Using video electroencephalography (video-EEG) as supporting evidence, we aim to characterize clinical correlates of transient neurological attacks due to plateau waves, or paroxysmal episodes of intracranial hypertension.

Plateau waves of intracranial pressure occur in patients with leptomeningeal disease, whether from carcinomatosis or infection.  They may lead to stereotyped episodes of transient neurological attacks that are often clinically misdiagnosed in the acute setting as seizures and ineffectively treated with antiepileptic drugs.

We report the case of a 53-year-old man presenting with 2 years of worsening headaches and weight loss, and one month of stereotyped transient attacks. These were described as rapid onset extensor posturing with right-sided head turn and intact awareness, lasting for 1-2 minutes, followed by hours of slow, scanning speech, confusion, and right-sided weakness. He was found to have chronic leptomeningitis due to fungal infection, with elevated intracranial pressure demonstrated on serial lumbar punctures with opening pressure of 60cmH₂O. At another institution, these events were labeled seizures and he was treated with escalating doses of antiepileptic drugs without benefit. At our institution, we demonstrate via video-EEG captured spells and their EEG correlates, including changes in background waves from theta to generalized rhythmic delta activity and frontal rhythmic delta activity. The spells were then diagnosed as plateau waves of intracranial pressure. Treatment with serial lumbar punctures, topiramate, and acetazolamide led to a marked reduction in the frequency of attacks.