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Periodic Lateralized Epileptiform Discharges Can Survive Anesthesia Neurology International 2017; volume 9:6933 Periodic lateralized epileptiform discharges Introduction Correspondence: Edward C. Mader Jr., Department of Neurology, Louisiana State can survive anesthesia Pathological activation of a cortical University Health Sciences Center, 1542 and result in asymmetric region at a rate of about 1/s can be detected Tulane Ave Rm 111B, New Orleans, LA in the electroencephalogram (EEG) as peri- 70112, USA. drug-induced odic lateralized epileptiform discharges E-mail: [email protected] burst suppression (PLEDs), a term introduced by Chatrian et al. in 1964.1 PLEDs consist of periodic sharp Key words: PLEDs; Burst suppression; Seizure; Anesthesia; Propofol. Edward C. Mader Jr., waves, slow waves, and/or multiwave com- Louis A. Cannizzaro, Frank J. Williams, plexes that are lateralized, i.e. electrodes near the cortical generator on one side of the Disclosure: the authors were not directly Saurabh Lalan, Piotr W. Olejniczak involved with the care and management of the head record the highest voltage while elec- Department of Neurology, Louisiana patient. Their role was limited to EEG moni- trodes distant from the generator on the con- toring and interpretation. State University Health Sciences Center, tralateral side may or may not pick up some 1,2 New Orleans, LA, USA of the volume conducted signal. When two Conflict of interest: the authors declare no cortical foci, one in each hemisphere, gener- potential conflict of interest. ate PLEDs independently, the pattern is referred to as bilateral independent PLEDs Acknowledgments: we are grateful to our Abstract (BiPLEDs).3 Two PLEDs-generating foci EEG technologists Thomas Miller, Sheryl may also be in the same hemisphere.4 Other Wagamonte, and Lisa Keppard for recording Drug-induced burst suppression (DIBS) less familiar variants include three or more high-quality electroencephalograms. is bihemispheric and bisymmetric in adults PLEDs-generating foci,5,6 PLEDs with max- and older children. However, asymmetric Received for publication: 13 October 2016. imum voltage in the midline,7 and alternating DIBS may occur if a pathological process is Accepted for publication: 9 January 2017. PLEDs.8 Most PLEDs occur in patients with affecting one hemisphere only or both acute focal destructive brain lesions (e.g. only hemispheres disproportionately. The usual This work is licensed under a Creative stroke, herpes encephalitis, traumatic brain Commons Attribution NonCommercial 4.0 suspect is a destructive lesion; an irritative injury), chronic brain lesions (e.g. tumors, License (CC BY-NC 4.0). or epileptogenic lesion is usually not inflammatory lesions), and epilepsy (with or invoked to explain DIBS asymmetry. We without discrete lesions).9-13 PLEDsuse and ©Copyright E.C. Mader Jr et al., 2017 report the case of a 66-year-old woman with Licensee PAGEPress, Italy BiPLEDs have also been reported in a vari- new-onset seizures who was found to have Neurology International 2017; 9:6933 a hemorrhagic cavernoma and periodic lat- ety of toxic and metabolic encephalopathies, doi:10.4081/ni.2017.6933 eralized epileptiform discharges (PLEDs) in encephalitides, and neurodegenerative 2,3,9-13 the right temporal region. After levetirac- processes. etam and before anesthetic antiepileptic PLEDs are considered epileptiform nomena. PLEDs are resistant to treatment 22 drugs (AEDs) were administered, the elec- because patients with PLEDs have a high with antiepileptic drugs (AEDs). In this troencephalogram (EEG) showed continu- probability of experiencing seizures; in regard, PLEDs resemble focal interictal ous PLEDs over the right hemisphere with some series the probability is about 50- spikes more than seizures. It may very well 12-14 maximum voltage in the posterior temporal 100%. Reiher et al. reported a higher be the case that PLEDs represent neuro- region. Focal electrographic seizures also incidence of seizures when PLEDs are physiological processes that are distributed 13 occurred occasionally in the same location. commercialaccompanied by low-voltage fast rhythms along an interictal-ictal continuum. The Propofol resulted in bihemispheric, but not (PLEDs-plus) than when they are not underlying brain injury, preexisting seizure 15 in bisymmetric, DIBS. Remnants or frag- (PLEDs-proper). However, Chong et al. propensity, and coexisting acute metabolic ments of PLEDs that survived anesthesia found that PLEDs-proper rarely occur in derangements determine whether a patient increased the amplitude and complexity of isolation and that the EEG often fluctuates develops interictal PLEDs, ictal PLEDs, 16 the bursts in the right hemisphereNon leading to between PLEDs-proper and PLEDs-plus. electrographic seizures, or a combination of 16 asymmetric DIBS. Phenytoin, lacosamide, It has been debated for decades whether these patterns. Some authors have pro- ketamine, midazolam, and topiramate were PLEDs are ictal or interictal. Those who posed a treatment algorithm for PLEDs and administered at various times in the course argue that PLEDs are ictal point to the clin- other EEG patterns based on the theory of of EEG monitoring, resulting in suppres- ical correlates of PLEDs, such as motor, an interictal-ictal continuum.23,24 sion of seizures but not of PLEDs. sensory, and cognitive changes,17 or to the There is also evidence that PLEDs are Ketamine and midazolam reduced the rate, presence of focal glucose hypermetabolism not always epileptiform. Gross et al report- amplitude, and complexity of PLEDs but on positron emission tomography (PET)18 ed chronic PLEDs during sleep in a patient only after producing substantial attenuation and focal hyperperfusion on single-photon with ipsilateral caudate nucleus atrophy25 of all burst components. When all anesthet- emission computed tomography and Wheless et al reported PLEDs in a ics were discontinued, the EEG reverted to (SPECT),19 not to mention the resolution of patient with acute thalamic stroke.26 the original preanesthesia pattern with con- these findings when PLEDs disappear. Because the presence of an underlying tinuous non-fragmented PLEDs. The fact Nonetheless, some studies have shown that epileptic disturbance and the risk of neu- that PLEDs can survive anesthesia and focal hypermetabolism and/or hyperperfu- ronal injury are still unknown in some peri- affect DIBS symmetry is a testament to the sion may also occur during focal interictal odic and rhythmic EEG patterns (PLEDs robustness of the neurodynamic processes spikes.20,21 Electrographic seizures may included), the American Clinical underlying PLEDs. emerge during PLEDs, coexist with PLEDs, Neurophysiology Society (ACNS) adopted or evolve on top of PLEDs10,14 suggesting a nomenclature for rhythmic and periodic that seizures and PLEDs are distinct phe- EEG patterns, first published in 200527 and [Neurology International 2017; 9:6933] [page 1] Case Report updated in 2012.28 The goal was to have a gency department (ED) and was treated care unit (ICU). On admission, her vital standard terminology for research and with lorazepam 4-mg IV and levetiracetam signs, oxygen saturation, blood cell counts, expert communication. Terms with clinico- 1500-mg IV load/750-mg q12. Her past glucose, electrolytes, liver and kidney func- pathologic undertones, such as triphasic medical history was significant for diabetes tion tests, urinalysis, and toxicology were waves and epileptiform, were discouraged mellitus and hypertension but negative for all within normal limits. in favor of terms that are more descriptive seizure or epilepsy. The patient remained Head CT was performed in the ED, fol- of the EEG pattern and that are non-com- stuporous and was admitted to the intensive lowed 12 h later by a magnetic resonance mittal with respect to pathophysiology. Thus, the new term lateralized periodic dis- charges or LPDs is preferred to the old term PLEDs. ACNS is not necessarily suggesting that we completely abandon all of the old terms for clinical use.27,28 In this paper, we will continue using the old and familiar term PLEDs. Burst suppression was initially observed as a response of the EEG to high doses of anesthetic agents.29 Like PLEDs, drug-induced burst suppression (DIBS) is periodic with bursts of high-voltage activity alternating with periods of severe back- ground attenuation or suppression.29,30 The cortical discharges in DIBS are clustered into bursts with variable amounts of slow waves, fast waves, and sharp waves (usual- ly higher in amplitude than PLEDs) and the only periods of suppression are characterized by isoelectric or severely attenuated EEG (usu- ally more attenuated than the background in PLEDs).30 DIBS is used to monitor the use effectiveness of anesthetic AEDs during treatment of refractory status epilepti- cus.31,32 The presence of DIBS in the EEG is often equated with adequate suppression of epileptic activity, including ictal and interictal PLEDs. However, whether DIBS is appropriate for all cases of status epilep- ticus and the duration and interburst interval of DIBS that is optimal for suppressing epileptic activity without causing hypoten- sion and other anesthesia-related morbidi- ties remains unknown.31-34 commercial We report a case [note that the authors were involved with EEG monitoring but not with the clinical management of the patient] wherein PLEDs survived treatment with multiple AEDs, including three anestheticsNon (propofol, ketamine, and midazolam), and persisted during DIBS in the form of PLEDs remnants or fragments that resulted Figure 1. Brain structural
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