PMC6537057_01
Routine EEG denotes one electrographic seizure from the right hemisphere.
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After the procedure, the patient's convulsive seizures decreased, but focal seizures persisted (Figure 1).
MRI of the brain (a): axial T2 sequence image shows encephalomalacia
secondary to the right temporal lobectomy 15 years before the patient's
first visit to this clinic and (b) coronal T2 flair sequence image.
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A magnetic resonance imaging (MRI) of the brain showed encephalomalacia secondary to right temporal lobectomy (Figure 2).
EEG before the IV methylprednisolone treatment: (a) before the IV
methylprednisolone treatment, the EEG displayed on the bipolar reference
montage showed constant generalized rhythmic high amplitude sharp waves;
(b) the EEG of (a) was displayed on the bipolar reference montage with
decreased sensitivity (10 microV/mm); (c) when the EEG was displayed on the
average reference montage, it showed endless generalized rhythmic high
amplitude sharp waves; and (d) the EEG was displayed on the average
reference montage with decreased sensitivity (10 microV/mm). During this
spell (10-30 min long) (designated as blue stars in Figure 4), the EEG abnormality
remained continuous.
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EEG showed recurrent long bursts of constant generalized rhythmic high amplitude sharp waves. Each long burst lasted from 10 to 30 min, which did not meet the criteria of electrographic seizure per se (Figure 3).
Quantitative EEG analysis: (a) before the IV methylprednisolone
treatment, the continuous EEG monitoring showed spells of constant
generalized rhythmic high amplitude sharp waves. These spells lasted
from 10 to 30 min (denoted by the blue stars). (b) Two hours after the
IV methylprednisolone treatment, the continuous EEG monitoring showed
resolution of these generalized rhythmic sharp waves (the blue stars
disappeared). (c) Before the IV methylprednisolone treatment, the EEG
displayed on the bipolar reference montage showed constant generalized
rhythmic high amplitude sharp waves. (d) After the IV methylprednisolone
treatment, the EEG displayed on the bipolar reference montage showed
resolution of the generalized rhythmic sharp waves.
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On average, these spells of prolonged generalized rhythmic sharp waves appeared once every hour (indicated by the blue stars in Figure 4). Two hours after the first dose of IV 1000 mg methylprednisolone, the EEG abnormalities dramatically subsided (the blue stars were no longer present 2 h after IV methylprednisolone in Figures 4 and 5).
EEG after the IV methylprednisolone: (a) around 2 h after the IV
methylprednisolone was administered, the EEG displayed on the bipolar
reference montage showed remission of the generalized rhythmic sharp
waves. Normal EEG background started to appear and mixed with the
generalized rhythmic sharp waves. (b) The same EEG of (a) was displayed
on the average reference montage. The breach rhythm over the right
hemisphere was visible.
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Two hours after the first dose of IV 1000 mg methylprednisolone, the EEG abnormalities dramatically subsided (the blue stars were no longer present 2 h after IV methylprednisolone in Figures 4 and 5).
A historical timeline of events.
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Since our team had not documented any steroid-responsive neuropsychiatric symptoms, the diagnosis of SREAT was not made at the time of discharge, despite her extremely elevated thyroperoxidase antibody (TPOAb; >9540 IU/mL, Ref.: 0-9 IU/mL) (Table 1 and Figure 6).