Mehta, trusha, DO

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eCommons at Roseman University

Epilepsy Partialis Continua With Transient Post-Ictal Changes on MRITrusha Mehta D.O., Jasmine Chopra D.O., Alan Arismendez D.O, Adena Shahinian D.O., Paul H. Janda D.O. J.D. esq, Aroucha Vickers D.O.PROGNOSISHOSPITAL COURSECONCLUSION/DISCUSSIONREFERENCESCockerell OC, Rothwell J, Thompson PD, et al. Clinical and physiological features of epilepsia partialis continua. Cases ascertained in the UK. Brain 1996; 119 ( Pt 2):393.Juul-Jensen P, Denny-Brown D. Epilepsia partialis continua. Arch Neurol 1966; 15:563.Khan, Z. (2020, March 10). Epilepsia Partialis ContinuaLin Lin Lee, V., Kar Meng Choo, B., Chung, Y., P Kundap, U., Kumari, Y., & Shaikh, M.(2018, March 15). Treatment, Therapy and Management of Metabolic Epilepsy: A Systematic Review.INTRODUCTIONIMAGINGEpilepsy Partialis Continue (EPC) is a rare form of epilepsy that typically is described as a focal motor status epilepticus commonly localized to one limb. EPC is typically a highly resistant form of status epilepticus that has numerous etiologies such as stroke, metabolic derangements, vascular malformations, inflammatory processes or other infectious lesions (juul-jenson cockerel). Inherited or acquired metabolic derangements such as acidosis, hypoglycemia, vitamin deficiency and thyroid disorders have been cited as causes of epilepsy (Lin Lin Lee). MRI, in EPC, has been used to delineate structural lesions such as focal cortical dysplasia and Rasmussen encephalitis (Khan). This case describes a clinical presentation of new onset of constant semirhythmic clonic twitching, left hemifacial spasms in the setting of myxedema coma. This case of EPC was found to have restricted diffusion evident on MRI of the right temporal lobe during the post ictal stages with resolution of the diffusion restriction evident on repeat MRI after extinction of the patient’s EPC.Patient: 81 year old right handed caucasain femalePresentation: Altered mentation, Right sided persistent semirhythmic facial spasms and lethargy.Medical History: Hypothyroidism, Focal Motor Epilepsy, GlaucomaMedications: Levetiracetam, gabapentin, levothyroxine, pilocarpine, phenytoinPhysical Exam: Repetitive involuntary twitching of the left face including eyelid and mouth. Patient had dysarthric speech and was heavily somnolent on the initial exam.Treatment: Patients home Levetiracetam was started via IV and IV Lacosamidewhich was titrated to maximum dose. Pt was also started on Clonazepam.Results: EEG report initially showed several episodes of spikes lasting approximately 20-30 seconds followed by spike and slow wave complexes of approximately 20-30 seconds duration originating from the left frontotemporal hemisphere with secondary generalization. Two days later EEG report was only significant for bihemispheric slowing. Patient was tested for COVID and negative for COVID. Patient did not undergo a Lumbar Puncture.  Initial MRI of the brain subsequently after the initial EEG and prior to repeat EEG showed right temporal cortical increased signal on T2 with restricted diffusion. Repeat MRI one week after the seizure showed Persistent abnormal T2 signal hyperintensity in the inferior right frontal lobe near the sylvianfissure with diminished or resolved restricted diffusion compared to the study prior.Modifications: During her stay patients medications were adjusted to include Lacosamide and Clonazepam. Patient was also treated with IV levothyroxine for myxedema coma.Follow up: After resolution of EPC, and patient returning back to base line of A&Ox3 the patient was discharged to an LTAC. Patient was seen again at different hospitals throughout Las Vegas after having seizures secondary to medical noncompliance. Patient also was notably restarted on Phenytoin in the outpatient setting .Resolution: Patients initial symptoms of lethargy and Focal Motor Seizures reached complete resolution with 48 hours, as evident on EEG, of aggressive AED management and IV levothyroxine for myxedema coma.This case report summarizes MRI evidence in a patient presenting with EPC likely secondary to myxedema coma. The case presentation highlights the benefits of serial MRI imaging to chase the resolution of EPC along with EEGs and Clinical presentation. The incidence of EPC is infrequent and therefore has led to a paucity of data. This report also dissects the unique etiologies of EPC such as hypothyroidism and provides evidence in the utility of obtaining an EEG and MRI in the post ictal stages of EPC. EPC tends to be a nonurgent condition to treat and the seizures tend to have minor impact on daily life. Treatment goals are usually a fusion of antiepileptics and sedating agents that help patients live with possible vexing symptoms. The management of EPC appears to not only include the appropriate medication regimen but also serial monitoring via EEG and MRI.The decision of the appropriate AEDs was based on the patient's home regime and clinical judgement along with a combination of guidelines. Along with Levetiracetam and Lacosamide, patients appeared to have a good clinical response from scheduled Clonazepam. Apart from the appropriate management of medications, treatment of other factors predisposing the patient to EPC such as myxedema coma; the study highlighted the importance of serial imaging. Although the EEGs appeared to show resolution of the EPC and slow brain wave activity, the MRI repeats showed resolution of restricted diffusion on the diffusion weight sequence. This was significant in the reassurance that patient no longer had postictal changes and was clinically responding to the appropriate cocktail of AEDs.Epilepsia partialis continua (EPC) is typically described as focal motor status epilepticus, typically localized to one limb, that can be caused by numerous etiologies, such as stroke, heterotopias, vascular malformations, inflammatory processes, abscess or other infectious lesion Juul-Jensem, Cockerell . These seizures can develop in adults and tend to only have a minor impact on the day to day life Cockerell. They tend to be medically refractory, and have a variable duration such as days, weeks and can last as long as decades Juul-Jensem. EPC tends to be a condition that is less urgent to treat in comparison to generalized status epilepticus, the goal tends to be a fine balance of symptom control and avoiding over sedationCockerell. The purpose of this study provides evidence in the utilization of serial MRI imaging to monitor the efficacy of treatment and the overall prognosis for the patient. To the author’s best knowledge, thisisthe first case depicting the resolution of the post- ictal MRI changes after Image 1: The MRI images starting from the top left corner, in clockwise order include the diffusion weighted image (DWI), apparent diffusion coefficient (ADC), fluid-attenuated inversion recovery (FLAIR), and transverse relaxation time (T2) images respectively. These images demonstrate the initial MRI Brain without contrast done demonstrating right temporal cortical increased signal on the T2 and DWI images, thought to demonstrate post-ictal changes.Image 2: The MRI images starting from the top left corner, in clockwise order include the DWI, ADC, FLAIR, T2 images respectively. These images demonstrate the MRI Brain without contrast done after treatment of epilepsia partialis continua. It reveals diminished or resolved restricted diffusion in the right temporal lobe.DWIDWIADCADCT2FLAIRT2BeforeAFTERFLAIR

C29: Epilepsy Partialis Continua With Transient Post-Ictal Changes on MRI

https://ecommons.roseman.edu/cgi/viewcontent.cgi?article=1094&amp;context=researchsymposium

C29: Epilepsy Partialis Continua With Transient Post-Ictal Changes on MRI

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