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WORK, REST AND PLAY; THE CLINICAL SPECTRUM OF NON–CONVULSIVE STATUS EPILEPTICUS
  1. Ann Johnston,
  2. Malisa Pierri,
  3. Zed Ahmed,
  4. Khalid Hamandi
  1. University Hospital of Wales; Cardiff University

    Abstract

    Introduction Non–convulsive status epilepticus (NCSE) is defined as prolonged seizure activity in the absence of motor features or a change in behaviour and/or mental processes from baseline associated with continuous epileptiform discharges on electroencephalogram (EEG). The absence of obvious motor features undoubtedly is in part responsible for the fact that NCSE is probably an under recognised clinical entity. We present two clinical cases of NCSE which illustrate the subtly in diagnosis even in experienced hands, the clinical spectrum of the disorder, the role and accessibility of investigations and its treatable nature.

    Case histories

    •  Case 1: A 55–year–old woman, with unclassified epilepsy characterised by sleep–related generalised tonic–clonic seizures well controlled on carbamazepine, presented with new onset ‘vague’ episodes. She described these as a feeling of vagueness, as if in a ‘zombie’–state with difficulty talking and interacting, yet with retained awareness. The episodes were of 4–48 hours in duration and had increased in frequency despite dose escalations of carbamazepine. She was able to continue working throughout and continued to drive.

    •  Case 2: A 52–year–old woman with learning disability and symptomatic focal epilepsy characterised by daily simple focal seizures secondary to a childhood encephalitic illness of unknown aetiology, presented with a 4–week history of declining social function and speech output. She had been free of generalised tonic–clonic seizures for many years, and was taking carbamazepine and levetiracetam. Over the previous 4 weeks she had become increasingly emotional, lost the ability to stand, had become incontinent of urine and had stopped playing card games; her favourite pastime.

    Investigations In case 1 an interictal EEG recording was unremarkable, so in order to increase the EEG yield an on–demand/rapid–access/walk–in EEG was facilitated in order to capture a clinical event. This capitalised on her employment in a hospital setting and required negotiation with the local neurophysiology department. Case 2 was admitted following a generalised tonic–clonic seizure whereupon an EEG was performed.

    Results and conclusions The diagnosis of NCSE in both cases was confirmed on an ictal EEG recording. Both cases help to illustrate the diverse clinical spectrum of NCSE, its disabling nature in those with learning disability, and often it's clinical subtly in high–functioning individuals. It also serves to highlight that continuous electrical activity in some cases of NCSE although altering awareness; individuals may still be able to function at work and albeit unknowingly against DLVA guidelines, continue to drive while awaiting investigations and a diagnosis. These two clinical case vignettes raise the profile of the spectrum of NSCE and highlight the need for continued investment in the timely availability of EEG.

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