Electroencephalographic manifestations of intracranial hypertension in a patient with ventriculoperitoneal shunt malfunction.

BACKGROUND

Differentiating epileptic seizures from manifestations of intracranial pressure (ICP) fluctuations can be challenging in patients with a ventriculoperitoneal shunt (VPS). We report a case of intermittent VPS malfunction presenting with focal motor events initially misdiagnosed as refractory status epilepticus. A 27-year-old man with childhood-onset hydrocephalus treated with a right VPS and a previous history of focal epilepsy-managed with levetiracetam, perampanel, and lacosamide-presented with increased seizure frequency and intermittent headaches. Initial treatment included continuous infusions of valproate, lacosamide, and levetiracetam under the presumption of status epilepticus. However, prolonged (15-hour) video-EEG monitoring during the clinical events showed diffuse delta activity with suppression of the background rhythm rather than ictal discharges. These EEG changes coincided with episodes of arterial hypertension, profound bradycardia (as low as 20 bpm), and papilledema on funduscopic examination. Revision of the shunt system resulted in complete resolution of symptoms and withdrawal of antiseizure medications.

CONCLUSION

Extended video-EEG monitoring can be a useful tool to distinguish epileptic seizures from paroxysmal manifestations of paroxysmal intracranial hypertension due to VPS malfunction.