case_images: PMC11440254_01
case_images: Graphical illustration of disease course. A) Intermittent and continuous EEG findings were simplified and categorized according to the two dimensions "epilepticity" and "generalized slowing" (upper part) in order to convey potential effects of pharmacological and surgical interventions (middle and lower part). Timepoints of serial MRI findings as shown in Fig. 3 are noted (lower part). Representative EEG snippets are shown as inlays (Fig. 1B, C and D) and as full-size images in Fig. 2. B) Generalized electrographic seizure as noted on continuous EEG on day 12 despite high-dose midazolam IV. C) Ictal-interictal continuum (2 Hz generalized periodic discharges) as noted on continuous EEG on day 24 despite sevoflurane narcosis and achievement of intermittent burst-suppression pattern. D) Alpha-beta background activity without epileptiform discharges as noted on continuous EEG on day 33 while tapering midazolam IV. Note the sudden disappearance of epileptiform findings on day 32. ASM, anti-seizure medication; BRV, brivaracetam; BSP, burst-suppression pattern; CLN, clonazepam; DEX, dexamethasone; EEG, electroencephalogram; ESE, electrographical status epileptics; ESz, electrographical seizure; EVD, external ventricular drain; IV, intravenous; KTM, ketamine; LCM, lacosamide; LEV, levetiracetam; LOR, lorazepam; MDZ, midazolam; MRI, magnetic resonance imaging; PB, phenobarbital; PER, perampanel; PGB, pregabalin; PO, per os; PRO, propofol; RPP, rhythmic or periodic pattern; SED, sporadic epileptiform discharges; SEV, sevoflurane; THP, thiopental; VPA, valproic acid.
case_images: gr1.jpg
case_images: PMC11440254_01_gr1.jpg
case_images: f0005
case_images: The NCSE was treated in the following weeks with multiple combinations of antiseizure medications (ASM) including lacosamide, brivaracetam, phenobarbital, pregabalin and perampanel, as well as continuous infusion of clonazepam, ketamine, propofol, thiopental, and the inhaled anaesthetic sevoflurane (Fig. 1a). Despite this, epileptic activity with generalized periodic discharges at a frequency of 2 Hz (Fig. 1c, Fig. 2b) could only be suppressed for short period of time and rebounded after reduction of the medications, thus constituting a SRSE. Three days after starting dexamethasone, a complete resolution of generalized periodic discharges was documented by EEG and continuous background activity emerged (Fig. 1d, Fig. 2c).
case_images: Longitudinal magnetic resonance imaging. For comparability, all transverse sections were taken at the level of the splenium corpori callosi and all sagittal sections were taken slightly lateral to the midline. A) Bilateral mesodiencephalic inflammatory T2/FLAIR-hyperintensities typical of TBE on day 15. B) Progression of the aforementioned findings on day 28. Furthermore, newly developed hydrocephalus despite placement of an external ventricular drain and generalized infratentorial edema. C) Further progression of the aforementioned findings on day 38. Regression of the infratentorial edema after bilateral suboccipital craniectomy in the meantime. D) Regression of supra- and infratentorial inflammatory findings on day 67. Meanwhile, a ventriculoperitoneal shunt was placed (note the artifact in the right parietal region).
case_images: gr3.jpg
case_images: PMC11440254_01_gr3.jpg
case_images: f0015
case_images: The MRI on day 15 showed constant changes typical of TBE (Fig. 3a).