Case StudyClass: END 2463

by: Mais Mujarkesh Instructor: Stacy Pedigo

A 57 y/o Female with PMH significant for:

• HCV cirrhosis [hepatitis C].• HCC [hepatocellular carcinoma]: a cancer arising from

the liver. • HTN [hypertension].• DM [diabetes mellitus].

Family Medical History: • Uncle- Heart failure. • Grandfather- DM, HTN.

Pt was presented to ED on 5/22/13 and admitted till 5/28/13 with AMS and abdominal pain.

She was diagnosed with ascites, hepatic hydrothorax, and colitis. She was treated with rocephine and azithromycin. Then was discharged.

• The pt end up being re-admitted on 5/29/13 to the ER with AMS, hallucination, and combative behavior. She was treated with Zoloft after she was evaluated by a psychiatrist and was discharged.

Few days later, family noticed that pt was confused, which continued to worsen.

On 6/4/13 Pt was brought back to ED, she was treated with cipro and transferred to TSICU for further evaluation were she witnessed a generalized tonic clonic seizure. No tongue biting, bowel or bladder incontinence was noticed.

She then was treated with Keppra for the seizure.

Diagnostic Tests• CT scan of the head (6/5/13): was negative for acute abnormalities.

MRI Brain (6/11/13): Persistent cortical edema in the right lateral parietal lobe, insula, and anterior temporal lobe. Persistent signal abnormality in the ventral medial thalamus. ADC changes have resolved and there is no abnormal enhancement. Findings may represent evolution of encephalitis, post ictal changes. Findings are not typical of acute or subacute ischemia.

EEG

  Electroencephalogram was requested to investigate for

seizure tendency. A routine adult EEG was recorded digitally, utilizing the International 10-20 electrode placement system with the patient awake and asleep.

On (6/24/13) The pt was presented to the EEG department in a confused state.

Slow ODR.

Pt appears asleep. Notice the unilateral periodic PLEDs on the right.

During Photic stimulation. Periodic lateralized epileptiform discharges over the right parietal occipital region.

Periodic unilateral PLEDs continued throughout the EEG.

EEG Results

The background consists of 6 Hz frequency activity. PLEDs [Periodic lateralized epileptiform discharges] were seen over the right parietal occipital region at a frequency of 1 Hz. Upon sleep, the patient continued to have PLEDs over the right parietal occipital region. Photic stimulation was performed and triggered no specific abnormalities.

This encephalogram is considered abnormal due to moderate generalized slowing along with the unilateral periodic discharges [PLEDs] over the right parietal occipital region with increased risk for seizure from this area.

More Diagnostic Tests• MRI (7/9/13):There has been spread of the previously described

pathologic process into new areas, specifically the right occipital lobe.

The lack of any encephalomalacia change in the previously affected areas exclude the diagnosis of stroke or post ictal change.

All suggestive of hepatic encephalopathy.

• CT scan of abdomen (7/15/13):1. Hepatic cirrhosis. [is a chronic degenerative disease in

which normal liver cells are damaged and are then replaced by scar tissue.]

 

2. Enlargement masses in segment 7 and 4B, concerning for HCC.

Patient’s condition

• The pt was following simple commands, until she was decompensated again with concern for pneumonia, was intubated and started on Fentanyl drip. Without significant improvement in mental status.

Treatment

1. Continue antibiotic for acute episode of infection.

2. Continue to aggressively treat hepatic encephalopathy.

3. Continue Vimpat, Keppra, and Trileptal for seizure.

Final Report• On 7/27/13The pt was unresponsive to verbal and tactile stimuli, pupils

were fixed and dilated, and no spontaneous respiration were noted. Peripheral pulses were absent and no heart beat on auscultation.

The patient was pronounced dead.

PLEDs

Was first discovered by Chatrian and colleagues in 1964 .

“PLEDs are periodically recurring paroxysmal discharges of sharp waves, spike-waves, or complex discharges consisting of mixed theta-delta waves arising from one hemisphere or a relatively restricted area within one hemisphere.” (Yamada, and Meng , pg207)

This discharge in EEG is seen in patient’s with:

1. acute cerebral infarct.2. herpes simplex encephalitis.3. other types of encephalitis [infectious mononucleosis].

“PLEDs are often caused or seen in acute ischemic stroke, tumors, hemorrhages or infection.”

http://www.sharecare.com/question/what-are-pleds

• According to (Tyner, Knott, and Mayer 156) Most of the time patients with history of tumors, and spikes in their EEG will have seizures.

• In aggressive growing tumors we might see periodic lateralized Epileptiform discharges.

“High grade tumors were more likely to be associated with high amplitude focal slowing, diffuse slowing, background attenuation, IRDA, PLEDs.”

http://epilepsygroup.com/epilepsy-research-detail5-60-9/abst-2073.htm

• Seizures often occur acutely in patients with PLEDS discovered on a routine EEG.

• http://emedicine.medscape.com/article/1139025-overview#a30

In conclusion• EEG has been an invaluable tool in diagnosing neurological

abnormalities such as brain tumors.

• It helps in localizing the affected area of the brain based on the EEG study. For example, the area of the tumors can be isolated, but the exact type cannot be known.

• I believe that the patient above with her medical history, had disturbances in the right hemisphere of the brain causing the seizure and then the epileptic discharge to be seen during the encephalogram test. “PLEDs have been reported to be usually associated with an acute process and occur early during the course of illness.”http://www.jsnm.org/files/paper/anm/ams203/ANM20-3-11.pdf

reference Page

  Yamada, and Meng, Practical Guide for Clinical Neurophysiologic Testing. EEG, Lippincott Williams & wilkins. 2010. Tyner, Knott, and Mayer, Fundamentals of EEG TECHNOLOGY, Lippincott, 1989. Print. http://www.sharecare.com/question/what-are-pleds http://epilepsygroup.com/epilepsy-research-detail5-60-9/abst-2073.htm http://www.jsnm.org/files/paper/anm/ams203/ANM20-3-11.pdf http://epilepsygroup.com/epilepsy-research-detail5-60-9/abst-2073.htm