Spontaneous and stimulus induced rhythmic periodic or ictal discharges (SIRPIDs) with rhythmic eye blinking and ocular dipping in a post anoxic comatose patient: a case report
Stimulus induced rhythmic, periodic, or ictal discharges (SIRPIDs) were proposed and named in 2004 [1] They are consistently induced by alerting stimuli, e.g. auditory stimuli, sternal rubs, suctioning, turning, and other patientcare activities in critically ill encephalopathic patients. Clinical status epilepticus is more common in patients with focal or ictal appearing SIRPIDs than in those without. Nevertheless, only a few of these patients with subtle seizures have clinically overt seizures [1] A careful clinicalEEG correlation is necessary to recognize these patients. Here, we report a patient with hypoxic encephalopathy showing spontaneously overt seizures and timeand stimulilocked SIRPIDs, which were elicited by his corneal reflex. A 51 year old man with Kennedy disease was admitted to our hospital for pneumonia. He had intermittent dyspnea and choking episodes but refused to accept a nasogastric (NG) tube. Intravenous sultamicillin (3 g/6 h) and oral azithromycin (500 mg/24 h) were prescribed first, and then were shift to intravenous piperacillin/tazobactam (4.5 g/ 8 h) use due to poor airway hygiene and prolonged fever on the fourth day. However, he was found in the ward unconscious after an intense choking incident that led to cardiac arrest on the fifth day. After immediate cardiopulmonary resuscitation (CPR) and intubation, his spontaneous circulation returned, but his consciousness did not. He was then transferred to the intensive care unit (ICU) Emergent brain CT showed no obvious abnormalities. One generalized tonic clonic convulsion (GTC) occurred thereafter, but spontaneously resolved without medication. Subsequently, he exhibited spontaneous and stimulus induced continuous rhythmic eye blinking associated with ocular dipping. We gave him intravenous midazolam (0.2 mg/kg) and phenytoin (100 mg/Q8H) because of suspicion of seizures. The next day, similar ocular phenomena intermittently occurred, and EEG monitoring showed quasi generalized periodic discharges (GPDs) at a frequency of 1 1.5 Hz (Fig. 1) When the patient's cornea was touched with a cotton swab during a corneal reflex evaluation, the ocular phenomena synchronized with continuously rhythmic generalized 2 Hz spikes, bi spikes, and slow wave complexes, which appeared for about 40 s (Fig. 2) We suspected SIRPIDs and non convulsive status epilepticus (NCSE) This EEG pattern and the eye blinking resolved after treating the patient with diazepam (Fig. 3) We uptitrated midazolam to 1 mg/kg/h and the EEG became generalized delta and theta activity without spikes or sharp elements, but we did not aim for burst suppression, because the patient had unstable vital signs. We gave him intravenous levetiracetam (1000 mg) and then valproic acid (600 mg/8 h) and midazolam (0.6 mg/kg/h) for 48 h. Two days later, the EEG showed generalized theta activity, and he showed neither spontaneous nor stimulus induced rhythmic eye blinking. Two weeks later, his consciousness level improved (Glasgow Coma Scale: E4VeM4) though he was still in a stupor. Most case reports about SIRPIDs delineate the noxious or alerting nature of stimulation, time locked or not. Fluri Chin Wei Huang huangcw@mail.ncku.edu.tw
Neurological Sciences