De-novo simple partial status epilepticus presenting as Wernicke’s aphasia

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jou r nal h o mep age: w ww.earrest occur with seizures originating in the frontal or temporallobes of either hemisphere.1,2 Prolonged aphasia as the solemanifestation of focal status epilepticus is, however, a rarelydescribed phenomenon in adults.3,4 Ictal or postictal behavioralchanges include aphasia, speech arrest, or speech vocalization.Aphasia as an ictal or postictal event is well described and has alsobeen reported as an aura in about 17% of patients with complexpartial seizures.5 These language disturbances usually occur withother features of seizures or in episodic fashion, suggesting theirlikely epileptic origin. In the absence prior history of seizures,sustained but reversible aphasia as the sole manifestation of partialstatus epilepticus is rare.6,7 A few cases have been described in theliterature. Brocas or mixed aphasia is more frequent thanWernickes aphasia. We report a case of Wernickes aphasia dueto simple partial status epilepticus.

2. Case report

A 60 year old lady presented to the emergency department withhistory of sudden onset speech disorder. Her main difculties werepoor comprehension and confusion. There were no otherassociated symptoms. She was fully conscious and examinationof her cranial nerves and limbs was normal. Her speech was uent

occasions, she appeared confused with inappropriate responses toquestions. Detailed language assessment revealed severe receptiveand mild expressive difculties. She had mild difculties withwritten comprehension. Comprehension of spoken communica-tion was severely impaired. There was variable comprehension ofnon-verbal communication (did not understand gestures). Herspeech was uent with frequent perseveration but there wasoccasional hesitation due to word nding difculties. She becamestuck in loops of semantic errors.

Her past medical history included resection of left parietalmeningioma six weeks prior to presentation. The meningioma wasidentied during investigations for mild deafness. She was onthyroid replacement therapy.

A CT head and MRI brain scan on admission showed postoperative changes in the left parietal lobe and superior temporalgyrus. There was no evidence of tumour recurrence, mass effect orcerebral infarct. A carotid Doppler ultrasound did not showevidence of carotid stenosis or atheroma. Transthoracic echocar-diogram was normal. She did not have signicant risk factors forstroke.

Electroencephalogram (EEG) performed on the third day ofadmission showed continuous focal seizure pattern over the leftmid and posterior temporal regions consistent with focal statusepilepticus, on occasions transforming into a fast frequency seizurerhythm. There was dramatic response to oral levetiracetam withcomplete resolution of the symptoms over 3 days. A follow-up EEGshowed complete resolution of the epileptiform abnormalities.There was focal slowing in the left temporal/posterior temporalregion (Figs. 1 and 2).

* Corresponding author. Tel.: +44 1173403655; fax: +44 1173406797.

E-mail address: [email protected] (A. Oware).a Department of Neurology, James Cook University Hospital, Middlesbrough,

United Kingdom.

1059-1311/$ see front matter 2011 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.seizure.2011.10.010Case report

De-novo simple partial status epileptic

Bhimanagouda Patil a, Agyepong Oware *

Department of Clinical Neurophysiology, Frenchay Hospital, Frenchay Park Road, Bristo

1. Introduction

Language disturbances manifesting as brief periods of speech

A R T I C L E I N F O

Article history:

Received 9 July 2011

Received in revised form 26 October 2011

Accepted 30 October 2011

Keywords:

Wernickes aphasia

Status epilepticus

Partial seizures

A B S T R A C T

Language disturbances m

the frontal or temporal lo

seizures or may occur in

reversible aphasia as the

history of prior seizures.

aphasia seems to be more

with Wernickes aphasia s

seizures. The diagnosis w

201 presenting as Wernickes aphasia

nited Kingdom

with frequent perseverations and paraphasic errors. She spoke acollection of nonsensical German words (German is her secondlanguage). She was able to understand simple instructions. On

esting as brief periods of speech arrest occur with seizures originating in

. These language disturbances are usually present with other features of

episodic fashion suggesting their likely epileptic origin. Sustained but

manifestation of partial status epilepticus is rare, particularly without a

ew cases have been described in the literature where Brocas or mixed

mon than Wernickes aphasia. Here we describe a patient who presented

dary to simple partial status epilepticus but without any other features of

onrmed on EEG and the aphasia reversed after antiepileptic treatment.

itish Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

re

l s evier . co m/lo c ate /ys eiz

B. Patil, A. Oware / Seizure 21 (2012) 2192222203. Discussion

Acute onset aphasia is commonly due to stroke. Investigationsare initially directed towards nding a cerebrovascular pathology.Aphasia as the sole manifestation of status epilepticus is rare. Thediagnosis of Wernickes aphasia in the emergency department is

Fig. 1. (a) Focal ictal discharges over the left temporal region. (b) Evolution in the challenging. Patients may present with apparent confusion whichcan mimic an acute confusional state. Isolated Wernickes aphasia isnot uncommonly misdiagnosed as conversion disorder. In ourpatient, a detailed speech and language assessment conrmed theclinical diagnosis of Wernickes aphasia. The EEG ndings and theresponse to anticonvulsant conrmed that this was due to a partial

frequency of the discharges. (c) Patient unable to understand the technologist.

Fig. 1. (Continued ).

B. Patil, A. Oware / Seizure 21 (2012) 219222 221status epilepticus. Partial status epilepticus due to a small cerebralinfarct presenting with aphasia has been reported.5 There was noevidence of cerebral infarct in our case. Language assessment isextremely difcult during complex partial seizures because of theimpaired consciousness. Isolated language decits may only clearlybe appreciated in the context of simple partial seizures as in our case.Fig. 2. EEG after the treatment, note some After initial assessment excluded acute infarct, seizure wasconsidered a possible diagnosis because of the recent history ofmeningioma resection. In patients with intracranial meningiomasundergoing resection, 2530% have pre-operative epilepsy. Ap-proximately 20% of the patients with intracranial meningiomaswithout history of preoperative epilepsy develop new onsetslowing over the left temporal region.

postoperative seizures. Convexity and parietal lobe locations ofmeningiomas are risk factors for post operative seizures.8,9 Otherrecognised risk factors peri-tumour oedema, haemorrhage andtumour recurrence were not present in our case. The main riskfactors for seizures in the rst post-operative week (early postoperative seizures) are cerebral oedema and haemorrhage at thesurgical sites. Tumour recurrence is the main cause of late postoperative seizures, dened as, onset after the rst post operativeweek.9 Our patient presented with seizures 6 weeks after surgerybut there was no evidence of tumour recurrence.

This case demonstrates the importance of including simplepartial status epilepticus in the differential diagnosis of prolongedisolated aphasia even in the absence of episodic language decitsor other signs of seizures. An EEG should be performed in all casesof unexplained isolated acute aphasia in order to identify this rarebut treatable cause.

References

1. Caplan LR, Zervas NT. Speech arrest in a dextral with a right mesial frontalastrocytoma. Arch Neurol 1978;35:2523.

2. Gilmore RL, Heilman KM. Speech arrest in partial seizures: evidence of anassociated language disorder. Neurology 1981;31:10169.

3. DePasquet ED, Gaudin ES, Bianchi A, De Mendilaharsu SA. Prolonged andmonosymptomatic dysphasic status epilepticus. Neurology 1976;26:2447.

4. Dinner DS, Lueders H, Lederman R, Gretter TE. Epileptic aphasia: a case report.Neurology 1981;31:88890.

5. Grimes AD, Guberman A. De novo aphasic status epilepticus. Epilepsia 1997;38(8):9459.

6. Racy A, Osborn MA, Vern BA, Molinari GF. Epileptic aphasia. First onset of prolongedmonosymptomatic status epilepticus in adults. Arch Neurol 1980;37(7):41922.

7. Rosenbaum DH, Siegel M, Barr WB, Rowan AJ. Epileptic aphasia. Neurology1986;36(6):8225.

8. Lieu AS, Howng SL. Intracranial meningiomas and epilepsy: incidence, prognosisand inuencing factors. Epilepsy Res 2000;38(1):4552.

9. Chow SY, Hsi MS, Tang LM, Fong VH. Epilepsy and intracranial meningiomas.Zhonghua Yi Xue Za Zhi (Taipei) 1995;55(2):1515.

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De-novo simple partial status epilepticus presenting as Wernicke's aphasiaIntroductionCase reportDiscussionReferences