A 70-year-old man with a history of coronary artery disease, Alzheimer dementia, epilepsy, and chronic kidney disease is admitted to the ICU after presenting with respiratory failure. He started spiking high fevers on the third day and grew Staphylococcus aureus in his sputum. On the fourth day of admission, he starts to have rhythmic jerking of his left upper extremity with gaze deviation. With lorazepam treatment the episode resolves. An MRI of the brain after the event shows atrophy, prominent in the right temporoparietal regions, with some ex vacuo ventricular dilation.
Which of the following is the MOST likely explanation for this event?
Correct Answer: C
Critical illness is commonly known to lower the threshold for seizures, especially in a patient with prior history of epilepsy. Even in those without a history of epilepsy, infections are a common trigger for seizures. Elderly patients and those with underlying structural brain disease are commonly affected. The common seizure triggers associated with critical illness are metabolic and electrolyte abnormalities, infections, and medication. Meningitis is a possibility in the setting of a known infection but would be less likely than breakthrough seizure in the setting of infection. Mycotic aneurysms may occur in patients with bacteremia, but there is no evidence of that in this patient. Amyloid spells are spectrum of transient focal neurological episodes reported to occur in cerebral amyloid angiopathy patients. Overall, they are not common and less likely seen in intubated, critically ill patients. Hypoxic injury is a possibility in this patient who has had respiratory failure, but with an MRI that does not demonstrate any early cortical ischemic changes and a presentation consistent with seizures, this option will be lower on the differential.
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A 69-year-old woman with excessive alcohol intake (2 bottles of wine a day) suffers an out-of-hospital cardiac arrest. She receives several rounds of cardiopulmonary resuscitation, achieves return of spontaneous circulation, and is brought to the hospital. She undergoes 24 hours of therapeutic hypothermia. Her urine drug screen is positive for benzodiazepines. After rewarming, she is found to have rapid twitching movements of her face and extremities. An EEG is attached and it shows abnormal rhythmic activity.
Which of the following is MOST true about this condition?
Correct Answer: B
Postanoxic myoclonic status epilepticus can be seen after hypoxicischemic brain injury following cardiac arrest. Its presence generally portends a poor prognosis. In some cases, they may be noticed only after rewarming from therapeutic hypothermia. Levetiracetam and valproic acid have shown some benefit in controlling these phenomena. Although presence of EEG activity is a better sign than having no EEG activity at all after a cardiac arrest, postanoxic myoclonic status epilepticus has poor prognostics values. Given urine drug screen is positive for benzodiazepines, patient is at risk of benzodiazepine withdrawal which could rarely present as seizures only, yet, given patient’s alcohol history, it should be on the differential diagnosis. Given there is no report of fever or other evidence for ongoing infection, there is no acute indication for a lumbar puncture.
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