case_images: PMC6745135_01
case_images: Electroencephalography (EEG): (a) EEG seizure arising from the right hemisphere, maximum temporo-parietal region. Seizures were seen occurring at a rate of 6-10 per hour lasting up to 3 minutes in duration without clinical signs. Seizures were frequent despite levetiracetam, lacosamide, phenobarbital, valproic acid, phenytoin, ketamine, midazolam, and pentobarbital. Sharply contoured generalized periodic discharges were seen interictally (b). Two hours after perampanel load (32 mg), the EEG transitioned to background suppression, and no further seizures were observed for the next 72 hours (c). Bitemporal montage, sens 7 uV, Lf 1.6 Hz, HF 70 Hz, 15 s epoch.
case_images: CRICC2019-3218231.001.jpg
case_images: PMC6745135_01_CRICC2019-3218231.001.jpg
case_images: fig1
case_images: His CEEG showed predominantly a burst suppression pattern but prolonged bursts (>30 s) had evolving seizures (Figure 1(a)). A few hours after his perampanel dose, his continuous seizures broke, and he was able to be maintained in burst suppression to complete suppression for 48 hours with no clinical or electrographic seizures (Figures 1(b) and 1(c)).
case_images: PMC6745135_02
case_images: Electroencephalography (EEG): (a) Generalized burst suppression was seen occurring at a rate of 5-8 bursts per minute. Each burst was associated with generalized myoclonus despite the use of levetiracetam, valproic acid, and propofol. (b) Following 32 mg of perampanel, the bursts reduced to about 1-2 times per minute. Bitemporal montage, sens 7 uV, Lf 1.6 Hz, HF 70 Hz, 60 s epoch.
case_images: CRICC2019-3218231.002.jpg
case_images: PMC6745135_02_CRICC2019-3218231.002.jpg
case_images: fig2
case_images: CEEG was placed which showed a burst-suppression pattern with 5-8 bursts per minute (Figure 2(a)). After 30 minutes, his CEEG showed 1-2 bursts per minute (Figure 2(b)).
case_images: PMC6745135_03
case_images: Electroencephalography (EEG): (a) Generalized slowing is seen with lateralized slowing in the left hemisphere. Periodic lateralized epileptiform discharges are seen in the left parieto-occipital region (red box). (b) Frequent seizures without clinical signs were seen arising from the left parieto-occipital region (red box). (c) Immediately before perampanel. At this time, the patient was receiving levetiracetam, lacosamide, valproic acid, and midazolam infusion. (d) 2 hours after perampanel, there is diffuse slowing. No further seizures occurred. Midazolam was stopped. He was eventually weaned off the levetiracetam and lacosamide and discharged on perampanel and valproic acid. Bitemporal montage, sens 7 uV, Lf 1.6 Hz, HF 70 Hz, 15 s epoch.
case_images: CRICC2019-3218231.003.jpg
case_images: PMC6745135_03_CRICC2019-3218231.003.jpg
case_images: fig3
case_images: CEEG showed generalized slowing as well as lateralized slowing in the left hemisphere with periodic discharges in the left parieto-occipital region (Figure 3(a)). His CEEG then showed frequent non-convulsive seizures arising from the left parieto-occipital region (Figure 3(b)). Midazolam infusion was started along with load of perampanel 32 mg (Figures 3(c) and 3(d)).
case_images: PMC6745135_04
case_images: Electroencephalography (EEG): (a) Generalized myogenic artifact is seen throughout the record. (b) Following sedation and paralytic, generalized periodic discharges were seen. She was loaded with levetiracetam without improvement in the CEEG. (c) She was subsequently loaded with 32 mg of perampanel. (d) Two hours post load, her myoclonus had improved. CEEG, however, continued to show the generalized periodic discharge. Bitemporal montage, sens 7 uV, Lf 1.6 Hz, HF 70 Hz, 15 s epoch.
case_images: CRICC2019-3218231.004.jpg
case_images: PMC6745135_04_CRICC2019-3218231.004.jpg
case_images: fig4
case_images: She was subsequently given a sedative and a paralytic, which showed an underlying generalized periodic discharge (Figures 4(a) and 4(b)). She was loaded with levetiracetam (2000 g) without improvement in CEEG (Figure 4(c)).