Good functional outcome after prolonged postanoxic comatose myoclonic status epilepticus in a patient who had undergone bone marrow transplantation

Abstract

In anoxic coma, myoclonic status epilepticus and other nonreactive epileptiform patterns are considered as signs of poor prognosis. We report the case of a good recovery in a prolonged comatose myoclonic status epilepticus (MSE) after a cardiac arrest (CA) treated with mild therapeutic hypothermia (TH) in a patient who had undergone a bone marrow transplantation for Hodgkin's lymphoma. This case emphasizes the opportunity of performing an electroencephalogram (EEG) in the acute period after an hypoxic-ischemic insult and underlines the diagnostic difficulties between MSE and Lance-Adams syndrome, which classically occurs after the patient has regained consciousness, but can also begin while the patient is still comatose or sedated. Major problems in prognostication for postarrest comatose patients will also be pointed out.

Figure 1

EEG pattern 36 hours after the patient suffered a cardiac arrest and treated with mild therapeutic hypothermia. After the sedative discontinuation, the EEG appeared unreactive with diffuse epileptiform discharges (polyspike-wave complexes) associated with continuous spontaneous generalized multifocal jerks, involving the face, limbs, and axial muscles.

Figure 2

(a) An urgent cranial computed tomography scan was negative for cerebral oedema, hemorrhage, and structural lesions. (b) The magnetic resonance imaging, obtained three weeks after the initial event, demonstrated a mild hyperintensity in the lenticular nuclei and periventricular areas bilaterally in T2 sequences.

Figure 3

Repeated EEG recordings obtained (a) 4 days, (b) one week, (c) two weeks, and (d) one month after the initial insult confirmed the presence of anomalies, including polyspike-waves, sometimes followed by brief depressions of the electrical activity, even though a tendency toward a gradual quantitative decrease of pathologic potentials was noted.

Figure 4

A follow-up EEG obtained seven months later revealed a normal background activity, although isolated diffuse polyspike discharges time-locked with myoclonic jerks persisted, more evidently in the anterior regions.