CT Evidence of Seizure Activity

A 70-year-old male with a history of chronic hyponatremia and normal pressure hydrocephalus presented to the emergency department with new onset of seizures 2 days after the placement of a ventriculoperitoneal shunt. He had received lorazepam by emergency medical services with cessation of seizure activity. 

Endotracheal intubation was carried out for airway protection due to significant altered mental status. Electrolytes were within normal limits, except for the Na+ level, which was 128 mmol/L (baseline level). 

A CT scan of the head demonstrated a very small tract hemorrhage and no changes in ventricle size (Figure 1). CT scan also showed conjugately deviated pupils to the right side (Figure 2), which is an uncommon finding in sedated patients and highly specific for seizures. 

Neurointensivist evaluation and electoencephalogram confirmed nonconvulsive status epilepticus. Patient was loaded with levetiracetam, lacosamide, and lorazepam, with adequate control of seizure activity. 

The etiology of seizures was found to be multifactorial including alcohol withdrawal, chronic hyponatremia, and sleep deprivation. ■