De novo aphasic status epilepticus: Finally making the diagnosis by long-term EEG

Aphasic status epilepticus (SE) is a rare manifestation of non-convulsive SE (NCSE) and may occasionally be under-recognized. We report a 69-year-old male patient with a pre-existing left parietal oligodendroglioma WHO III after two resections and radio-chemotherapy. The patient was left with some word finding difficulties but had no history of overt seizures. He developed aphasic NCSE, which was only detected by long-term electroencephalography (EEG) monitoring. The 24-hour EEG revealed paroxysmal rhythmic theta-delta activity in left posterior regions that propagated to left temporo-parietal areas. Rhythmic activity appeared every 15-30 min and lasted for 10-110 s. Aphasia was continuously present with superimposed short-lasting clinical deteriorations during the day. Magnetic resonance imaging showed peri-ictal edema on diffusion-weighted images in the insula and fronto-parietal cortex, which supported the diagnosis of SE. NCSE persisted for seven months. The patient recovered upon addition of intravenous phenytoin. One should not only consider aphasic SE when language impairment is episodic, but also when there are prolonged manifestations, especially when the typical differential diagnoses have been excluded. Intravenous therapy may be required to terminate NCSE. With this report, we would like to draw attention to aphasic SE as a rare phenomenon that may be difficult to diagnose and delay management in clinical practice.