Ictal catatonia as a manifestation of nonconvulsive status epilepticus.

Abstract

SUMMARY Three patients with EEG documented ictal catatonia, a nonconvulsive status epilepticus, who responded dramatically to intravenous phenytoin are described. The EEG showed continuous bilateral pseudoperiodic sharp waves and spike discharges in one patient, spike and wave complexes were seen prominently in the right fronto-central region in another, and the EEG of the third patient showed periodic lateralising epileptiform discharges during the catatonic state. We postulate that such catatonia was due to involvement of the limbic system by seizure activity.Kahlbaum' first described a syndrome consisting of catalepsy and waxy flexibility, mutism, muscle rigidity, psychotic negativism, stereotypies and verbigeration. These symptoms are associated with conditions such as schizophrenia, affective disorders, and a variety of metabolic derangements and structural disorders of the brain.2 Adequately documented catatonia with concurrent epileptic discharges on the electroencephalogram (EEG) has been described only rarely.3-5 We report three cases of nonconvulsive status epilepticus, confirmed by EEG, manifested by catatonia which responded to intravenous phenytoin. Case reportsCase I A 55-year-old black male had a long history of chronic psychosis and was treated with thioridazine. He presented to another hospital with four generalised tonic/clonic seizures which were controlled with intravenous diazepam. On examination at the Philadelphia VA Medical Center the patient appeared awake but had a fixed and glassy-eyed stare. His eyes were in the midline. His face was immobile. He did not recognise his environment. Occasionally, upon repeated questioning, the patient would utter his name. Cranial nerve function was intact. Muscle tone was increased with no focal weakness. However, he exhibited waxy flexibility, maintaining the extremities indefinite in any passively placed bizarre posture. The EEG on the day of admission showed continuous bilateral pseudoperiodic sharp waves and spike discharges ( fig IA). Case 3 A 59-year-old male admitted with frequent episodes of confusion for three weeks. During these episodes he was observed to stare blankly with a decrease in verbal output and physical activity. One year prior to the admission he 833 by copyright.

Focal Status Epilepticus: Clinical Features and Significance of Different EEG Patterns

“…They are often considered a sign of neurologic damage after seizures or a stroke, but not constituting seizures, by themselves, at that time (30)(31)(32). Nevertheless, there are well-described cases of patients with slower PLEDs and clinical deficits clearly reversible with AEDs (9,33), and a clear cut-off frequency for the presence of clinical or treatable seizures is not likely to be established.…”

“…Except for series of patients with epilepsia partialis continua (EPC) (6,7) or simple partial seizures (5), most reports of focal SE are restricted to isolated cases or small series. A broad spectrum of focal SE has been described, including prolonged sensory seizures (S), ictal catatonia (9) or atonia (lo), anarthric SE due to opercular seizures ( I I ) , and more classic aphasias (12)(13)(14). Occipital lobe SE can mimic other conditions with visual loss (15).…”

Presentation, Evaluation, and Treatment of Nonconvulsive Status Epilepticus

“…Visual hallucinations and visual loss similar to those of migraine can be an unusual manifestation of focal NCSE (24). Catatonia (25) and atonia (26) have been described as manifestations of NCSE. Speech difficulties due to dysarthria rather than aphasia can be caused by SE arising in the opercular regions (27).…”

Non-convulsive status epilepticus in adults - an overview

“…Furthermore, it may become especially difficult to diagnose dyscognitive SE in elderly patients in whom it is as frequent as of 40% [67][68][69]. Typical psychiatric manifestations of dyscognitive SE include delirium [67,70,71], stupor or catatonia [72,73], mental slowing [74], cognitive decline [75], aggressive behaviour [76] and psychotic depression [77].When spreading to the neocortical areas of the temporal lobes, auditory or visual hallucinations may occur [78,79]. The EEG of dyscognitive SE is characterised by irregular or regular focal spikes or spikewave activity similar to the one observed in aura continua; however, the ictal activity in dyscognitive SE tends to involve a larger area which increases the likelihood to detect it by surface EEG ( fig.…”