American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Nonconvulsive status epilepticus masquerading as stroke☆,☆☆,★,★★ Abstract This case describes a patient with multiple stroke risk factors— including prior stroke—who presented to the emergency department with symptoms suggestive of stroke and who received a rapid stroke work up but was later found to be in nonconvulsive status epilepticus (NCSE). This case report highlights the challenge and importance of making an accurate diagnosis in NCSE, and we have included teaching points to help clinicians understand the clinical manifestations and diagnosis of NCSE as well as how it may impact a patient's prognosis. Given the growing attention to rapid stroke protocols in emergency departments across the country, it is important to remember that not all that appears as stroke is stroke, even in people who are at high risk for stroke or in whom stroke is the most likely cause of their neurologic deficits. A 66-year-old woman long-term care facility resident with a history of left-sided hemiparesis due to a prior stroke was brought to the emergency department after caregivers noticed sudden-onset right extremity weakness and sensory loss, right facial droop, and slurred speech. The patient's other stroke risk factors included hypertension, type 2 diabetes mellitus, hyperlipidemia, and paroxysmal atrial fibrillation. Home medications included metformin, lisinopril, and simvastatin. She was not taking aspirin or other antithrombotic medications. At presentation, the patient was responsive only to pain and loud stimuli, having a National Institutes of Health Stroke Scale score of 23 (points for decreased level of consciousness, partial gaze palsy, left hemianopia, right facial palsy, bilateral upper extremity weakness, bilateral lower extremity weakness, left-sided sensory loss, aphasia, and dysarthria). The remainder of her physical examination was noncontributory. An acute stroke protocol was initiated, and urgent noncontrast head computed tomography (CT) showed a large, remote right middle cerebral artery stroke with no evidence of hemorrhage. Computed tomography angiography of the head and neck revealed no large vessel stenoses or occlusions. During CT scanning, the patient's daughter arrived and reported the patient had no seizure history but had had a stroke 3 months prior, resulting in left-sided hemiplegia, facial droop, and dysphagia. The daughter witnessed an episode of vomiting, eyes rolling back, and full body shaking for 30 to 60 seconds preceding the onset of right-sided weakness on the day of presentation.
☆ Author contributions: CK drafted and revised the manuscript. AM assisted with revision of the manuscript. BDB assisted with revision and submission of the manuscript. SP was clinically responsible for the patient and assisted with revision of the manuscript. ☆☆ All authors read and approved the final manuscript. ★ Study funding: No targeted funding reported. ★★ Conflicts of interests: The authors have no conflicts of interest.
Based on the daughter's history and the patient's presentation, a continuous electroencephalogram (EEG) was obtained, showing rightsided temporal rhythmic/semirhythmic activity, at 1.5 to 4 Hz, consistent with focal status epilepticus. Initial anticonvulsant treatment consisted of intravenous lorazepam, fosphenytoin, and levetiracetam to halt the nonconvulsive status epilepticus (NCSE). She was subsequently transitioned to maintenance phenytoin and levetiracetam. Twelve hours after presentation, the patient remained lethargic, likely secondary to postictal sleepiness and anticonvulsant medications. She experienced eight 10- to 20-second seizures the night of admission but no additional seizures during the remainder of her stay. By day 2, her level of orientation improved, and she was able to follow commands easily. She had dysarthria and left-sided weakness consistent with her preadmission baseline. Her aphasia resolved, and her sensation and right-sided strength improved to baseline. The patient's hospital stay was complicated by a rise in creatinine from 0.8 to 2.4 mg/dL, likely caused by CT angiogram contrast. One week after admission, her creatinine had returned to normal. Her discharge National Institutes of Health Stroke Scale was 15, consistent with her preadmission baseline. The hallmark of NCSE is electrical status epilepticus on EEG without convulsions. This has also been referred to as subtle convulsive status epilepticus [1]. Nonconvulsive status epilepticus encompasses multiple seizure types, most commonly absence seizures or complex partial seizures with or without secondary generalization [2,3]. Nonconvulsive status epilepticus can have variable clinical presentations (Table) from mild cognitive impairment to coma. This diversity makes physical diagnosis impossible without support from an EEG. Because NCSE is diagnosed and treated differently than stroke, it is important to consider the possibility of NCSE in patients with stroke history who present with new neurologic changes. In the elderly, stroke is the most commonly identified antecedent for seizures with an incidence ranging from 3% to 14% in most studies [5,6]. A 2-year, prospective, population-based study in Germany identified 150 cases of NCSE and found that 74% of patients had an underlying acute or remote brain insult, usually stroke [7]. Another study of 23 emergency department patients with NCSE found that it took longer than 24 hours to diagnose 13 (54%) of them, with psychiatric disorders being the most likely misdiagnosis [3]. Failure to diagnose NCSE delays treatment, and misdiagnosis may cause inappropriate treatment because seizure at onset with postictal impairment is a relative contraindication for tissue plasminogen activator. Both delay to diagnosis and increased duration of seizure have been independently associated with increased mortality [1,4]. Death directly attributable to status epilepticus after stroke ranges from 12% to 16% [8,9]. Nonconvulsive status epilepticus also indicates serious pathology and has been linked to inpatient mortality rates ranging from 3% to 65%, with the higher end of the spectrum found in older and critically
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Kennel C, et al, Nonconvulsive status epilepticus masquerading as stroke, Am J Emerg Med (2014), http://dx.doi. org/10.1016/j.ajem.2014.08.066
2
C. Kennel et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
ill patients [4,7,10]. Notably, a prospective study of 134 Veteran's Affairs and university hospital patients with NCSE found that by 30 days, 65% had died, 27% remained hospitalized, and only 8% had been discharged [1]. This case raises several teaching points in the management of acute stroke symptoms. A thorough history is important when considering alternative diagnostic possibilities. When imaging does not reveal a new stroke in prior stroke patients who present with acute neurologic deficits, consider a stat EEG. However, the clinical picture should guide decisions about intravenous tissue plasminogen activator treatment, which should not be delayed for an EEG if acute ischemic stroke is likely. Lastly, because of the increased mortality and morbidity associated with NCSE, it is prudent to counsel patients and family members about the severity of illness when NCSE occurs, especially in the setting of significant comorbidities. Christopher Kennel BA Andreas Michas-Martin MD Brian D. Berman MD, MS Sharon Poisson MD, MAS ⁎ University of Colorado Denver, Anschutz Medical Campus Department of Neurology, 12401 E 17th Ave, Mail Stop L950 Aurora, CO, 80045, USA ⁎Corresponding author. Tel.: +1 303 724 2215 fax: +1 303 724 2212 E-mail addresses: [email protected] (C. Kennel) [email protected] (A. Michas-Martin) [email protected] (B.D. Berman) [email protected] (S. Poisson) http://dx.doi.org/10.1016/j.ajem.2014.08.066
Table Clinical manifestations suggestive of NCSE [4] 1) Prolonged “postictal state” after generalized convulsive seizures or prolonged reduction of alertness from an operative procedure or neurologic insult 2) Acute onset of impaired consciousness or fluctuating consciousness with episodes of normal mentation 3) Impaired mentation or consciousness with myoclonus of facial muscles or nystagmoid eye movements 4) Episodic blank staring, aphasia, automatisms (lip smacking, fumbling with fingers, etc), and perseverative activity 5) Aphasia without an obvious acute structural lesion 6) Other acute alterations in behavior without other obvious etiology
References [1] Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, et al. A comparison of four treatments for generalized convulsive status epilepticus. N Engl J Med 1998;339:792–8. [2] Meierkord H, Holtkamp M. Non-convulsive status epilepticus in adults: clinical forms and treatment. Lancet Neurol 2007;6:329–39. [3] Chang AK, Shinnar S. Nonconvulsive status epilepticus. Emerg Med Clin North Am 2011;29:65–72. [4] Young GB, Jordan KG, Doig GS. An assessment of nonconvulsive seizures in the intensive care unit using continuous EEG monitoring: an investigation of variables associated with mortality. Neurology 1996;47:83–9. [5] Menon B, Shorvon SD. Ischaemic stroke in adults and epilepsy. Epilepsy Res 2009; 87:1–11. [6] Lambrakis CC, Lancman ME. The phenomenology of seizures and epilepsy after stroke. J Epilepsy 1998;11:233–40. [7] Knake S, Rosenow F, Vescovi M, Oertel WH, Mueller HH, Wirbatz A, et al. Incidence of status epilepticus in adults in Germany: a prospective, population-based study. Epilepsia 2001;42:714–8. [8] Rumbach L, Sablot D, Berger E, Tatu L, Vuillier F, Moulin T. Status epilepticus in stroke: report on a hospital-based stroke cohort. Neurology 2000;54:350–4. [9] Velioglu SK, Ozmenoglu M, Boz C, Alioglu Z. Status epilepticus after stroke. Stroke 2001;32:1169–72. [10] Shneker BF, Fountain NB. Assessment of acute morbidity and mortality in nonconvulsive status epilepticus. Neurology 2003;61:1066–73.
Please cite this article as: Kennel C, et al, Nonconvulsive status epilepticus masquerading as stroke, Am J Emerg Med (2014), http://dx.doi. org/10.1016/j.ajem.2014.08.066
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Nonconvulsive status epilepticus masquerading as stroke☆,☆☆,★,★★ Abstract This case describes a patient with multiple stroke risk factors— including prior stroke—who presented to the emergency department with symptoms suggestive of stroke and who received a rapid stroke work up but was later found to be in nonconvulsive status epilepticus (NCSE). This case report highlights the challenge and importance of making an accurate diagnosis in NCSE, and we have included teaching points to help clinicians understand the clinical manifestations and diagnosis of NCSE as well as how it may impact a patient's prognosis. Given the growing attention to rapid stroke protocols in emergency departments across the country, it is important to remember that not all that appears as stroke is stroke, even in people who are at high risk for stroke or in whom stroke is the most likely cause of their neurologic deficits. A 66-year-old woman long-term care facility resident with a history of left-sided hemiparesis due to a prior stroke was brought to the emergency department after caregivers noticed sudden-onset right extremity weakness and sensory loss, right facial droop, and slurred speech. The patient's other stroke risk factors included hypertension, type 2 diabetes mellitus, hyperlipidemia, and paroxysmal atrial fibrillation. Home medications included metformin, lisinopril, and simvastatin. She was not taking aspirin or other antithrombotic medications. At presentation, the patient was responsive only to pain and loud stimuli, having a National Institutes of Health Stroke Scale score of 23 (points for decreased level of consciousness, partial gaze palsy, left hemianopia, right facial palsy, bilateral upper extremity weakness, bilateral lower extremity weakness, left-sided sensory loss, aphasia, and dysarthria). The remainder of her physical examination was noncontributory. An acute stroke protocol was initiated, and urgent noncontrast head computed tomography (CT) showed a large, remote right middle cerebral artery stroke with no evidence of hemorrhage. Computed tomography angiography of the head and neck revealed no large vessel stenoses or occlusions. During CT scanning, the patient's daughter arrived and reported the patient had no seizure history but had had a stroke 3 months prior, resulting in left-sided hemiplegia, facial droop, and dysphagia. The daughter witnessed an episode of vomiting, eyes rolling back, and full body shaking for 30 to 60 seconds preceding the onset of right-sided weakness on the day of presentation.
☆ Author contributions: CK drafted and revised the manuscript. AM assisted with revision of the manuscript. BDB assisted with revision and submission of the manuscript. SP was clinically responsible for the patient and assisted with revision of the manuscript. ☆☆ All authors read and approved the final manuscript. ★ Study funding: No targeted funding reported. ★★ Conflicts of interests: The authors have no conflicts of interest.
Based on the daughter's history and the patient's presentation, a continuous electroencephalogram (EEG) was obtained, showing rightsided temporal rhythmic/semirhythmic activity, at 1.5 to 4 Hz, consistent with focal status epilepticus. Initial anticonvulsant treatment consisted of intravenous lorazepam, fosphenytoin, and levetiracetam to halt the nonconvulsive status epilepticus (NCSE). She was subsequently transitioned to maintenance phenytoin and levetiracetam. Twelve hours after presentation, the patient remained lethargic, likely secondary to postictal sleepiness and anticonvulsant medications. She experienced eight 10- to 20-second seizures the night of admission but no additional seizures during the remainder of her stay. By day 2, her level of orientation improved, and she was able to follow commands easily. She had dysarthria and left-sided weakness consistent with her preadmission baseline. Her aphasia resolved, and her sensation and right-sided strength improved to baseline. The patient's hospital stay was complicated by a rise in creatinine from 0.8 to 2.4 mg/dL, likely caused by CT angiogram contrast. One week after admission, her creatinine had returned to normal. Her discharge National Institutes of Health Stroke Scale was 15, consistent with her preadmission baseline. The hallmark of NCSE is electrical status epilepticus on EEG without convulsions. This has also been referred to as subtle convulsive status epilepticus [1]. Nonconvulsive status epilepticus encompasses multiple seizure types, most commonly absence seizures or complex partial seizures with or without secondary generalization [2,3]. Nonconvulsive status epilepticus can have variable clinical presentations (Table) from mild cognitive impairment to coma. This diversity makes physical diagnosis impossible without support from an EEG. Because NCSE is diagnosed and treated differently than stroke, it is important to consider the possibility of NCSE in patients with stroke history who present with new neurologic changes. In the elderly, stroke is the most commonly identified antecedent for seizures with an incidence ranging from 3% to 14% in most studies [5,6]. A 2-year, prospective, population-based study in Germany identified 150 cases of NCSE and found that 74% of patients had an underlying acute or remote brain insult, usually stroke [7]. Another study of 23 emergency department patients with NCSE found that it took longer than 24 hours to diagnose 13 (54%) of them, with psychiatric disorders being the most likely misdiagnosis [3]. Failure to diagnose NCSE delays treatment, and misdiagnosis may cause inappropriate treatment because seizure at onset with postictal impairment is a relative contraindication for tissue plasminogen activator. Both delay to diagnosis and increased duration of seizure have been independently associated with increased mortality [1,4]. Death directly attributable to status epilepticus after stroke ranges from 12% to 16% [8,9]. Nonconvulsive status epilepticus also indicates serious pathology and has been linked to inpatient mortality rates ranging from 3% to 65%, with the higher end of the spectrum found in older and critically
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Kennel C, et al, Nonconvulsive status epilepticus masquerading as stroke, Am J Emerg Med (2014), http://dx.doi. org/10.1016/j.ajem.2014.08.066
2
C. Kennel et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
ill patients [4,7,10]. Notably, a prospective study of 134 Veteran's Affairs and university hospital patients with NCSE found that by 30 days, 65% had died, 27% remained hospitalized, and only 8% had been discharged [1]. This case raises several teaching points in the management of acute stroke symptoms. A thorough history is important when considering alternative diagnostic possibilities. When imaging does not reveal a new stroke in prior stroke patients who present with acute neurologic deficits, consider a stat EEG. However, the clinical picture should guide decisions about intravenous tissue plasminogen activator treatment, which should not be delayed for an EEG if acute ischemic stroke is likely. Lastly, because of the increased mortality and morbidity associated with NCSE, it is prudent to counsel patients and family members about the severity of illness when NCSE occurs, especially in the setting of significant comorbidities. Christopher Kennel BA Andreas Michas-Martin MD Brian D. Berman MD, MS Sharon Poisson MD, MAS ⁎ University of Colorado Denver, Anschutz Medical Campus Department of Neurology, 12401 E 17th Ave, Mail Stop L950 Aurora, CO, 80045, USA ⁎Corresponding author. Tel.: +1 303 724 2215 fax: +1 303 724 2212 E-mail addresses: [email protected] (C. Kennel) [email protected] (A. Michas-Martin) [email protected] (B.D. Berman) [email protected] (S. Poisson) http://dx.doi.org/10.1016/j.ajem.2014.08.066
Table Clinical manifestations suggestive of NCSE [4] 1) Prolonged “postictal state” after generalized convulsive seizures or prolonged reduction of alertness from an operative procedure or neurologic insult 2) Acute onset of impaired consciousness or fluctuating consciousness with episodes of normal mentation 3) Impaired mentation or consciousness with myoclonus of facial muscles or nystagmoid eye movements 4) Episodic blank staring, aphasia, automatisms (lip smacking, fumbling with fingers, etc), and perseverative activity 5) Aphasia without an obvious acute structural lesion 6) Other acute alterations in behavior without other obvious etiology
References [1] Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, et al. A comparison of four treatments for generalized convulsive status epilepticus. N Engl J Med 1998;339:792–8. [2] Meierkord H, Holtkamp M. Non-convulsive status epilepticus in adults: clinical forms and treatment. Lancet Neurol 2007;6:329–39. [3] Chang AK, Shinnar S. Nonconvulsive status epilepticus. Emerg Med Clin North Am 2011;29:65–72. [4] Young GB, Jordan KG, Doig GS. An assessment of nonconvulsive seizures in the intensive care unit using continuous EEG monitoring: an investigation of variables associated with mortality. Neurology 1996;47:83–9. [5] Menon B, Shorvon SD. Ischaemic stroke in adults and epilepsy. Epilepsy Res 2009; 87:1–11. [6] Lambrakis CC, Lancman ME. The phenomenology of seizures and epilepsy after stroke. J Epilepsy 1998;11:233–40. [7] Knake S, Rosenow F, Vescovi M, Oertel WH, Mueller HH, Wirbatz A, et al. Incidence of status epilepticus in adults in Germany: a prospective, population-based study. Epilepsia 2001;42:714–8. [8] Rumbach L, Sablot D, Berger E, Tatu L, Vuillier F, Moulin T. Status epilepticus in stroke: report on a hospital-based stroke cohort. Neurology 2000;54:350–4. [9] Velioglu SK, Ozmenoglu M, Boz C, Alioglu Z. Status epilepticus after stroke. Stroke 2001;32:1169–72. [10] Shneker BF, Fountain NB. Assessment of acute morbidity and mortality in nonconvulsive status epilepticus. Neurology 2003;61:1066–73.
Please cite this article as: Kennel C, et al, Nonconvulsive status epilepticus masquerading as stroke, Am J Emerg Med (2014), http://dx.doi. org/10.1016/j.ajem.2014.08.066
