CASE STUDIES

 

Specialized Healthcare Facility

A 30-year-old male living in a group home had moderate intellectual disabilities and a history of seizures characterized by drop attacks and episodes of diffuse rigidity, both of which had come under moderate control after instituting a complicated antiepileptic drug regimen.  However, there were also episodes of changes in behavior at mealtime in which the patient appeared to stare and turned away from being fed that had not improved with antiepileptic drug therapy.  Safe Passage Diagnostics was called in to perform Ambulatory video-EEG at the group home.  This revealed frequent prolonged bursts of approximately 2/second spike and wave discharges, along with generalized background slowing and multifocal spikes.  Episodes of diffuse tonic rigidity with ictal correlate were documented.  Notably however, episodes captured on video at the time of meals were unassociated with bursts of epileptic discharges.   Clinicians diagnosed the patient with Lennox-Gastaut Syndrome but the paucity of epileptic discharges during episodes at mealtime led to investigation of other potential causes of this behavior.  A gastrointestinal workup revealed evidence of pancreatitis that led to alterations of his medication regimen and ultimately resolution of behavioral symptoms.

 

Routine EEG

A medical center located in a rural region arranged for Safe Passage Diagnostics to provide technical support for the performance of routine EEGs and for hospital-based neurologists to perform EEG interpretations.  A routine EEG performed there on an 18 year old man was notable for the presence of focal sharply-contoured activity.  The interpreting physician considered the possibility of generalized spike and wave activity but wanted another opinion before issuing a report.   Safe Passage Diagnostics was able to log into the system and review the record in detail.  We were able to find additional similar waveforms at the time of artifact evident on an extracerebral channel.  At a separate time, fragments of a sharply shaped benign rhythm (Wicket spikes) that gave the false appearance of spikes, were identified.  These findings were conveyed to the interpreting physician who ultimately issued a report stating that the EEG was normal.

 
 

Critical setting long term Video-EEG

A 30 year old male with partial epilepsy with a history medication compliance, was brought to the emergency room after suddenly going into generalized convulsive status epilepticus.  In the emergency room, he received a benzodiazepine and second medication which abruptly aborted the convulsive activity.  Continuous video-EEG monitoring was instituted in the emergency room and during his transfer to the intensive care unit.  While observable clinical ictal activity was no longer apparent, EEG testing revealed persistent generalized seizure activity.  Over the next four hours and under the guidance of EEG monitoring, the patient was intubated and received additional agents, leading to definitive cessation of ictal activity and the patient regaining consciousness.

Inpatient Video-EEG

A 65-year-old man hospitalized for a compression fracture, was noted to have subtle confusion.  A routine EEG demonstrated mild generalized slow wave activity but no epileptiform activity.  Video-EEG was subsequently applied over the next 24 hours.  During that time, screening EEG technologists from     Safe Passage Diagnostics noted episodic rhythmic theta activity in the left temporal region.  The electroencephalographer at the hospital was alerted and he subsequently notified the physician caring for the patient that the patient was going in and out of nonconvulsive status epilepticus.  The patient was transferred to the intensive care unit, where an intravenous antiepileptic drug was initiated.  Within two hours of intervention, the patient’s mental status returned to normal.

Ambulatory Video-EEG

A 23-year-old male who missed breakfast in the morning, stood up from his chair at work at noontime, fell to the floor and exhibited transient generalized tremors before gradually regaining full consciousness.  He was brought to the emergency room, where his blood pressure was slightly diminished upon standing compared to a supine position, and where routine blood work and other physical examination findings were normal.  A routine EEG and CT scan of the brain were normal.

He was seen by a neurologic consultant who considered convulsive syncope to be the most likely diagnosis but noted that the possibility of a seizure could not be excluded. The patient was discharged from the emergency room with a follow-up appointment scheduled with the neurologist.  In the meantime, through arrangements between the hospital and Safe Passage Diagnostics, an ambulatory video-EEG was scheduled to be performed in the patient’s home.  That study revealed focal spikes in the right temporal region and a very subtle right hemispheric seizure in the middle of sleep.  Safe Passage Diagnostics notified the neurologist who immediately initiated antiepileptic drug therapy and saw the patient in follow-up the following day.  Ambulatory video-EEG had proved crucial in leading to the proper diagnosis.

Pediatric Ambulatory-EEG

An 8 year old female was evaluated by a pediatric neurologist for apparent problems with concentration, declining school performance and the teacher’s observation that she was recurrently daydreaming.  A routine EEG including a hyperventilation maneuver demonstrated approximately 3/second generalized spike and wave activity.  Antiepileptic therapy was initiated but episodes were not completed eliminated.  A 72 hour ambulatory video-EEG was performed documenting persistent brief absence seizures associated with generalized spike and wave activity.  Antiepileptic drug therapy was increased and a repeat ambulatory video-EEG performed two months later documented nearly complete attenuation of episodes and generalized spike activity.