NCCEd: Neurocritical Care Education for Residents

There's a lot of abnormal focal activity-- delta slowing, specifically. This signifies focal neuronal dysfunction. For this patient, the frequent right frontotemporal delta slowing is secondary to her prior right frontal region where her metastasis existed and was resected. It's helpful to know that this slowing is frequently rhythmic, as this then becomes LRDA with a frequency of 2Hz. It doesn't meet our threshold of 2.5Hz to be worried about seizures, and there's no evolution, also reassuring for that latter point. (But, we only got 60 minutes of record, so that's not to say she hasn't or won't get more concerning runs with evolution.) The abundant generalized delta activity is non-specific and correlates with what we know about her mental status being abnormal.

The lack of epileptiform abnormalities is encouraging. However, this doesn't indicate that she hasn't had prior seizures. Again, it's important to contextualize this test (and others) and factor in your pre-test probability.

The explicit message that clinical events were not captured is important. If we were trying to capture another spell of BUE shaking, well, this EEG doesn't help answer whether it was a seizure.

You go to examine the patient. She's lying in bed with her eyes closed. She awakens to voice. She perseverates on a particular phrase. She doesn't follow commands. She moves all extremities with at least antigravity strength.

Her exam is abnormal, but is non-focal. Reassuring, right? But, we've been suspecting symptomatic seizures from her known intracranial pathology (reminder: demonstrated leptomeningeal disease), so now it's time to connect to cEEG to better characterize her reported multiple events of BUE shaking, as well as to rule out NCSE. Was there anything else we should be thinking about?