Postoperative delirium mimicking epilepsy

We read with interest the article by Reuber et al. (Anaesthesia 2000; 55: 74–8) on postoperative pseudostatus. We think this paper deals with an important clinical scenario about which little has been reported so far. We wish to share our experience in managing a 47-year-old female with a history of long-standing epilepsy who had pseudoepileptic seizures due to postoperative delirium. She had suffered from epilepsy since the age of 14 years, for which she was treated with carbamezepine 300 mg qds and primidone 250 mg qds. Although her last epileptic fit was 14 years ago, she suffered status epilepticus following a decompression of carpal tunnel under general anaesthesia 9 years ago and an epileptic fit associated with collapse following lidocaine and epinephrine dental injection a year ago. Otherwise, she had several uncomplicated operations, mainly for congenital lumbar canal stenosis. During her current admission for elective laminectomy of the 5th lumbar vertebra for decompression of L5 and S1 nerve roots, she was extremely anxious on pre-operative assessment. She failed to relax despite 5 mg of midazolam and 1000 mg of thiopental for induction, and required isoflurane. Muscle relaxation was induced with succinylcholine and anaesthesia was maintained with isoflurane. Her operative course was uneventful. However, during recovery she had two episodes of generalised shaking movements lasting for 3 min each, but not associated with loss of consciousness, incontinence or tongue biting. Her oxygen saturations were maintained during recovery. She remained confused, drowsy but rousable. In view of the epileptiform movements she was intubated and ventilated on the intensive care unit overnight. However, these abnormal movements, which were thought to be ‘atypical’ seizures, persisted in the ensuing week despite the addition of intravenous phenytoin to her anti-epileptic medication. Her CT head scan and blood tests were normal. She also started hallucinating during abnormal movements. Her EEG, when she was confused, agitated and exhibiting abnormal movements, showed no epileptic activity. She was treated for postoperative delirium with droperidol 5–10 mg qds and her epileptiform shaking movements stopped. She also stopped hallucinating and remained well subsequently. Delirium during the recovery period has been mainly reported in elderly patients [1]. Typical diagnostic criteria for delirium include perceptual disturbance, incoherent speech, disorientation, memory lapses, and reduced awareness and attention. Our patient was at risk of developing postoperative delirium because of epilepsy, anticonvulsant drugs, previous numerous operations and anxiety. She suffered from hallucinations and agitated behaviour associated with abnormal movements, which mimicked epilepsy. She responded to neuroleptic medication, droperidol – the preferred treatment for delirium. These features suggest that her agitation and shaking during the postoperative period were not due to epilepsy.

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