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Complex partial status epilepticus following myelography with metrizamide.

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BRIEF COMMUNICATIONS A N D CASE REPORTS
Complex Partial
Status Epilepticus
following Myelography
with Metrizamide
D. Russell, MD, I. M. Anke, MD,
R. Nyberg-Hansen, MD, 0. Slettnes, MD,
0. Sortland, MD, and T. Veger, MD
Complex partial status epilepticus developed i n two
patients following myelography with metrizamide.
T h e status epilepticus was manifested by confusion
and complex motor symptoms, and electroencephalograms (EEGs) showed ictal activity alternating independently over both hemispheres. Immediate clinical
improvement occurred with antiepileptic treatment,
and to date no sequelae have been observed. Neither
patient had a previous history of epileptic seizures, b u t
both had preexisting EEG abnormalities.
Russell D, Anke IM, Nyberg-Hansen R, et al:
Complex partial status epilepticus following
myelography with metrizamide.
Ann Neurol 8:325-327, 1980
Complex partial status epilepticus (CPSE) is believed
to be rare L1-3, 13, 141, and there is disagreement
concerning its nature and classification. W e report
two patients w h o w e believe developed CPSE
following myelography with metrizamide (Amipawe).
Patient 1
A 58-year-old woman with progressive spastic paraparesis
for ten years had no history of epileptic attacks. In January,
1978, neurological examinatitin showed spastic paraparesis
with increased tendon reflexes and bilateral extensor plantar responses. She was not receiving drug treatment. Cerebral CT scans taken in 1078 and electroencephalograms
(EEGs) done in 1972, 1977, and 1978 were normal. An
EEG taken in October, 1976, however, showed two short
bursts of atypical bilateral spike and wave activity apparently beginning in the right frontotemporal region.
Myelography was carried out, with 15 ml of metrizamide
(210 mg of iodine per milliliter) being introduced by the
lumbar route. The upper level of visible contrast medium
From the Departments of Neurology and Neuroradiology, Rikshospitalet, The National Hospital, University of Oslo, Oslo, and
Troms6 Regional Hospital, University of Troms6, Tromsd, Norway.
Received Oct 31, 1979, and in revised form Jan 29, 1980. Accepted for publication Feb 2, 1980.
Address reprint requests to David Russell, MD, Department of
Neurology, Rikshospitalet, The National Hospital, University of
Oslo, Pilestredet 32, Oslo 1, Norway.
was in the middle cervical region. Approximately 8 hours
later the patient became confused and disoriented for time
and place. She became extremely restless and repeatedly
attempted to undress in full view of the other patients.
These symptoms continued for 4 hours before being successfully treated. EEG recordings during this period
showed, in addition to continuous generalized theta and
delta activity, spikes and sharp waves alternating independently over both hemispheres but with a right-sided preponderance (Fig 1).The patient was treated with diazepam
intravenously, which resulted in immediate clinical improvement: she became calm and in the space of a few minutes was oriented for time and place. She had, however,
amnesia for the period during which the symptoms occurred. Control EEG recordings were normal apart from an
examination taken two weeks following myelography,
which showed one short burst of bilateral atypical spike and
wave activity with probable inidation in the right frontotemporal region. The diagnosis on discharge was progressive spastic paraparesis of unknown cause.
Patient 2
A 60-year-old woman with progressive spastic paraparesis
for three years had no history of epileptic attacks. Neurological examination showed retardation of active movements in both arms and spastic paraparesis with bilateral
extensor plantar responses. She was not receiving drug
therapy. A cerebral CT examination showed ventricular
enlargement without dilatation of the cortical sulci. EEGs
taken in 1977, 1978, and 1979 demonstrated focal theta
and delta activity in the left temporal region. Myelography
was carried out, 15 ml of meuizamide (200 mg of iodine
per milliliter) being introduced by the lumbar route. The
upper level of visible contrast was in the lower cervical region. Contrary to usual routine, the patient lay down in bed
for approximately 15 minutes following this investigation
before her position was corrected.
Approximately fifteen hours later the patient became
confused and disoriented for time and place. Subsequently
she grew progressively more restless, and it became almost
impossible to confine her to bed. She continuously carried
out bizarre and unmotivated movements. During the
period of these symptoms, EEG recordings were carried
out on three occasions with a total recording time of approximately 2 hours. The EEG (Fig 2A) showed spikes and
sharp waves alternating independently over both frontotemporal regions with left-sided preponderance, together with generalized theta and delta activity. Twelve
hours after the onset of symptoms, the patient was treated
with 1 mg of clonazepam intravenously and the clinical
state and EEG findings were carefully noted. Within 2 minutes following the injection, both ictal and generalized
theta and delta activity disappeared and the EEG became
almost normal (Fig 2B). Marked clinical improvement occurred simultaneously-the patient became calm and was
oriented for both time and place, though she had amnesia
for the preceding 12 hours. Cerebral CT demonstrated
metrizamide over both cerebral hemispheres. Control
EEGs demonstrated focal theta activity with sharp components in the left frontotemporal region. The patient was
discharged with the diagnosis of multiple sclerosis.
0364-5134/80/090325-03$01.25 @ 1979 by David Russell
325
Fig 1 . (Patient 1) Representative EEG during status epilepticus, showing spikes and sharp wawes alternating independently wer both hemispheres together with continuous
generalized theta and delta activity.
Fig 2. (Patient 2) Electroencephalograms before (A)and 2
minutes afier (B) administration of 1 mg of clonazepam
intravenowly, shwing disappearance of both ictal and thetadelta activity. Notable clinical improvement occurred simultaneously.
326 Annals of Neurology Vol 8 No 3 September 1980
Discussion
In both patients the clinical picture that developed 8
to 15 hours following myelography with metrizamide
was similar, with confusion and repeated complex
motor symptoms lasting several hours. EEG recordings during these episodes showed almost continuous ictal activity, which alternated independently
over both hemispheres, together with continuous
theta and delta activity. Clinical recovery immediately followed intravenous administration of antiepileptic medication; in Patient 2 this improvement
was observed simultaneous with the disappearance
of ictal and generalized theta-delta activity from the
EEG. We believe therefore that these episodes
were caused by repeated ictal activity and represent a
nonconvulsive status epilepticus. Although petit ma1
status and CPSE may be difficult to differentiate
clinically, the EEG findings in both patients during
these episodes seem decisive. The bilateral synchronous symmetrical spike and slow wave activity
characteristic of petit ma1 status was not seen.
Although metrizamide is a well-tolerated contrast
medium and is now widely used in myelographic examinations, grand mal, petit mal, focal seizures, and
confusion have been reported following its use
[lo-121. To date, however, CPSE has not been recorded. This may suggest that such a complication is
rare, o r it may be that the possibility of CPSE has not
been given sufficient consideration in patients with
no history of seizures who become confused following myelography. The development of this complication may require the presence of preexisting epileptogenic activity. Prophylactic anticonvulsant therapy
should therefore be considered if potentially epileptogenic changes have been found on EEG recording.
The amount of metrizamide used during myelography and the concentration that flows intracranially
may also be important precipitating factors. In both
our patients, relatively high concentrations of metrizamide were used: 3.15 and 3.0 gm, respectively.
Also, for Patient 2 the usual routine was not followed
in that she lay down for approximately fifteen minutes following myelography.
To date we have not observed sequelae following
the status epilepticus in these two patients. Prolonged memory deficit can, however, follow CPSE
and may be evidence for prolonged if not permanent
interference with the function of limbic structures
[ 2 1. It is important, therefore, that this complication
following the use of metrizamide be recognized and
adequate antiepileptic treatment be initiated when
appropriate.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
und zu atypischen Dhrnerzustiinden und Verstirnmungen.
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Engel J, Ludwig BI, Fete11 M: Prolonged partial complex
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Escueta AV, Boxley J, Stubbs N , et al: Prolonged twilight
state and automatisms: a case report. Neurology (Minneap)
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Gastaut H, Roger J, Roger A: Sur la significationde certaines
fugues 4pileptiques. A propos d’une observation klectroclinique d’ “itat de ma1 temporal.” Rev Neurol (Paris)
94~298-301, 1956
Henriksen GF: Status epilepticus partialis with fear as clinical
expression. Epilepsia 14:39-46, 1973
Kroth N: Status with psychomotor attacks (abstract). Electroencephalogr Clin Neurophysiol 23:183-184, 1967
Lugaresi E, Pazzaglia P, Tassinari CA: Differentiation of “absence status” and “temporal lobe status.” Epilepsia 12:77-87,
1971
Markand ON, Wheeler GL, Pollack SL: Complex partial
status epilepticus (psychornotor status). Neurology 28: 189196, 1978
Mayeux R, Lueders H: Complex partial status epilepticus:
case report and proposal for diagnostic criteria. Neurology
28957-961, 1978
Nickel AR, Salem JJ: Clinical experience in North America
with metrizamide. Acta Radiol [Suppl] 355:409-416, 1977
Skalpe 1 0 : Adverse effects of water-soluble contrast media in
rnyelography, cisternography and ventriculogaphy. Acta
Radiol [Suppl] 355:359-370, 1977
Sortland 0, Lundervold A, Nesbakken R. Mental confusion
and epileptic seizures following cervical myelography with
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References
1. Dreyer R: Zur Frage des Status epilepticus mit psychomotoris-
chen Anfdlen. Ein Beitrag zum temporalen Status epilepticus
Case Report: Russell et al: Complex Partial Status Epilepticus 327
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statue, complex, metrizamide, epileptic, myelography, following, partial
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