A 54-year-old female presented with a decreased level of consciousness and loud stridor for one day. She had a history of left temporal astrocytoma status post resection, adjuvant chemotherapy, and radiotherapy, with complete remission for 20 years. She had secondary epilepsy manifested by recurrent speech arrest, controlled with levetiracetam (500 mg twice a day). Physical examination on admission showed no focal deficits. Laboratory findings and cerebrospinal fluid analysis were unremarkable. MRI of the brain revealed no acute pathology but showed cavernomas in the right frontal operculum and occipital area, along with left temporal encephalomalacia related to past surgery. An otolaryngologist, using flexible fiberoptic laryngoscopy, noted the stridor resulting from paradoxical vocal cord movements, suggesting a central etiology. EEG revealed continuous focal seizure activity, primarily right fronto-central.
Patient was loaded with Sodium Valproate and Levetiracetam. As the patient had a drop in her oxygen saturation, she was intubated and started on midazolam infusion with continuous EEG monitoring for 48 hours. Lacosamide, Perampanel and Phenytoin were added sequentially. EEG later showed cessation of seizure activity and midazolam was weaned off. Patient was extubated and woke up with no stridor. EEG continued to show no seizure activity. As patient clinical condition improved, she was discharged home. She was seen in the clinic a month later and her neurological exam revealed normal consciousness and no recurrence of stridor.