Subacute encephalopathy with seizures in alcoholics (SESA) syndrome: Relevant questions

• Published in: Epilepsy & behavior 2024-10, Vol.159, p.109968, Article 109968
• Main Authors: Fernández-Torre, José L., Kaplan, Peter W., Hernández-Hernández, Miguel A.
• Format: Article
• Language: English
• Subjects: Chronic alcoholism; Focal nonconvulsive status epilepticus; Lateralized periodic discharges; SESA syndrome
• ISSN: 1525-5050; 1525-5069; 1525-5069
• DOI: 10.1016/j.yebeh.2024.109968

•SESA syndrome has a stereotyped clinical onset, evolution, prognosis and natural history.•SESA syndrome seems to represent a subtype of focal NCSE.•Recurrent focal nonconvulsive seizures and dynamic state of ictal-interictal continuum are main causes of confusion in this condition.•Maladaptive homeostatic plasticity due to alcohol abuse in a brain with chronic microvascular ischemic lesions could be a relevant pathophysiological mechanism in SESA. The aim of this article is to answer three relevant issues: i/What epileptic condition is referred to as subacute encephalopathy with seizures in alcoholics (SESA) syndrome; ii/ Why it can be important to distinguish SESA syndrome in clinical practice and iii/ What do we know about its pathophysiology. We reviewed all cases published in the English language from the initial description of the syndrome to the present. All met the previously established criteria for SESA syndrome were included in our analysis. We found 34 patients diagnosed with SESA syndrome Fourteen (41.1%) out of 34 patients were over 60 years of age. In 12 (35.2 %), abstinence, and in 4 (11.7 %) excessive consumption of alcohol, were considered precipitating factors, respectively. Triggering causes were unknown in 18 cases (53.0 %). All cases (100 %) presented with altered mental status. Fourteen (41.1 %) subjects had a history of epileptic seizures in the context of alcohol withdrawal syndrome (AWS). Twenty (58.8 %) patients had focal motor seizures (FMSs), 24 (70.5 %) bilateral tonic-clonic seizures (BTCSs), and 15 (44.1 %) focal impaired awareness seizures (FIASs). In 8 (23.5 %), criteria for focal nonconvulsive status epilepticus (NCSE) were met. Twenty-eight (82.3 %) subjects had transient neurological deficits. In 29 (85.2 %) subjects, lateralized periodic discharges (LPDs) were observed on the EEG. Areas of signal hyperintensities and restricted diffusion in neuroimaging were mentioned in 22 subjects (64.7 %). Transfer to the intensive care unit was necessary in 8 (23.5 %) subjects. Thirteen (38.2 %) had recurrent episodes. Enduring brain damage was mentioned in 9 (26.4 %) cases. The most used anti-seizure medication (ASM) was levetiracetam, followed by phenytoin and lacosamide. SESA syndrome represents a well-defined subtype of focal NCSE in patients with chronic alcoholism. Its prompt recognition can facilitate the initiation of early ASM therapy and help design appropriate video-EEG evaluation and a treatment strategy.