Subacute encephalopathy with seizures in alcoholics (SESA syndrome)

Last revised by Rohit Sharma on 24 May 2024

Subacute encephalopathy with seizures in alcoholics (SESA syndrome) is a rare complication of chronic alcohol use that can present with seizures and a variety of neurological deficits. 

SESA syndrome is rare 1-3

The typical clinical presentation is of confusion, focal neurological deficits, and seizures in a patient with a history of longstanding and heavy ethanol use. Ethanol use may be recent or temporally disparate and presentation in the midst of both ethanol withdrawal and acute intoxication are described.

  • encephalopathy

    • ranging from agitation to delirium to obtundation

  • seizures

    • typically focal motor seizures with or without impaired awareness 6

    • status epilepticus (including epilepsia partialis continua and non-convulsive status epilepticus) may occur 7

    • tonic-clonic seizures (primary or focal-to-bilateral)

  • transient focal neurological deficits

    • hemianopsia

    • hemiparesis

    • aphasia

    • cortical blindness

In addition to features of SESA syndrome, neuroimaging in the majority of patients may demonstrate the sequelae resulting from chronic microvascular ischemia, which are typically diffuse and are accompanied by atrophic changes which may be generalized or demonstrate a temporal predominance ref.

  • areas of cortical-subcortical hyperintensity on T2/FLAIR sequences 4,6

  • frequent hippocampal and thalamic involvement ref

  • corresponding areas are hypointense on ADC and DWI sequences ref

  • lesions may resolve spontaneously over weeks ref

  • MR angiography may demonstrate hypervascularity ref

  • avid glucose utilization in aforementioned lesions

  • analogous lesions demonstrate an increase in vascularity

As patients with a history of SESA syndrome are prone to seizure recurrence, treatment with antiseizure medications is usually prescribed 3,4.

SESA syndrome was first described by Niedermeyer et al. in 1981 2

Recognition of this syndrome is crucial and management altering; conventional antiseizure medications are a rational therapeutic in those with SESA syndrome, as compared to alcohol withdrawal seizures which lacks an underlying epileptogenic focus. Clinical features which favor SESA include:

  • focal seizures with or without impaired awareness

  • an abnormal interictal EEG with focal findings

  • transient focal neurologic deficits

  • temporal relationship to alcohol cessation

Other conditions which may be pertinent to consider include 3,4:

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