Abstracts

Rationale: The condition now known as Spike-wave stupor, or Absence status was originally termed "petit mal status" by Lennox. These states of Generalized spike-wave activity and impaired consciousness were reported subsequently by various authors. There was a wave of interest concerning this condition during the early and mid 1950's, and has waned over the years. This condition is relatively not widely known and often misdiagnosed condition. With the frequent use of EEG's in many different presentations of confusion and as a part of the routine work up for encephalopathy and delirium, this condition would be expected to be reported more frequently now. We present two patients who presented with confusion and were found to be in "spike wave stupor". Methods: Case 1: 70 year old right handed female with history of epilepsy had multiple presentations with confusion, disorientation and stupor. Interictal EEG's showed bifrontal delta slow burst and left temporal sharps. Prompt routine EEG's during her spells always showed generalized spike and wave pattern. There was a clinical improvement and remission of the spike wave pattern on the EEG after increasing the anti epileptic medications. She was started initially on phenobarbital and Levetiracetam . Due to the level of phenobarbital being unpredictable in her, she was switched to Lacosamide and Levetiracetam; and she has been stable for over an year. Case 2: 56 year old right handed high function male ( mathematics teacher) withno prior history of seizures who with symptoms of confusion that started ~ 24 hrs prior to arrival to the ED. His responses to questions were one word answers and were mostly "yes" or "no". He was walking and moving around during this entire episode. He did not lose consciousness. No convulsions, automatisms, focal motor or sensory symptoms were noted. CBC, CMP, Urine drug screen, LP,CT head without contrast were unremarkable. MRI of brain did not show significant pathology. A routine EEG showed generalized continuous spike and wave pattern. He was given Lorazepam, Valproate, Levetiracetam . His continuous video EEG monitoring showed generalized spike and wave discharges diffusely. He was awake and was interacting with his family albeit with minimal verbal responses. His epileptic discharges completely disappeared 14 hrs into EEG monitoring, with clinical improvement. Results: Both our patients presented with only confusion or twilight states. One patient had a history of primary generalized epilepsy while the other patient had no prior history of epilepsy and this presentation was a first time seizure. Both of the patients responded after initiation of anti-epileptic medications and had clinical and electrographic improvement on the EEG. The continuous spike wave activity on the EEG in these patients who presented with confusion was somewhat unexpected Spike wave stupor can be prolonged and last for hours days or months. The spike wave complexes are frequently atypical rather than classical. Because the EEG shows a variety of spike wave frequencies and patterns during the clouded consciousness, SWS has been suggested as a more accurate term to describe the behavioral twilight. But for the EEG laboratory work and imaging has not been helpful in published cases. Diagnosis becomes clear if the possibility is suspected in the differential and is evaluated by EEG. Conclusions: EEG should be incorporated as a routine investigation in the work up of encephalopathy so that spike wave stupor and other similar states could be promptly identified and the required treatment administered. With the more frequent use of EEG there would be increased reporting of this fascinating phenomenon. The still obscure pathophysiology and the optimum antiepileptic therapy is yet to be determined. Funding: None