Opercular myoclonic-anarthric status epilepticus: A report of two cases
A 72-year-old right-handed female presented with sudden onset of abnormal, involuntary movements of tongue, lips, lower jaw and larynx for the last 2 days. She had speech and swallowing difficulties, occasionally associated with choking episodes. She had no difficulty in voluntary movements of facial, palatal muscles and tongue. She was a known hypertensive for the last 6 years and was on irregular treatment.\nOn general physical examination, vital data was normal except for elevated blood pressure (180/100 mmHg). Central nervous system examination revealed that speech was slow and dysarthric and bilateral, symmetrical continuous, involuntary, repetitive and synchronized rhythmic myoclonus involving tongue, lips, chin, jaw and larynx at a rate of 90-110/min []; rest of the neurological examination was normal.\nLaboratory investigations including hemogram, serum biochemistry and 2D-echocardiogram were normal. Carotid/vertebral arterial Doppler study showed thrombosis of right internal carotid artery. EEG was abnormal and revealed diffuse theta slow waves and intermittent bursts of sharp and slow waves over posterior temporal, centro-parietal, occipital regions and occasionally generalized epileptiform discharges []. Single photon emission computerized tomography (SPECT) showed areas of intense radio-tracer uptake in right frontal region []. MRI brain-DWI showed restriction in right high frontal region suggesting acute infarct. MRA of brain showed thrombosis of right internal carotid artery.\nShe was started on oral clonazepam (0.5 mg twice daily) initially and later sodium valproate (20 mg/kg/body weight) was added. Myoclonic jerks were not controlled in 5 days. Then levetiracetam (20 mg/kg/body weight) and gabapentin (100 mg 3 times daily) were added. Oral amlodipine 5 mg once daily was started for control of hypertension; oral aspirin (150 mg once daily) and rosuvastatin (10 mg once daily) were started for the treatment of ischemic stroke. Long-term warfarin therapy was prescribed. During hospital stay, myoclonus improved over a period of 10-12 days []; swallowing difficulties and speech had gradually improved in 14-16 days. During the follow-up period of 2 months, the patient had no recurrence of myoclonus.