Clinical Reasoning: A 56-Year-Old Man With Unusual Presentation of Subacute Encephalopathy and Seizure

A 56-year-old, right-handed man presented with subacute confusion and seizures following a recent stroke. The ischemic event occurred in the left medial temporal region, resulting in right-sided hemiparesis, dysphagia, and dysarthria. The patient’s family noticed cognitive decline after the stroke, including difficulties with reading, spelling, and recognizing faces. The stroke workup revealed elevated low-density lipoproteins (200) and hemoglobin A1c (6.5), as well as a normal echocardiogram. A treatment of aspirin and atorvastatin was started. The first seizure, which occurred 1 month after the stroke, also prompted the use of levetiracetam (500 mg) twice a day. This treatment proved effective until the day of admission, when the patient presented with multiple episodes of focal motor to bilateral tonic-clonic seizure, persisting more than 5 minutes, and convulsive status epilepticus. He received lorazepam, which successfully resolved the episodes.

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