How to use these
Read the vignette, look at the trace, decide what you would write and what you would do. Then read on.
1 · Fever and confusion
A 54-year-old with three days of fever, headache and odd behaviour has a focal seizure with impaired awareness.
Reading: lateralized periodic discharges over the left hemisphere, maximal temporally, on a slow background. Next: this is herpes simplex encephalitis until shown otherwise. Intravenous aciclovir (10 mg/kg every 8 hours in adults with normal renal function) starts now, before the lumbar puncture result and the MRI. LPDs carry a high risk of further seizures: keep monitoring. 17,25
2 · Not waking after cardiac arrest
A 61-year-old, 36 hours after return of spontaneous circulation, rewarmed, sedation stopped 12 hours ago. No motor response to pain.
Reading: burst suppression, unreactive. Next: a highly malignant pattern beyond 24 hours, but no single test decides. Confirm that sedation and temperature do not explain it, then complete multimodal assessment at 72 hours or later: pupillary and corneal reflexes, somatosensory evoked potentials, neuron-specific enolase, imaging. 7,8
3 · Still drowsy after a convulsion
A 70-year-old had a generalized tonic-clonic seizure that stopped with lorazepam. Ninety minutes later she is still unresponsive, with subtle twitching of the right face.
Reading: a left temporal seizure with clear evolution; if these recur without recovery between them, non-convulsive status epilepticus. Next: treat as status epilepticus with a second-line agent, and continue EEG to confirm that the seizures have stopped, not only the movements. 1,2,16
4 · Cirrhosis and drowsiness
A 58-year-old with cirrhosis becomes sleepy and disorientated, with asterixis.
Reading: generalized periodic discharges with triphasic morphology on a slow background, increasing with stimulation. Next: consistent with a metabolic encephalopathy; look for the precipitant and review the drug chart for cefepime and other culprits. If the picture does not fit or does not improve, a monitored benzodiazepine trial is reasonable: only clinical improvement counts. 1,22
5 · Rapid decline over eight weeks
A 66-year-old with eight weeks of memory loss, ataxia and startle myoclonus.
Reading: generalized periodic sharp wave complexes at about 1 Hz on an attenuated background. Next: supports sporadic Creutzfeldt-Jakob disease; MRI with diffusion-weighted imaging and CSF RT-QuIC carry more diagnostic weight. First exclude treatable mimics: autoimmune encephalitis, non-convulsive status, toxic and metabolic causes. 20
6 · Events that resist treatment
A 27-year-old has had prolonged shaking episodes for two years despite three anti-seizure medications. During video-EEG she has a typical event: eyes closed, asynchronous limb movements waxing and waning for six minutes.
Reading: a normal posterior dominant rhythm before, during and after the event. Next: a documented functional (dissociative) seizure. Explain the diagnosis clearly and without blame, refer for psychological treatment, and withdraw anti-seizure medication gradually if there is no evidence of coexisting epilepsy. 19,28
The habit behind all six: describe what you see in standard terms, state how sure you are, and tie the reading to the patient in front of you.