How is CPSE diagnosed?

Updated: Feb 13, 2018
  • Author: Julie L Roth, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Answer

The approach to a patient with a confusional or stuporous picture that suggests complex partial SE (CPSE) is similar to the approach in simple partial SE and epilepsy partialis continua. The first pivotal step is including CPSE in the differential diagnosis. Numerous authors report that CPSE is often overlooked and that correct diagnosis is often considerably delayed. This problem stems from the close clinical overlap between CPSE and other, more common encephalopathies in hospitalized patients.

When CPSE occurs in the setting of previous epilepsy, search for new medical stressors (eg, toxins, metabolic derangements, alcohol, proconvulsant medications, subtherapeutic anticonvulsants, intercurrent illness, hypoxemia) that may trigger its expression. [59]

Another common clinical scenario leading to CPSE, especially in patients without previous epilepsy, involves overt yet self-limited generalized convulsion, often in the context of a new serious medical illness, after surgery, or after an acute CNS process. In this familiar scenario, the patient does not have the expected timely recovery to neurologic baseline after the brief convulsion.

Anticonvulsants are often started in response to the overt seizure, though frequently with inconsistent attention to blood levels. The patient's persistent stupor is initially misattributed to the concomitant medical illness or a diminished recuperative ability (in older patients) to the newly acquired CNS process. Potentially diagnostic EEGs may be wrongly deferred after that new-onset convulsion in this setting because the overt seizure is long over and the diagnosis of CPSE is overlooked.

Numerous authors have highlighted the frequent association of CPSE with previous or late generalized convulsive seizures. This constellation of features includes the following sequence:

  1. Serious medical, surgical, or neurological illness

  2. A brief convulsive seizure

  3. Protracted stupor with fluctuating neurologic findings, subtle nystagmus, or focal twitching

The presence of these elements should prompt consideration of CPSE and expedient EEG evaluation. After EEG results confirm CPSE, the workup proceeds as outlined for simple partial status epilepticus/epilepsy partialis continua.


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