Non-electrographic Seizures Due to Subdural Hematoma: A Case Series and Review of the Literature
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REVIEW ARTICLE
Non-electrographic Seizures Due to Subdural Hematoma: A Case Series and Review of the Literature Joseph Driver1 • Aislyn C. DiRisio1 • Heidi Mitchell2 • Zachary D. Threlkeld3 • William B. Gormley1
Ó Springer Science+Business Media, LLC, part of Springer Nature & Neurocritical Care Society 2018
Abstract Seizures due to subdural hematoma (SDH) are a common finding, typically diagnosed using electroencephalography (EEG). At times, aggressive management of seizures is necessary to improve neurologic recovery and outcomes. Here, we present three patients who had undergone emergent SDH evacuation and showed postoperative focal deficits without accompanying electrographic epileptiform activity. After infarction and recurrent hemorrhage were ruled out, seizures were suspected despite a negative EEG. Patients were treated aggressively with AEDs and eventually showed clinical improvement. Long-term monitoring with EEG revealed electrographic seizures in a delayed fashion. EEG recordings are an important tool for seizure detection, but should be used as an adjunct to, rather than a replacement for, the clinical examination in the acute setting. At times, aggressive treatment of suspected postoperative seizures is warranted despite lack of corresponding electrographic activity and can improve clinical outcomes. Keywords Seizures Intensive care Subdural hematoma
Background and Importance Subdural hematoma (SDH) is the most frequent extra-axial hemorrhage requiring emergent neurosurgical evacuation, accounting for about 90,000 hospitalizations annually in the USA [1]. One of the most frequent sequelae is focal seizure, and in a subgroup of chronic subdural hematomas in elderly patients, generalization is not uncommon. Subdural blood products are particularly epileptogenic, and effective detection and management of the resultant seizures are critical to mitigate negative consequences. While we frequently use surface electroencephalography (EEG) to aid diagnosis, EEG suffers from limited sensitivity. Even in the absence of electrographic seizures, a suggestive & William B. Gormley [email protected] 1
Department of Neurosurgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
2
Massachusetts General Hospital Institute of Health Professions, Boston, MA, USA
3
Department of Neurology, Massachusetts General Hospital and Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
history, examination, and clinical course warrant presumptive—and at times aggressive—treatment, especially once other etiologies of postoperative neurologic deficit have been ruled out. We present three cases in which patients underwent emergent subdural hematoma evacuation and postoperatively suffered fluctuating focal neurologic deficits clinically presumed secondary to seizure. These cases demonstrate the importance of maintaining high clinical suspicion for seizure as a cause of worsening neurologic status following subdural hematoma evacuation in
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