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Epileptic seizures heralding intracerebral haemorrhage : case report and systematic review of the literature
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Introdução: Crises epiléticas precursoras de acidente vascular cerebral (“heraldic seizures”) têm sido descritas como podendo representar um sinal de alarme para um evento cerebrovascular major subsequente. Este trabalho tem como objetivo a descrição de um caso clínico e a revisão sistemática de casos de crises epiléticas precursoras de hemorragia intracerebral (HIC) como apresentação inicial de angiopatia amiloide cerebral (AAC).
Métodos: Pesquisa no PubMed e análise das referências cruzadas.
Caso clínico: Mulher de 82 anos apresentou três episódios transitórios de hemiparésia esquerda com evolução para episódios paroxísticos de postura tónica e movimentos clónicos do membro superior esquerdo, seguidos por sinais focais pós-ictais prolongados, pelo que iniciou terapêutica antiepilética. Apresentou ainda dois episódios de estado confusional prolongado, que responderam à otimização da terapêutica antiepilética. Vários eletroencefalogramas (EEG) mostraram atividade lenta focal e atividade epileptiforme frequente nas regiões temporo-parieto-occipitais direitas. A TC-CE e a RM-CE 0,5T excluíram uma lesão cerebral e o líquor não mostrou alterações. Trinta e dois meses após as primeiras manifestações, um novo episódio de prostração e hemiparesia esquerda revelou uma hemorragia aguda do lobo frontal direito. Foram excluídas causas traumáticas e hipertensivas, e a angio-TC não apresentou alterações. O EEG revelou atividade epileptiforme na região temporal direita, bem como na região fronto-temporal esquerda. Três meses depois foi internada por crise epilética com generalização e hemiparesia direita, tendo sido diagnosticado um extenso hematoma lobar temporoparietal esquerdo. A doente faleceu duas semanas depois.
Resultados da revisão sistemática: Foram encontrados três casos clínicos de HIC primária em doentes com AAC precedidos de crises epiléticas como sua primeira manifestação clínica.
Conclusão: Estes casos exemplificam o conceito de “crises precursoras”, sugerindo que a AAC é a causa subjacente das crises epiléticas e da HIC subsequente. As crises epiléticas e as alterações eletroencefalográficas podem representar um marcador para uma condição oculta, podendo antecipar uma HIC iminente relacionada com AAC.
Introduction: The term “heraldic seizures” has been used to describe epileptic seizures occurring prior to a stroke being a warning sign for a major cerebrovascular event. We aimed to describe one case and perform a systematic review of case-reports of epileptic seizures heralding an intracerebral haemorrhage (ICH) as the initial presentation of cerebral amyloid angiopathy (CAA). Methods: We searched PubMed and screened cross-references. Case report: An 82-year-old female presented three transient episodes of left side weakness. They evolved to paroxysmal episodes of tonic posturing and clonic jerks of the left arm, followed by prolonged post-ictal focal signs, leading to the introduction of anti-epileptic therapy. She also had two episodes of protracted confusional state which responded to anti-epileptic therapy optimization. Several EEGs showed focal slow activity and frequent epileptiform activity over the right temporo-parieto-occipital regions. Cranial CT scans and a 0.5T-brain MRI excluded a brain lesion and CSF was unremarkable. Thirty-two months after the first symptom, a new episode of prostration and left hemiparesis disclosed an acute right frontal lobe haemorrhage. Traumatic and hypertensive causes were excluded, and CT angiography did not show any abnormality. EEG revealed epileptiform activity over the right temporal region but also over left fronto-temporal regions. Three months later, she was admitted with seizures and persistent right hemiparesis and an extensive left temporo-parietal lobar haematoma was diagnosed. The patient died two weeks later. Systematic review results: We found three case-reports of primary ICH in CAA-patients preceded by epileptic seizures as its first clinical manifestation. Conclusion: These cases exemplify the concept of "heraldic seizures", suggesting that CAA is the underlying cause of both seizures and subsequent ICH. Epileptic seizures and electroencephalographic changes might be a biomarker for an otherwise occult condition, and they might be a predicting sign for an impending CAA-related ICH.
Introduction: The term “heraldic seizures” has been used to describe epileptic seizures occurring prior to a stroke being a warning sign for a major cerebrovascular event. We aimed to describe one case and perform a systematic review of case-reports of epileptic seizures heralding an intracerebral haemorrhage (ICH) as the initial presentation of cerebral amyloid angiopathy (CAA). Methods: We searched PubMed and screened cross-references. Case report: An 82-year-old female presented three transient episodes of left side weakness. They evolved to paroxysmal episodes of tonic posturing and clonic jerks of the left arm, followed by prolonged post-ictal focal signs, leading to the introduction of anti-epileptic therapy. She also had two episodes of protracted confusional state which responded to anti-epileptic therapy optimization. Several EEGs showed focal slow activity and frequent epileptiform activity over the right temporo-parieto-occipital regions. Cranial CT scans and a 0.5T-brain MRI excluded a brain lesion and CSF was unremarkable. Thirty-two months after the first symptom, a new episode of prostration and left hemiparesis disclosed an acute right frontal lobe haemorrhage. Traumatic and hypertensive causes were excluded, and CT angiography did not show any abnormality. EEG revealed epileptiform activity over the right temporal region but also over left fronto-temporal regions. Three months later, she was admitted with seizures and persistent right hemiparesis and an extensive left temporo-parietal lobar haematoma was diagnosed. The patient died two weeks later. Systematic review results: We found three case-reports of primary ICH in CAA-patients preceded by epileptic seizures as its first clinical manifestation. Conclusion: These cases exemplify the concept of "heraldic seizures", suggesting that CAA is the underlying cause of both seizures and subsequent ICH. Epileptic seizures and electroencephalographic changes might be a biomarker for an otherwise occult condition, and they might be a predicting sign for an impending CAA-related ICH.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2020
Palavras-chave
Crises precursoras Hemorragia intracerebral Angiopatia amiloide cerebral Epilepsia de início tardio Doença cerebrovascular Neurologia