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What Causes Episodes Of Status Epilepticus?
Question: My Mother Aged 83 Years Has the Following Co Morbid Conditions.
1.Polymyalgia Rheumatica on Small Doses of Steroids since 15 Years
2.Non Valvular AF on Rate Control Lopressor and Geraitric dose of digoxin .Is Well Controlled has good ejection fraction of 65% and Thallium scan was Negative for stress induced ischemia ,thyroid function tests were normal . Is on Anticoagulat Dabigratan 110 Mg OD, as with BiD dose had a bleeding episode ( Epistaxis)
3.Had a largeRight Fronto Parietal Infarct of the brain 5 years back and had a almost full recovery. Carotid Doppler, although normal was started on Plavix 75 MG OD
4. Has wedge fractures of the Thoracis spine ( Osteprosis) and is on Denusumab.Fortunately no Neurodeficit
She was ambulatory and was looking after her day to day needs.
Had a Recent Episode of Status Epilepticus right Focal becoming generalised , followed by deep coma requiring Intubation. is on Kepra Injectable.
Is Not Recovering Regarding Extubation in the last 17 Days.
Recent CT Scan Reveals Right Fronto parietal Encephalomalacia with age related Changes, No SDH or any infarct. MRI Recent evealed Right Fronto parital enceplomalacia and smalleftl Insular infarct.
She is Intubated and and doe snot require sedation and is not moving her limbs or hands.
How long due you consider that this will last ?
What do you think that she is not recovering from this?
What else is the likely cause
Can we do something else?
1.Polymyalgia Rheumatica on Small Doses of Steroids since 15 Years
2.Non Valvular AF on Rate Control Lopressor and Geraitric dose of digoxin .Is Well Controlled has good ejection fraction of 65% and Thallium scan was Negative for stress induced ischemia ,thyroid function tests were normal . Is on Anticoagulat Dabigratan 110 Mg OD, as with BiD dose had a bleeding episode ( Epistaxis)
3.Had a largeRight Fronto Parietal Infarct of the brain 5 years back and had a almost full recovery. Carotid Doppler, although normal was started on Plavix 75 MG OD
4. Has wedge fractures of the Thoracis spine ( Osteprosis) and is on Denusumab.Fortunately no Neurodeficit
She was ambulatory and was looking after her day to day needs.
Had a Recent Episode of Status Epilepticus right Focal becoming generalised , followed by deep coma requiring Intubation. is on Kepra Injectable.
Is Not Recovering Regarding Extubation in the last 17 Days.
Recent CT Scan Reveals Right Fronto parietal Encephalomalacia with age related Changes, No SDH or any infarct. MRI Recent evealed Right Fronto parital enceplomalacia and smalleftl Insular infarct.
She is Intubated and and doe snot require sedation and is not moving her limbs or hands.
How long due you consider that this will last ?
What do you think that she is not recovering from this?
What else is the likely cause
Can we do something else?
Brief Answer:
Please rule out -Non convulsive status epilepticus
Detailed Answer:
Hi XXXXXXX,
Thanks for being here on Healthcaremagic.com.
I am Dr.Ajay Panwar,a neurologist,here to answer your query.
Your mother apparently got intubated because of status epilepticus with likely semiology of Right partial seizures with secondary generalisation and is failing to get extubated for almost 3 weeks. Main causes can be -
1) Ongoing 'non- convulsive status epilepticus' in which patient does not display seizures but his/her brain continuously have electrographic seizures or persistent abnormal electrical activity.An Electroencephalogram(EEG) can detect this.
2) Metabolic disturbances like abnormal serum electrolytes,creatinine,blood glucose,liver enzymes.
3) Infection like 'sepsis'.
4) Blood pressure abnormalities.
Old stroke was on right frontoparietal cortex-if it would have caused seizure,it would have been a left focal with generalisation and not right focal with generalisation.
Fresh capsular lacunar infarct should not be causing seizure.
Please tell GCS(Glassgow coma score) of the patient. Please share all the investigations. That will give a better idea regarding the recovery of the patient. With these details, it is difficult to tell in how many days she will recover.
Please follow-up with details and I shall be glad to answer your query.Wish your mother a good health.
Dr.Ajay Panwar,
MD,DM(Neurology)
Please rule out -Non convulsive status epilepticus
Detailed Answer:
Hi XXXXXXX,
Thanks for being here on Healthcaremagic.com.
I am Dr.Ajay Panwar,a neurologist,here to answer your query.
Your mother apparently got intubated because of status epilepticus with likely semiology of Right partial seizures with secondary generalisation and is failing to get extubated for almost 3 weeks. Main causes can be -
1) Ongoing 'non- convulsive status epilepticus' in which patient does not display seizures but his/her brain continuously have electrographic seizures or persistent abnormal electrical activity.An Electroencephalogram(EEG) can detect this.
2) Metabolic disturbances like abnormal serum electrolytes,creatinine,blood glucose,liver enzymes.
3) Infection like 'sepsis'.
4) Blood pressure abnormalities.
Old stroke was on right frontoparietal cortex-if it would have caused seizure,it would have been a left focal with generalisation and not right focal with generalisation.
Fresh capsular lacunar infarct should not be causing seizure.
Please tell GCS(Glassgow coma score) of the patient. Please share all the investigations. That will give a better idea regarding the recovery of the patient. With these details, it is difficult to tell in how many days she will recover.
Please follow-up with details and I shall be glad to answer your query.Wish your mother a good health.
Dr.Ajay Panwar,
MD,DM(Neurology)
Above answer was peer-reviewed by :
Dr. Bhagyalaxmi Nalaparaju
Dear Dr XXXXXXX Panwar,
Thanks for your reply.
We have done all this except EEG. She was in a local hospital ICU in XXXXXXX for 8 days since Dec10th. After that my brother, Dr M M XXXXXXX who is a Nephrologist himself brought her home and created the ICU environment there itself since the hospital was not adding any value and just insisting on putting her on a ventilator. As you might be aware , hospitals in XXXXXXX are not quiet up to the mark for handling such cases. Paramedical Staff visit her 3 times daily and do the needful besides continous monitoring by my brother and family members. Only 2 places in XXXXXXX do Brain EEG and they dont have any portable machine for the same.
She has Unequalupils and absent Dolls eye moments . Brainstem Functions
GSC score 1to 2
She is only breathing
She had two episodes of Apnea with XXXXXXX cardia and Hypotension which lasted a few minutes.
Her Vitals are RR 40/ Min BP 110/70 0 Mm of Hg with lopresoor 50 Mg BID.
Her Electrolytes were normal Na K Ca MG
Her TLC count was high to begin with but was on tazobactam for 14 days.
Kindly advise as per the latest additional information provided above.
Thanks in advance,
Best regards, XXXXXXX -0000
XXXXXXX- 0000
Thanks for your reply.
We have done all this except EEG. She was in a local hospital ICU in XXXXXXX for 8 days since Dec10th. After that my brother, Dr M M XXXXXXX who is a Nephrologist himself brought her home and created the ICU environment there itself since the hospital was not adding any value and just insisting on putting her on a ventilator. As you might be aware , hospitals in XXXXXXX are not quiet up to the mark for handling such cases. Paramedical Staff visit her 3 times daily and do the needful besides continous monitoring by my brother and family members. Only 2 places in XXXXXXX do Brain EEG and they dont have any portable machine for the same.
She has Unequalupils and absent Dolls eye moments . Brainstem Functions
GSC score 1to 2
She is only breathing
She had two episodes of Apnea with XXXXXXX cardia and Hypotension which lasted a few minutes.
Her Vitals are RR 40/ Min BP 110/70 0 Mm of Hg with lopresoor 50 Mg BID.
Her Electrolytes were normal Na K Ca MG
Her TLC count was high to begin with but was on tazobactam for 14 days.
Kindly advise as per the latest additional information provided above.
Thanks in advance,
Best regards, XXXXXXX -0000
XXXXXXX- 0000
Brief Answer:
She has a bad prognosis.EEG could have been of value.
Detailed Answer:
Hi XXXXXXX,
Thanks for being in follow-up.
I feel really concerned about your mother.
Answer to query-
You told that your mother is having a GCS of 1 to 2,with unequal pupils(which is of significance unless it is unequal due to some surgery like operated cataract or by birth) and absent brainstem reflexes(though you mentioned absent doll's eye but not pupillary reaction and corneal reflex).Definitely,she appears to have a bad prognosis here.But, one big query is why is she having a persistently low GCS(though it can be explained from low blood pressure as she is maintaining BP on ionotropic support,and low BP can cause 'diffuse hypoxic brain damage' which can cause comatose status),when -
1)MRI reveals nothing new except a capsular infarct which should not cause comatose status,
2)Serum electrolytes are normal(if renal function tests,blood sugar and liver function tests are abnormal,they can also cause comatose condition),
3)She has been given good antibiotics to cover infection.
EEG could have been of value in ruling out one potential cause of her unconsciousness,that is ongoing electrographic seisures(as mentioned above).If it would have been the cause,her anticonvulsants could have been modified to see the response.
Another investigation,I suggest is serum ammonia levels.PLEASE DISCUSS MY ADVISE WITH YOUR BROTHER WHO IS A NEPHROLOGIST.
I wish your mother a good health.If you have any follow-up questions,I shall be glad to answer them else,please close the thread-rate it.and write a review.
Dr.Ajay Panwar,
MD,DM(Neurology)
She has a bad prognosis.EEG could have been of value.
Detailed Answer:
Hi XXXXXXX,
Thanks for being in follow-up.
I feel really concerned about your mother.
Answer to query-
You told that your mother is having a GCS of 1 to 2,with unequal pupils(which is of significance unless it is unequal due to some surgery like operated cataract or by birth) and absent brainstem reflexes(though you mentioned absent doll's eye but not pupillary reaction and corneal reflex).Definitely,she appears to have a bad prognosis here.But, one big query is why is she having a persistently low GCS(though it can be explained from low blood pressure as she is maintaining BP on ionotropic support,and low BP can cause 'diffuse hypoxic brain damage' which can cause comatose status),when -
1)MRI reveals nothing new except a capsular infarct which should not cause comatose status,
2)Serum electrolytes are normal(if renal function tests,blood sugar and liver function tests are abnormal,they can also cause comatose condition),
3)She has been given good antibiotics to cover infection.
EEG could have been of value in ruling out one potential cause of her unconsciousness,that is ongoing electrographic seisures(as mentioned above).If it would have been the cause,her anticonvulsants could have been modified to see the response.
Another investigation,I suggest is serum ammonia levels.PLEASE DISCUSS MY ADVISE WITH YOUR BROTHER WHO IS A NEPHROLOGIST.
I wish your mother a good health.If you have any follow-up questions,I shall be glad to answer them else,please close the thread-rate it.and write a review.
Dr.Ajay Panwar,
MD,DM(Neurology)
Above answer was peer-reviewed by :
Dr. Yogesh D
Answered by
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