Abstracts

Rationale: Subacute encephalopathy with seizures in alcoholics (SESA) syndrome is an under recognized disorder, manifesting as encephalopathy with focal or generalized seizures and focal EEG abnormalities occurring in the setting of chronic alcohol abuse. We describe a case of SESA syndrome presenting as focal status epilepticus and encephalopathy, evolving into super-refractory focal non-convulsive status epilepticus (NCSE). Methods: A 58-year-old male with history of alcohol abuse with last drink 2 days prior presented to our institution for altered mental status. On arrival, he had multiple episodes of rhythmic jerking of right upper and lower extremities with right gaze deviation without return to baseline in between. He was given intravenous (IV) lorazepam and levetiracetam which resulted in cessation of clinical seizure activity, however he remained poorly responsive and unable to follow commands. A 20-minute electroencephalogram (EEG) revealed left frontal lateralized periodic discharges plus fast activity (LPD’s + F) superimposed on a background of generalized delta activity, for which continuous video EEG monitoring was performed. The patient continued to have frequent focal electrographic seizures from the left frontocentral region without associated clinical change consistent with focal NCSE, and also had intermittent brief clinical seizures with the same semiology as on admission. This was refractory to multiple anti-epileptic drugs (AEDs) including levetiracetam, lacosamide, valproic acid, propofol and scheduled diazepam for alcohol withdrawal. Seizures ceased after 4 days and EEG monitoring was discontinued. Around this time, he began following commands and was extubated 1 week after admission. He was continued on levetiracetam, lacosamide and valproic acid and was discharged to a rehabilitation facility. AEDs were weaned and stopped in outpatient clinic resulting in seizure recurrence 1 month after, therefore AEDs were restarted and continued. Results: In addition to video EEG monitoring, patient underwent extensive workup including lumbar puncture, which was remarkable only for a urinary tract infection. Given the EEG findings, there was concern for an underlying structural abnormality, thus MRI head with and without contrast was obtained which revealed mild restricted diffusion in left medial temporal lobe and left medial thalamus. Conclusions: This is an unusual case of SESA syndrome presenting with focal status epilepticus and encephalopathy which evolved into super-refractory NCSE. This case illustrates the importance of early recognition of SESA syndrome and differentiation from typical alcohol withdrawal seizures. The timing of seizure onset 2 days after alcohol cessation could be consistent with alcohol withdrawal seizures. However, focal seizure semiology raises suspicion for SESA syndrome which was confirmed by LPDs and focal electrographic seizures on EEG and absence of structural lesion on MRI. Transient diffusion restriction on MRI corresponding to the location of LPDs has been described in SESA syndrome and most commonly occurs in the temporal lobe. Focal motor seizures occur in less than 40% of cases of SESA syndrome and focal convulsive status epilepticus occurs even less commonly. The evolution into super-refractory NCSE makes this case particularly unusual and highlights the importance of continuous EEG monitoring in this condition. Unlike alcohol withdrawal seizures, SESA syndrome typically requires chronic treatment with AEDs as recurrence is common. Funding: No funding