Adult aphasic status epilepticus: A systematic review and patient-level synthesis of clinical phenotypes and multimodal diagnostic evidence.

BACKGROUND

Aphasic status epilepticus (ASE) is an uncommon manifestation of focal status epilepticus in which aphasia is the sole or predominant clinical feature. Recognition may be difficult because consciousness can be relatively preserved, convulsive activity may be absent, and the presentation can mimic acute stroke.

OBJECTIVE

To characterize diagnostic phenotypes of adult ASE and synthesize clinical, electrographic, and neuroimaging features across published cases.

METHODS

We conducted a systematic review and patient-level synthesis of adult ASE cases. Eligible patients were adjudicated as definite or probable ASE using prespecified criteria. Clinical phenotype, electroencephalographic (EEG) findings, neuroimaging, initial diagnostic impressions, treatment, and language outcomes were extracted.

RESULTS

Ninety-nine publications contributed 168 adults with ASE, including 89 definite and 79 probable cases. Aphasia was the sole manifestation in 42.9% and predominant in 57.1%, while consciousness was preserved in 78.0%. Ictal EEG activity or electrographic status epilepticus was documented in 53.0%, and 41.7% had supportive epileptiform abnormalities. Among cases with interpretable EEG laterality, 92.7% were left-lateralized. Peri-ictal MRI abnormalities occurred in 41.2% of performed interpretable studies. Among 55 patients with interpretable functional perfusion or metabolic imaging, hyperperfusion was reported in 32. FDG-PET hypermetabolism was treated as a distinct metabolic finding. Stroke or transient ischemic attack was the most frequent reported initial impression (44.2%). Complete language recovery was reported in 77.4% of evaluable patients.

CONCLUSIONS

Published adult ASE cases show a heterogeneous phenotype in which recognition commonly rests on concordance between language disturbance and focal EEG abnormalities, with peri-ictal imaging providing complementary evidence. These findings do not establish diagnostic accuracy of individual features or multimodal combinations.