case_images: PMC10492485_01
case_images: Axial cranial magnetic resonance imaging (MRI) taken 2 days post-admission. Both diffusion-weighted images (DWI) (left panel) and fluid-attenuated inversion recovery (FALIR) images (middle panel) showed some increased signals in the grey-white matter junction (white arrows) with decrease signal on the apparent diffusion coefficient (ADC) map, and increased signals at the cortical ribbon of both hemispheres.
case_images: 10.1177_11795735231200740-fig1.jpg
case_images: PMC10492485_01_10.1177_11795735231200740-fig1.jpg
case_images: fig1-11795735231200740
case_images: Cranial magnetic resonance imaging (MRI) showed some increased signals in the grey-white matter junction and at the cortical ribbon of both hemispheres (Figure 1).
case_images: Panel A: Interictal electroencephalography (EEG) on day 1 post-admission. The patient displayed frequent twitches on the right side of her face and left thumb, followed by generalized convulsions. EEG revealed frequent sharp waves, mainly observed in bilateral frontotemporal areas. Panel B: 24-hour EEG monitoring (montages, monopolar; paper feed speed, 30 mm/sec; sensitivity, 200 muV/cm; high cut, 30 Hz; low cut, .3 Hz; notch filter, OFF) on day 71 post-admission. EEG showing generalized spike and slow wave complexes. Panel C: 24-hour EEG monitoring (montages, monopolar; paper feed speed, 30 mm/sec; sensitivity, 100 muV/cm; high cut, 30 Hz; low cut, .3 Hz; notch filter, OFF) on 96-hour post-lidocaine initiation. EEG showing no epileptiform activity.
case_images: 10.1177_11795735231200740-fig2.jpg
case_images: PMC10492485_01_10.1177_11795735231200740-fig2.jpg
case_images: fig2-11795735231200740
case_images: Epileptiform activity such as spikes and waves, were predominantly evident in the frontotemporal area on the interictal electroencephalogram (Figure 2A). The 24-hour EEG monitoring (Figure 2B) showed generalized spike and slow wave complexes approximately every 30 min despite the use of the following intravenous sedative drugs: propofol (maximum dose, 4 mg/kg/h); midazolam (maximum dose, .4 mg/kg/h); thiamylal (maximum dose, 5 mg/kg/h); and ketamine (1 mg/kg/h). At 96 hours, sharp waves in the frontal and temporal regions (Figure 2C), which had occasionally been observed prior to lidocaine initiation on continuous EEG monitoring, were absent.
case_images: Clinical course of refractory convulsions, anti-seizure medications, and immunotherapies. LEV = levetiracetam; PER = perampanel; LCM = lacosamide; PB = phenobarbital; TPM = topiramate; GBP = Gabapentin; VPA = valproic acid; PHT = Phenytoin; IVMP = intravenous methylprednisolone; PE = plasma exchange; IVIg = intravenous immunoglobulin; RIT = Rituximab.
case_images: 10.1177_11795735231200740-fig3.jpg
case_images: PMC10492485_01_10.1177_11795735231200740-fig3.jpg
case_images: fig3-11795735231200740
case_images: She underwent three courses of methylprednisolone pulse therapy (1000 mg/day for 3 days), intravenous immunoglobulin (400 mg/kg/day for 5 days), plasmapheresis, and four courses of weekly rituximab (375 mg/m2) (Figure 3).