Prolonged and monosymptomatic dysphasic status epilepticus

Aphasic Status Epilepticus Associated with Alzheimer's Disease: Clinical and Electrographic Characteristics

In aphasic status epilepticus (ASE), aphasia is the sole manifestation of seizure in patients with this disorder. Alzheimer's disease (AD) is one of neurological disorders causing ASE. Herein, we report two cases of ASE associated with AD, and discuss their clinical characteristics. Patient 1 presented Broca's aphasia, and patient 2 presented global aphasia during the ictal period. Both patients exhibited atypical ictal electroencephalographic (EEG) patterns, which improved after antiepileptic drug administration. ASE was the presenting symptom of AD in patient 1. ASE can develop at any stage of AD. Alterations in clinical symptoms and EEG patterns after treatment with antiepileptic drug are the key to diagnosis. Prompt diagnosis and treatment are critical for preventing further consciousness dysfunction.

Epileptic aphasia - A critical appraisal

INTRODUCTION

Aphasic and other language disturbances occur in patients with epilepsy during and after epileptic seizures. Moreover, the interictal language profile in these patients is heterogeneous, varying from normal language profile to impairment in different language functions. The aim of this paper was to critically review the terms and concepts of ictal language alterations.

MATERIAL AND METHOD

For this review we performed an extensive literature search on the term "epileptic aphasia" and analyzed the semiology and terminology indicating language-associated seizure symptoms. In addition, we give an overview on EEG, etiology, and brain imaging findings and ictal language disorders.

RESULTS

In the literature, a plethora of terms indicates language-associated seizure symptoms. Simultaneous Video-EEG monitoring represents the gold standard to correctly classify ictal versus postictal language disturbances and to differentiate aphasic symptoms from speech automatisms. Different rhythmic and periodic EEG patterns associated with ictal language disturbances are recognized. Cerebral magnetic resonance imaging (cMRI) is essential in the diagnosis of seizures and epilepsy. Brain tumors and acute or remote cerebrovascular lesions are the most frequently reported structural etiologies underlying ictal language alterations. However, it has to be recognized that brain imaging may show alterations being the consequence of seizures itself rather than its cause. Functional brain imaging might be informative in patients with inconclusive EEG and MRI findings. Overall, seizure-associated aphasia is reported to have good lateralizing significance.

CONCLUSION

Various language disturbances are caused by different types of seizures, epilepsies and underlying etiologies. In the clinical context, simultaneous Video-EEG monitoring facilitates precise classification of ictal versus postictal language alterations and differentiation of aphasic symptoms from speech automatisms.

Three Cases of Aphasic Status Epilepticus: Clinical and Electrographic Characteristics

Aphasic status epilepticus (ASE) is unusual and has clinical characteristics similar to those of other disorders. Herein, we report 3 cases of ASE. A left-handed man (patient 1) showed continuous aphasia after the administration of flumazenil. He had underlying alcoholic liver cirrhosis and traumatic brain lesions in the right hemisphere. Electroencephalography (EEG) revealed periodic epileptiform discharges in the right frontotemporal area, which were intervened by rhythmic activity with spatiotemporal evolutions. A right-handed woman (patient 2) showed recurrent aphasia. Blood tests revealed a high blood glucose level (546 mg/dL) and high serum osmolality (309 mMol/L). Her EEG showed rhythmic activity in the left frontotemporal area with spatiotemporal evolutions on a normal background rhythm. She became seizure-free after the administration of an antiepileptic drug and strict glucose regulation. A right-handed woman (patient 3) developed subacute aphasia a week before hospital admission. She had a gradual decline of cognition 1 year before. Her EEG showed intermittent quasi-rhythmic fast activity in the frontotemporal area bilaterally, with fluctuating frequency and amplitude. The patient became seizure-free after the administration of an antiepileptic drug. Brain single-photon emission tomography performed after seizure control showed decreased perfusion in the left frontotemporal area. After discharge, her cognitive function gradually declined to a severe state of dementia. ASE can be caused by diverse etiologies; it is usually caused by cerebral lesions and less frequently by non-lesional etiologies or degenerative disorders. Adequate treatment of underlying disorders and seizures is critical for curing the symptoms of ASE.

Nonconvulsive Status Epilepticus With Neuropsychological Symptoms: Two Case Reports

Nonconvulsive status epilepticus with neuropsychological symptoms other than aphasia or amnesia is rare. We report two such cases. Case 1, a 62-year-old man with a history of a subcortical hemorrhage in the right lateral temporal lobe and a brain infarct in the left medial temporo-occipital lobes, suddenly developed left unilateral spatial neglect and visual object agnosia. Diffusion-weighted imaging indicated status epilepticus, not stroke. His deficits resolved immediately after treatment with diazepam and phenytoin sodium. Case 2, a 61-year-old man with a history of brain infarcts in the right lateral temporal and left medial temporo-occipital lobes, suddenly developed global aphasia and cortical deafness. An MRI revealed no new lesions, including infarcts. An EEG revealed lateralized periodic discharges in the left temporo-parieto-occipital area, and single-photon emission computed tomography revealed a transient high-uptake lesion in the left temporoparietal lobes, indicating status epilepticus. His deficits also resolved immediately after treatment with diazepam and phenytoin sodium. The two patients' neuropsychological symptoms-visual object agnosia and cortical deafness-were associated with focal nonconvulsive status epilepticus and were successfully treated with anti-epileptic medications. It is suggested that individuals with acute neuropsychological symptoms be diagnosed with MRI and/or EEG as well as CT for differential diagnoses other than cerebrovascular diseases.

Aphasic status epilepticus of frontal origin treated by resective surgery

Aphasic status epilepticus (SE) is a clinical entity of SE, but it has not been well recognized. We report a 43-year-old female with a chronic drug-resistant epilepsy with aphasic SE, treated by resective surgery. The patient showed long-lasting weekly episodes of hypokinesia, slow verbal response, and dysphasia, which were diagnosed as symptoms of aphasic SE. Magnetic resonance imaging showed encephalomalacia in the left frontal lobe with a hemosiderin rim. Intracranial electroencephalography revealed continuous spikes, predominantly on the left superior frontal gyrus with hemosiderin deposit. The aphasic symptoms were seen when ictal discharges gradually spread to the wide area of the left anterior frontal lobe, including the language area. The episodes of recurrent aphasic SE had disappeared by one year after the left anterior frontal resection. We should consider aphasic SE when language impairment is episodic, and consider surgical intervention in cases where it repeatedly occurs despite appropriate medical therapy.

•

Long-lasting slow verbal response and dysphasia could be manifestations of aphasic status epilepticus of frontal origin

•

Epilepsy surgery should be considered for repeat aphasic SE under appropriate medical treatment after definite diagnosis

•

Precise time correlations between aphasic symptoms and ictal discharges could be unclear even by intracranial electroencephalography.

Sudden Onset Fluent Aphasia: Stroke or Seizure?

Conventional understanding of acute onset language deficits indicates that fluent aphasias are due to perisylvian lesions in the dominant hemisphere, most often in the setting of acute stroke. Case studies and retrospective analyses, however, suggest the need to keep ictal phenomena as an alternative diagnostic possibility. The following case illustrates an epileptic mechanism of sudden onset fluent aphasia mimicking an acute stroke presentation. We utilize the case to illustrate means by which to differentiate stroke versus ictal etiology by way of electroencephalography/response to antiseizure drugs as well as perfusion/diffusion imaging. We review the literature case reports to demonstrate that isolated fluent aphasia typically localizes to left-hemispheric, temporal foci. Finally, we provide a brief synthesis of potential neurologic mechanisms by which left temporal lesions may cause fluent aphasia.

Aphasic status epilepticus as the sole symptom of epilepsy: A case report and literature review

Aphasia is a common symptom encountered by neurologists. However, the presence of aphasia as the sole manifestation of partial status epilepticus is rare. The present study reports a case of aphasic status epilepticus in a 27-year-old right-handed female who presented after the abrupt onset of aphasia, which had persisted for 1.5 days. The patient's medical history included head trauma followed by a craniectomy and cranioplasty. Computed tomography scans revealed a lesion in the patient's left parietal lobe, and an electroencephalogram showed a spike and slow wave pattern in the left hemisphere of the brain during aphasia. The patient's condition improved after the oral administration of oxcarbazepine daily. In the present study it was observed that EEGs were a simple method to diagnose aphasic seizures and therefore EEG recordings should be performed in all cases of unexplained aphasia. In addition, the present study reviewed previously reported cases of aphasic status epilepticus.

Recurrent aphasic status epilepticus after prolonged generalized tonic-clonic seizures versus a special feature of Todd's paralysis

Postictal aphasia may be a feature of Todd's paralysis or the presentation of aphasic nonconvulsive status epilepticus (NCSE). We describe a 74-year-old woman with three episodes of aphasic status epilepticus after prolonged generalized tonic-clonic seizures. In the first episode, the NCSE was not definitively diagnosed, but an increase in the epileptic medication led to resolution of the epileptic activity within 2 weeks. During the second episode, NCSE was terminated within 7 days under intensified antiepileptic treatment. In the third episode, phenytoin treatment led to intoxication and resulted in further treatment on an intensive care unit. The patient required several months to recover from this episode. NCSE in the elderly is difficult to recognize, especially when it presents as a prolonged postictal deficit like aphasia. Once diagnosed it has to be treated carefully, because in the elderly, aggressive treatment strategies may be associated with a high risk of adverse events.

Persisting aphasia as the sole manifestation of partial status epilepticus

OBJECTIVES

Persisting aphasia presenting as an isolated inability to vocalize is an uncommon presentation of simple partial status epilepticus and only eight such cases have been reported over the past 40 years.

METHODS

We studied a patient with a 5-year history of recurrent episodes of inability to talk, without any other motor or cognitive impairments. Episodes lasted as long as 24 h, interictal EEGs were normal and she was diagnosed as a conversion disorder.

RESULTS

EEG recordings during one of the episodes showed continuous discharges in the right frontal and parasagital areas demonstrating the ictal nature of the deficits. During the episode the patient had no deficits of strength, or in her ability to perform skilled movements to command, imitation or manipulation of objects. Comprehension of complex verbal commands was preserved and she would make attempts to articulate words and correctly answered questions with head nodding or monosyllables, yes or no. She could hum but had no other vocalizations.

CONCLUSIONS

This is the first case of aphasic status epilepticus secondary to epileptogenic discharges of the right hemisphere. The case is also unique for the isolated involvement of production of language during the seizure.

Inhibitory simple partial (non-convulsive) status epilepticus after intracranial surgery

OBJECTIVES

To report on five patients who developed, 2 to 4 days after an intracranial neurosurgical procedure, new, persistent, focal neurological deficits which were due to inhibitory simple partial (non-convulsive) status epilepticus, and resolved with anticonvulsant treatment.

METHODS

The age range of the five patients was 15-74 years. The operations were: aneurysm clipping (three patients) and resections of an oligodendroglioma and a cavernous haemangioma (one patient each). The new focal deficits were: right hemiparesis and aphasia (two patients), aphasia alone (two patients), and left hemiparesis (one patient). The deficits were not explained by CT (obtained in all patients) or cerebral angiography (performed in two).

RESULTS

Electroencephalography showed, in all patients, continuous or intermittent focal seizures arising from cortex regionally relevant to the clinical dysfunction. Subtle positive epileptic phenomena (jerking) occurred intermittently in three patients as a late concommitant. Administration of anticonvulsant drugs resulted in significant improvement within 24 hours in four patients, with parallel resolution of ictal EEG activity. The fifth patient improved more slowly. Two patients relapsed when anticonvulsant concentrations fell, and improved again when they were raised.

CONCLUSIONS

It is suggested that inhibitory simple partial (non-convulsive) status epilepticus be considered in the differential diagnosis when a new unexplained neurological deficit develops after an intracranial neurosurgical procedure. An EEG may help to diagnose this condition, leading to definitive treatment.

Ictal paraphasia induced by language activity

Four patients with ictal speech disturbance were studied. Their seizures featured isolated, or series of, brief episodes of fluent paraphasia, paragraphia, and comprehension deficit. These episodes were often induced by language activity. Six patients with ictal paraphasia or paragraphia, as a recurrent habitual seizure, are reported in the literature. All ten cases, including the four cases described here and the six cases reported in the literature, featured patients who uttered meaningless speech fluently or displayed paragraphia. The syllables uttered during seizures contained many neologisms and resembled the neologistic jargon of patients with fluent aphasias of the Wernicke type. Nine patients had clusters or status of brief seizures and four patients had auditory hallucination as an ictal event. The seizures in six patients were easily induced by the use of language. Seizure focus was on the left side in all patients mentioned. The possibility of another type of language-induced seizures than those seen in reading epilepsy or language-induced epilepsy is suggested in which myoclonias of the jaw and face, or upper extremities are the main seizure types.

De novo aphasic status epilepticus

The literature contains only a handful of reports of patients with aphasia as the principal or only obvious manifestation of partial status epilepticus. Even fewer patients of this type have been well documented both clinically and by ictal EEG monitoring. We studied an otherwise healthy woman with abrupt onset of aphasia initially thought to be the result of an infarct of the left temporoparietal area. We were able to document partial status epilepticus involving the left temporoparietal area with EEG/video monitoring and showed rapid reversal of the aphasic disorder with antiepileptic drug (AED) treatment. The case is presented with a review of previous reports to underscore the importance of considering this diagnosis in patients with abrupt onset of aphasia.

Simple dysphasic seizures as the sole manifestation of relapse in multiple sclerosis

In a patient with multiple sclerosis (MS), dysphasic seizures were the only manifestation of a relapse. There was a strong correlation between time course of seizures and EEG, and between a localized EEG focus and a magnetic resonance imaging (MRI)-verified encephalitic plaque in the left temporal lobe.

Global aphasia with seizure onset in the dominant basal temporal region

A 33-year-old right-handed woman had intractable simple and complex partial seizures (SPS, CPS) that began with global aphasia. EEG closed-circuit TV (EEG-CCTV) monitoring with sphenoidal electrodes showed left inferomesial temporal ictal onset of CPS. Subdural electrodes were implanted over the left frontotemporal convexity, subtemporally and subfrontally. Stimulation of the basotemporal cortex produced global aphasia. A posterolaterotemporal language area was also identified. Spontaneous SPS had focal onset in the basal temporal language area (BTLA). Ictal discharges did not involve the posterotemporal region. This case shows that aphasic speech arrest at seizure onset may be due to seizure discharge in the basotemporal region and that the BTLA is clinically relevant in seizure semiology.

Epileptic electroencephalographic abnormalities and developmental dysphasias: a study of 32 patients

The relationships between severe developmental dysphasias and epilepsy were analysed in 32 patients with congenital dysphasias. The mean age was 8 years 2 months; 19 of 32 had never had seizures; 9 had had occasional seizures; 4 were epileptic. Twenty-two of 32 had normal repeated standard EEGs, but 10 (2 of which never had seizures) showed epileptic interictal discharges. During prolonged EEG after sleep deprivation, epileptic abnormalities were observed in 13 of the 32 cases (4 of which never had seizures). The overall night sleep recordings showed epileptic abnormalities in 30 of the 32 cases (17 of which had never had seizures). The epileptic interictal abnormalities varied considerably in intensity and aspect in the same patient from one examination to another. Developmentally aphasic children show a higher incidence of abnormal EEG than expected, particularly during overall night recordings. In most cases, the physiopathology of the language disturbance might be identical to that in Landau-Kleffner syndrome.

Aphasia as the Sole Manifestation of Simple Partial Status Epilepticus

Aphasia due to simple partial status epilepticus is rare, particularly in the absence of a seizure history. No previous report describes acute aphasia as the sole clinical manifestation of EEG-monitored status epilepticus, with prompt resolution with treatment. We report a 45-year-old man with a left temporal glioblastoma who acutely developed a global aphasia, during which an EEG revealed continual repetitive sharp waves emanating from the left hemisphere. After injection of i.v. diazepam, the EEG seizure activity ceased, and the patient's language output returned to preseizure levels.

The temporal sequence of aura-sensations in patients with complex focal seizures with particular attention to ictal aphasia

The sequences of aura sensations in 143 patients with complex partial seizures, were analysed with special emphasis on aphasic symptoms. Anxiety, epigastric sensation and visual hallucination were experienced early in the course of the aura, while illusion of familiarity and aphasia occurred late in the course of the aura. Three groups of interconnections of aura sensations were found which corresponded possibly to the types of seizure constellations proposed by Weiser. Close interconnections between impairment of verbal comprehension during seizures and paroxysmal thought disorder, as well as between paroxysmal paraphasia and illusion of familiarity were noted. Paroxysmal aphasia in patients with complex partial seizures was characterised as a positive symptom in contrast to stable aphasia.

Paroxysmal aphasias

Forty cases of paroxysmal aphasia were found in a sample of 4,000 patients with epilepsy. Twenty-five had structural brain damage demonstrated by CT scan. Except for two cases, the epileptic focus was located in the left hemisphere. Two patients had a paroxysmal alexia associated with the aphasic disorder. Though preliminary, our data suggest a correlation of dysphasic components with posterior lesions and phonatory components with anterior lesions.

Complex partial status and schizophrenia

Three cases of complex partial status which were diagnosed as psychotic episodes are presented. The scans of two of these cases show structural abnormalities in the left temporal lobe. It is proposed that there are similar neurophysiological mechanisms in primary schizophrenia and in the perceptual, affective and cognitive phenomena apparent is some complex and psychic partial seizures. The hippocampal-amygdaline system plays a central role in both cases.

Epileptic aphasia and dysphoria interpreted as endogenous depression

A case is reported of a 29-yr-old female with attacks of aphasia/dysphasia over a period of several months which lasted days to weeks accompanied by a dysphoric state. The patients was for long regarded as endogenous depressive with a hysterical speech disorder. However, the diagnosis of epilepsy was finally made based on generalized attacks, appropriate EEG changes, and the response to anti-epileptic therapy.

Non-convulsive status epilepticus

Status epilepticus can complicate any type of seizure activity. A group of 13 children with non-convulsive status has been studied. Five presented with chronic fluctuating neurological features, while eight had intermittent episodes of their atypical status, although each of these lasted for several days. The clinical features, treatment, and outcome for these groups of children are described. Most of the children in both groups are mentally retarded after regressing at the time of their status epilepticus. The recognition and aggressive treatment of atypical status is important in reducing the risk of subsequent mental handicap.

Protracted epileptiform encephalopathy: an unusual form of partial complex status epilepticus

An 11-year-old previously healthy boy had an abrupt onset of partial complex, focal, multifocal, and generalized seizures, with interictal expressive aphasia, extreme emotional lability, agitation, and complex visual and auditory hallucinations. EEGs showed frequent runs of rhythmic high-voltage delta over the right and subsequently over the right and left temporal and frontal regions. All other studies were negative (repeated computed tomography, spinal fluids, viral titers, and cultures). Nadir during the second month showed virtual unresponsiveness, prolonged rhythmic motor and apneic seizures, total anorexia, and sleeplessness. Remission of the electrical and clinical seizure activity and a gradual improvement through a state of agitation and emotional lability occurred during the third and fourth months. One year later he was entirely normal. Compared with the other previously documented cases of prolonged partial complex status, this case is notable for its florid and severe symptomatology, long duration, and final benign outcome.