Subacute encephalopathy and seizures in alcoholics (SESA) presenting with non-convulsive status epilepticus

Abstract

Subacute encephalopathy with seizures in chronic alcoholism (SESA) was first described in 1981 by Niedermeyer who reported alcoholic patients presenting with confusion, seizures and focal neurological deficits and is quite distinct from patients presenting with typical alcohol withdrawal seizures. EEG often reveals periodic discharges and spikes, but SESA presenting with non-convulsive status epilepticus has rarely been described. We report a case of SESA with non-convulsive status epilepticus in a patient who was initially suspected of having a typical alcohol withdrawal seizure. A 61 year old woman with a history of chronic alcoholism was admitted at an outside hospital for confusion thought to be secondary to an alcohol withdrawal seizure. She had right hemiparesis and later developed right facial twitching that did not respond to intravenous fosphenytoin and levetiracetam. She was transferred for further management. Upon arrival, lorazepam and fosphenytoin were given and right face clonic movements resolved. However, continuous EEG monitoring revealed ongoing non-convulsive status epilepticus (NCSE). Following treatment with IV valproate and lacosamide, there was resolution of NCSE. SESA is likely an under recognized clinical syndrome that is quite distinct from typical alcohol withdrawal seizures and requires a different diagnostic and management approach. NCSE is likely to account for the encephalopathy and focal neurological deficits seen in patients presenting with the clinical syndrome of SESA. Therefore, a high degree of suspicion is warranted and continuous EEG monitoring is recommended for alcoholic patients with encephalopathy and focal neurological deficits.

Ethosuximide reduces electrographical and behavioral correlates of alcohol withdrawal seizure in DBA/2J mice

“…A few reports have indicated nonconvulsive seizure-like activity in EEG recordings of patients undergoing withdrawal (Fernández-Torre & Martínez-Martínez, 2007; LaRoche & Shivdat-Nanhoe, 2011) and although inconsistencies exist in these findings, several abnormalities in EEG of alcoholics have been identified (Cohen, Porjesz, Begleiter, & Wang, 1997; Coutin-Churchman, Moreno, Añez, & Vergara, 2006; Feige, Scaal, Hornyak, Gann, & Riemann, 2007; Porjesz & Begleiter, 2003; Rangaswamy et al, 2003; Rodriguez Holguin, Porjesz, Chorlian, Polich, & Begleiter, 1999; Salety-Zyhlarz et al, 2004). Individuals with multiple relapses have a lower seizure threshold; however, more work is needed to determine whether the lowering of seizure threshold in one seizure type may influence the progression to generalized convulsions and the physiological consequences of abnormal EEG activity.…”

Alcohol withdrawal syndrome: mechanisms, manifestations, and management

“…Physical examination and investigations should be directed toward detecting common signs and symptoms of AWS that are listed in Table 1 6, 10, 14, 15, 16, 17, 18…”

“…They can last up to 6 d. The appearance of acute symptomatic seizures may emerge 6–48 h after the last drink 19. Delirium tremens (DT, onset 48–72 h after cessation of drinking) represents characteristics of severe withdrawal that may last for up to 2 weeks (late withdrawal) 6, 10, 15, 18. The chronological development of the various symptoms is illustrated in Fig.…”

“…This is especially important in patients who have not had a previous history of DT. Differential diagnoses for severe alcohol withdrawal are listed in Table 2 10, 15…”

Use of Newer Anticonvulsants for the Treatment of Status Epilepticus

“…Although LCM is not FDA approved for SE, it has been evaluated in this setting in multiple case series, case reports, and retrospective reviews . The populations studied varied in the types of SE encountered: generalized, convulsive, absence, focal, complex partial, nonconvulsive, refractory, and super refractory (Table ).…”