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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282X

Arq. Neuro-Psiquiatr. vol.72 no.8 São Paulo Aug. 2014 

Images in Neurology

Stimulus-induced Rhythmic, Periodic, or Ictal Discharges (SIRPDs) associated with seizures in cefepime neurotoxicity

Descargas ictais, periódicas ou rítmicas induzidas por estímulos (SIRPIDs) associadas a crises epilépticas na neurotoxicidade por cefepime

Valmir Passarelli

Maria Paula Oliveira Moutinho da Conceição

Eduardo Sturzeneker Trés

José Furtado Alves Junior

Meire Argentoni Baldocchi

1Departamento de Neurologia, Hospital Santa Marcelina, Sao Paulo SP, Brazil.

Cefepime was started for a patient with urinary tract infection and renal failure. The next day, she started confusion and seizures. EEG recorded Stimulus-induced Rhythmic, Periodic, or Ictal Discharges (SIRPIDS) associated with seizures (Figure). Cefepime was discontinued. Subsequent EEG demonstrated only slowed background (SB).

Figure Initial EEG. Prior to stimulation, slowing of background (A). After sternal rub, bilateral triphasic waves (repeated every 0.5 s) prominent in the fronto-central regions of the two hemispheres, left and median predominated (B). This activity was associated with jerks affecting right upper limb. 

The EEG in cefepime neurotoxicity (CN) is considered non-reactive to stimulation, and characterized for SB associated or not with periodic discharges, including triphasic waves (TWs). Discordantly, we describe SIRPIDS in CN1,2.

Our report and the recent description of repeated TWs as ictal pattern3,4 demonstrate that at least some discharges in CN are epileptic related.

Alerting stimuli activate the arousal circuitry, and, when combined with hyperexcitable cortex, result in SIRPIDS and seizures5.


. Jallon P, Fankhauser L, Du Pasquier R, et al. Severe but reversible encephalopathy associated with cefepime. Neurophysiol Clin 2010;30:383-386. [ Links ]

. Bragatti JA, Rossato R, Ziomkowski S, Kliemann FAD. Cefepime-induced encephalopathy: clinical and electroencephalographic features in seven patients. Arq Neuropsiquiatr 2005;63:87-92. [ Links ]

. Bragatti JA. The role of triphasic waves in the care of critically ill patients. Clin Neurophysiol 2013;124:1924. [ Links ]

. Sutter R, Stevens RD, Kaplan PW. Significance of triphasic waves in patients with acute encephalopathy: A nine-year cohort study. Clin Neurophysiol 2013;124:1952-1958. [ Links ]

. Hirsch LJ, Pang T, Claassen J, et al. Focal motor seizures induced by alerting stimuli in critically ill patients. Epilepsia 2008;49:968-973. [ Links ]

Received: February 18, 2014; Revised: May 02, 2014; Accepted: May 22, 2014

Correspondence: Valmir Passarelli; Rua Oscar Freire, 1380 / apto 51; 05409-010 São Paulo SP, Brasil; E-mail:

Creative Commons License This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.