Abstracts

Rationale: A 54-year-old female was transferred to a university hospital for severe sepsis and multi organ failure. A clinical seizure was noted and she was placed on continuous EEG. During EEG monitoring she developed status epilepticus (SE). After consultation with family it was the decided not to escalate treatment due to her overall medical condition. She proceeded sequentially through the 5 stages of status epilepticus described by Treiman et al, over 22 hours and 30 minutes and then developed electrocerebral silence. This case is the first report of a single individual experiencing all five stages of status epilepticus.Methods: A continuous bedside EEG utilizing the International 10-20 system of electrode placement was recorded.Results: The first EEG pattern of SE observed in our patient was discrete seizures with interictal slowing. (Figure 1A). Associated with this pattern was generalized muscle artifact secondary to tonic-clonic seizures. After a clinical seizure a slow background was observed between seizures. The patient s EEG pattern then progressed to merging seizures with waxing and waning ictal discharges (Figure 1B). The next pattern of the EEG observed was continuous ictal activity (Figure 1C) followed by continuous ictal activity with periods of diffuse suppression (Figure 1D). Periods of suppression lasted between 0.5 to 8 seconds. The next pattern observed was periodic epileptiform discharges on a suppressed background (Figure 1E). The last pattern observed was electocerebral silence (Figure 1F). Autopsy revealed fulminant Aspergillus infection resulting in myocardial infarction; as well as pulmonary, liver, and renal failure. No evidence of infection was seen in the brain.Conclusions: This case demonstrates that a single individual may experience all five stages of status epilepticus reported in animal models; (1) discrete seizures with interictal slowing; (2) merging seizures with waxing and waning amplitude and frequency of EEG rhythm; (3) continuous ictal activity; (4) continuous ictal activity punctuated by low voltage flat periods; and (5) periodic epileptiform discharges on a flat background. This provides new insights into the pathophysiology of status epilepticus by establishing that humans may proceed sequentially through the same stages as seen in animal models. The rapid course illustrates the need for prompt treatment of status epilepticus, as all stages were observed in less than 24 hours. If untreated, status epilepticus may yield electrocerebral silence as an unfortunate sixth stage.