1528 - Myoclonic Balancing Act: Lessons From a Classic Presentation of Lance-Adams Syndrome

Case Diagnosis: Refractory post-anoxic myoclonic epilepsy secondary to anoxic brain injury (ABI)

Case Description: 65-year-old male who sustained an ABI after 15 minutes of cardiopulmonary arrest. He developed myoclonus during his acute hospital stay and was started on Levetiracetam, Depakote, and Clonazepam. He was first discharged to subacute rehabilitation. Within a week, he was readmitted due to increased aggression and agitation. This was controlled by discontinuing Levetiracetam and starting Olanzapine. The patient was then discharged to inpatient rehabilitation (IPR). On admission, patient exhibited no voluntary control over myoclonic movements and was total assistance in all Functional Independence Measure (FIM) categories based on therapy evaluations. Electroencephalogram demonstrated focal epileptiform discharges consistent with cortical myoclonic seizure. Brivaracetam was initiated leading to decreased myoclonus and better overall volitional control. Close titrations of medications were performed to balance myoclonic control with worsening somnolence and agitation.

Discussions: Patient remained controlled on Clobazam, Depakote, and Brivaracetam and FIM scores improved to moderate-maximum assist for the majority of functional domains. Lance-Adams Syndrome is a rare and difficult condition to treat classically caused by ABI following prolonged cardiopulmonary resuscitation. Myoclonus is worsened by intentional action, leading patients to become dependent in various functional domains due to loss of voluntary motor control. Limited case reports demonstrate using anti-epileptic medications, predominantly Depakote, Levetiracetam, and Clonazepam, to treat this sequela of brain injury. However, these medications may often exacerbate and worsen various deficits following ABI including agitation, cognition, arousal, etc. Thus, improved control of myoclonus may exacerbate conditions leading to worsened functional outcomes.

Conclusions: Lance-Adams Syndrome and the spectrum of myoclonic seizures/epilepsy is hard to treat. Reported medications often involve side effects such as drowsiness, increased agitation, slowed cognitive recovery which can amplify symptoms of ABI. From a rehabilitation perspective, there needs to exist a careful balancing act between medication titration to achieve the best functional results.