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Cortical myoclonus during IV thrombolysis for ischemic stroke.

Bentes C, Peralta R, Viana P, Morgado C, Melo TP, Ferro JM - Epilepsy Behav Case Rep (2014)

Bottom Line: We describe a patient with an acute middle cerebral artery ischemic stroke developing subtle involuntary movements of the paretic upper limb with cortical origin during rt-PA perfusion.Despite the multiple potential pathophysiological mechanisms for the relationship between thrombolysis and epileptic activity, seizures during this procedure are scarcely reported.We aimed to draw attention to the recognition challenge of this paroxysmal motor behavior, highlighting this clinical and neurophysiological identification using video recording and back-average analysis of the EEG.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, Hospital de Santa Maria, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal ; EEG/Sleep Laboratory, Department of Neurology, Hospital de Santa Maria, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal.

ABSTRACT
We describe a patient with an acute middle cerebral artery ischemic stroke developing subtle involuntary movements of the paretic upper limb with cortical origin during rt-PA perfusion. Despite the multiple potential pathophysiological mechanisms for the relationship between thrombolysis and epileptic activity, seizures during this procedure are scarcely reported. Our hypothesis is that subtle and transient clinical seizures, like those described in our patient, may not be detected or are misdiagnosed as nonepileptic involuntary movements. We aimed to draw attention to the recognition challenge of this paroxysmal motor behavior, highlighting this clinical and neurophysiological identification using video recording and back-average analysis of the EEG.

No MeSH data available.


Related in: MedlinePlus

A) EMG channel recording the left flexor digitorum superficialis capturing brief, repetitive, and almost periodic muscle activations (arrows). B) EEG back-average analysis disclosing a negative transient (arrows) with a peak (yellow line) of 10 ms before EMG activations (dotted line) at right central electrodes (C4/FC4).
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f0005: A) EMG channel recording the left flexor digitorum superficialis capturing brief, repetitive, and almost periodic muscle activations (arrows). B) EEG back-average analysis disclosing a negative transient (arrows) with a peak (yellow line) of 10 ms before EMG activations (dotted line) at right central electrodes (C4/FC4).

Mentions: A 72-year-old male with a past history of hypertension, dyslipidemia, chronic kidney disease, and an ischemic stroke 15 years ago, with no poststroke seizures and from which he had completely recovered, presented to the emergency department with sudden onset of left central facial palsy, hemiparesis, homonymous hemianopsia, and right gaze deviation (NIHSS score = 10). Electrocardiogram showed atrial fibrillation, and blood analysis revealed acute renal failure (creatinine = 4 mg/dL, blood urea nitrogen = 134 mg/dL). Plain head computed tomography (CT) disclosed old occipital, parietal, and frontal ischemic lesions and a right medial cerebral artery (MCA) hyperdensity. Intravenous recombinant tissue-type plasminogen activator (rt-PA) was started 140 min after symptom onset. Twenty minutes after starting the infusion period, involuntary movements of the upper paretic limb were noticed. The movements involved either the distal or the proximal muscles, independently, and could be jerk-like, irregular, myoclonic-like, or slow and brief (Video). During rt-PA perfusion, a 72-channel EEG (International 10/10 System) with an EMG channel recording the left flexor digitorum superficialis (sample frequency of 1000 Hz) captured brief, repetitive, and almost periodic muscle activations (Fig. 1A). No epileptiform activity was apparent in the raw EEG data. Back-average analysis of the EEG time-locked with the onset of the recorded myoclonus (538 activations) was performed (BESA software, version 6.0), revealing a right frontocentral negative wave. This EEG transient preceded muscle activation by 30 ms (Fig. 1B). No antiepileptic drug was given, and the involuntary movements lasted approximately 40 min, stopping by the end of the rt-PA perfusion. The neurological deficit did not improve after thrombolysis. Transcranial Doppler showed no recanalization. Computed tomography at 24 h disclosed an acute MCA infarct scoring 5 on ASPECTS, with spared cortical areas within the infarct zone (Fig. 2). The patient partially recovered after 7 days (NIHSS score = 6). No further involuntary movements or clinically suspected seizures were observed despite transitory worsening of renal function during hospitalization. One year after stroke, the patient is alive and independent (NIHSS = 1 and mRS = 1), with no report of late poststroke seizures.


Cortical myoclonus during IV thrombolysis for ischemic stroke.

Bentes C, Peralta R, Viana P, Morgado C, Melo TP, Ferro JM - Epilepsy Behav Case Rep (2014)

A) EMG channel recording the left flexor digitorum superficialis capturing brief, repetitive, and almost periodic muscle activations (arrows). B) EEG back-average analysis disclosing a negative transient (arrows) with a peak (yellow line) of 10 ms before EMG activations (dotted line) at right central electrodes (C4/FC4).
© Copyright Policy - CC BY-NC-ND
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4307875&req=5

f0005: A) EMG channel recording the left flexor digitorum superficialis capturing brief, repetitive, and almost periodic muscle activations (arrows). B) EEG back-average analysis disclosing a negative transient (arrows) with a peak (yellow line) of 10 ms before EMG activations (dotted line) at right central electrodes (C4/FC4).
Mentions: A 72-year-old male with a past history of hypertension, dyslipidemia, chronic kidney disease, and an ischemic stroke 15 years ago, with no poststroke seizures and from which he had completely recovered, presented to the emergency department with sudden onset of left central facial palsy, hemiparesis, homonymous hemianopsia, and right gaze deviation (NIHSS score = 10). Electrocardiogram showed atrial fibrillation, and blood analysis revealed acute renal failure (creatinine = 4 mg/dL, blood urea nitrogen = 134 mg/dL). Plain head computed tomography (CT) disclosed old occipital, parietal, and frontal ischemic lesions and a right medial cerebral artery (MCA) hyperdensity. Intravenous recombinant tissue-type plasminogen activator (rt-PA) was started 140 min after symptom onset. Twenty minutes after starting the infusion period, involuntary movements of the upper paretic limb were noticed. The movements involved either the distal or the proximal muscles, independently, and could be jerk-like, irregular, myoclonic-like, or slow and brief (Video). During rt-PA perfusion, a 72-channel EEG (International 10/10 System) with an EMG channel recording the left flexor digitorum superficialis (sample frequency of 1000 Hz) captured brief, repetitive, and almost periodic muscle activations (Fig. 1A). No epileptiform activity was apparent in the raw EEG data. Back-average analysis of the EEG time-locked with the onset of the recorded myoclonus (538 activations) was performed (BESA software, version 6.0), revealing a right frontocentral negative wave. This EEG transient preceded muscle activation by 30 ms (Fig. 1B). No antiepileptic drug was given, and the involuntary movements lasted approximately 40 min, stopping by the end of the rt-PA perfusion. The neurological deficit did not improve after thrombolysis. Transcranial Doppler showed no recanalization. Computed tomography at 24 h disclosed an acute MCA infarct scoring 5 on ASPECTS, with spared cortical areas within the infarct zone (Fig. 2). The patient partially recovered after 7 days (NIHSS score = 6). No further involuntary movements or clinically suspected seizures were observed despite transitory worsening of renal function during hospitalization. One year after stroke, the patient is alive and independent (NIHSS = 1 and mRS = 1), with no report of late poststroke seizures.

Bottom Line: We describe a patient with an acute middle cerebral artery ischemic stroke developing subtle involuntary movements of the paretic upper limb with cortical origin during rt-PA perfusion.Despite the multiple potential pathophysiological mechanisms for the relationship between thrombolysis and epileptic activity, seizures during this procedure are scarcely reported.We aimed to draw attention to the recognition challenge of this paroxysmal motor behavior, highlighting this clinical and neurophysiological identification using video recording and back-average analysis of the EEG.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, Hospital de Santa Maria, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal ; EEG/Sleep Laboratory, Department of Neurology, Hospital de Santa Maria, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal.

ABSTRACT
We describe a patient with an acute middle cerebral artery ischemic stroke developing subtle involuntary movements of the paretic upper limb with cortical origin during rt-PA perfusion. Despite the multiple potential pathophysiological mechanisms for the relationship between thrombolysis and epileptic activity, seizures during this procedure are scarcely reported. Our hypothesis is that subtle and transient clinical seizures, like those described in our patient, may not be detected or are misdiagnosed as nonepileptic involuntary movements. We aimed to draw attention to the recognition challenge of this paroxysmal motor behavior, highlighting this clinical and neurophysiological identification using video recording and back-average analysis of the EEG.

No MeSH data available.


Related in: MedlinePlus