Polyneuropathy Idiopathic Polyneuropathy Hypothyroidism Hypothyroidism Hyperlipidemia Hyperlipidemia Past Psych Hx: Past Psych Hx: Major Depression, Single Episode, no hospitalizations, suicidality, or psychotic symptoms in the past. Major Depression, Single Episode, no hospitalizations, suicidality, or psychotic symptoms in the past. Social Hx: Social Hx: Lives in ALF alone, protestant, widowed 3 months ago, occasional glass of wine, no tobacco or illicit drug use. 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. Family Hx: Non-Contributory, no family psych history.

6 Med/Psych History Medications: Medications: Calcium citrate + vitamin D 2 tabs po BID-CC Calcium citrate + vitamin D 2 tabs po BID-CC Docusate 100mg po daily Docusate 100mg po daily Levothyroxine 88mcg po daily Levothyroxine 88mcg po daily Omeprazole 20mg po daily Omeprazole 20mg po daily Simvastatin 20mg po qhs Simvastatin 20mg po qhs Risperidone 1mg po qhs Risperidone 1mg po qhs Enoxaparin 40mg subQ daily Enoxaparin 40mg subQ daily Insulin 4 units subQ TID-AC + SSI Insulin 4 units subQ TID-AC + SSI

7 Exam Findings Vital Signs: T 36.8, BP 120/55, P 98, RR 20 Vital Signs: T 36.8, BP 120/55, P 98, RR 20 PE: PE: Gen: WD/WN, Elderly female, NAD Gen: WD/WN, Elderly female, NAD Skin/Mucosa: No rashes/lesions, Membranes moist Skin/Mucosa: No rashes/lesions, Membranes moist HEENT: NC/AT, EOMI, PERRLA HEENT: NC/AT, EOMI, PERRLA Neck: Supple, No LAD, No thyromegaly, nl JVP Neck: Supple, No LAD, No thyromegaly, nl JVP CV: RRR, S1/S2 nl, no m/r/g CV: RRR, S1/S2 nl, no m/r/g Resp: CTAB, no wheezes Resp: CTAB, no wheezes Abd: +BS, soft, NT/ND, no HSM, no rebound/guarding Abd: +BS, soft, NT/ND, no HSM, no rebound/guarding Ext: No C/C/E 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. 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: MSE: Fragile elderly female, anxious, cooperative yet guarded. Speech regular rate with normal intonation and tone with increased latency. 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. 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.” 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). 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: Labs: WBC 10.6, Hgb 15.1, Hct 43, Plt 246 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 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 TSH 4.01, fT4 1.19 ESR 20 ESR 20 UA – SG 1.031, 1+ Prot, 3+ Glucose, No ketones, 1+ blood, 6 RBC, normal WBC, no bacteria UA – SG 1.031, 1+ Prot, 3+ Glucose, No ketones, 1+ blood, 6 RBC, normal WBC, no bacteria Urine and Blood Toxicology Negative Urine 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.

10 Hospital Course Admitted to General Medicine Service/Geriatric Hospitalist Admitted to General Medicine Service/Geriatric Hospitalist Initial workup significant for hyperglycemia without evidence of acidosis as well as hyponatremia. 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. 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. 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. 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.” 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: Emergent EEG performed with findings of: Background activity of predominantly intermixed theta and delta activity. 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. 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. 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 Neurology Consult Patient transferred to Neuro ICU and loaded on IV phenytoin and levetiracetam and underwent continuous video EEG. Patient transferred to Neuro ICU and loaded on IV phenytoin and levetiracetam and underwent continuous video EEG. MRI Brain: MRI Brain: no acute findings and extensive white matter chronic small vessel ischemic disease. no acute findings and extensive white matter chronic small vessel ischemic disease. Lumbar Puncture: Lumbar Puncture: One nucleated cell, 13 RBC, Protein 52, Glucose 133, Gram Stain neg, VDRL PCR neg, HSV PCR neg. 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. 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 Definition Status Epilepticus defined as single seizure or series without recovery of consciousness between seizures lasting at least 20-30 minutes. 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” 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.” 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 2007;53:388-396; NEJM 1998.338(14)

19 Nonconvulsive Status Epilepticus Meierkord. Lancet Neurology 2007;6:329-39.

20 Nonconvulsive Status Epilepticus Categories Categories Generalized or Absence NCSE Generalized or Absence NCSE Focal or Complex Partial NCSE Focal or Complex Partial NCSE Electrographic Criteria (no pathognomonic EEG pattern) Electrographic Criteria (no pathognomonic EEG pattern) Frequent or continuous focal EEG seizures Frequent or continuous focal EEG seizures Frequent or continuous generalized spike wave discharges without history of seizure 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 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 2007;53:388-396

21 EEG in NCSE Beyendburg. Gerontology 2007;53:388-396

22 EEG in NCSE 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.

23 Nonconvulsive Status Epilepticus Common Clinical Presentations Common Clinical Presentations De novo somnolence, stupor, or coma of primary unknown origin 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 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 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. AMS with clinical signs of epileptic activity: subtle myoclonus, chewing, blinking, staring, nystagmus, etc. Autonomic disturbances (e.g. belching, borborygmi, flatulence) Autonomic disturbances (e.g. belching, borborygmi, flatulence) Prolonged post-ictal period Prolonged post-ictal period The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396

24 Nonconvulsive Status Epilepticus Clinical Situations when NCSE on DDx Clinical Situations when NCSE on DDx AMS associated with myoclonus or ocular symptoms and/or fluctuating mental status AMS associated with myoclonus or ocular symptoms and/or fluctuating mental status AMS of unexplained etiology, especially in patient with a seizure history AMS of unexplained etiology, especially in patient with a seizure history Unexplained AMS in the elderly Unexplained AMS in the elderly Stroke patients who appear clinically worse than expected Stroke patients who appear clinically worse than expected Prolonged (>2 hours) post-ictal period after a generalized tonic-clonic seizure Prolonged (>2 hours) post-ictal period after a generalized tonic-clonic seizure The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396

25 Nonconvulsive Status Epilepticus Disorders Mimicking NCSE Disorders Mimicking NCSE Metabolic encephalopathy Metabolic encephalopathy Migraine aura Migraine aura Posttraumatic amnesia Posttraumatic amnesia Prolonged post-ictal confusion Prolonged post-ictal confusion Psychiatric disorders Psychiatric disorders Substance de- or intoxication Substance de- or intoxication Transient global amnesia Transient global amnesia Transient ischemic attack Transient ischemic attack Meierkord. Lancet Neurology. 2007;6:329-39.

26 Nonconvulsive Status Epilepticus Diagnosis 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. 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. 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. 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 2003;74:189-191

27 Algorithm for Management of SE Lowenstein. NEJM. 1998;338(14).

28 Nonconvulsive Status Epilepticus Treatment/Management Treatment/Management Transfer to Neurologic Service or Neuro-ICU (if available) for monitoring (i.e. EEG, airway, etc.) Transfer to Neurologic Service or Neuro-ICU (if available) for monitoring (i.e. EEG, airway, etc.) Benzodiazepines are the first-line treatment 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). 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. 1998;338(14); The Mt Sinai J of Med Vol.73 No.7 Nov 2006; Gerontology 2007;53:388-396

29 Antiepileptic Drug Therapy for SE Lowenstein. NEJM. 1998;338(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 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.

31 Questions?

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