PLEDs in Creutzfeldt–Jakob disease following a cadaveric dural graft Masahito Fushimi a, * , Kazuhiro Sato a , Tetsuo Shimizu a , Hiroshi Hadeishi b a Department of Neuropsychiatry, Akita University School of Medicine, Akita, Japan b Department of Surgical Neurology, Research Institute for Brain and Blood Vessels, Akita, Japan Accepted 4 April 2002 Abstract Introduction: Periodic synchronous discharges (PSDs) are a well-known electroencephalographic finding associated with Creutzfeldt– Jakob disease (CJD), but only a few reports have documented the appearance of periodic lateralized epileptiform discharges (PLEDs) in CJD and there has been no discussion as to why PLEDs appear with unilateral (right or left) dominance. Case report and discussion: We report on a 61-year-old man who received a cadaveric dura mater graft and developed CJD 14 years later. Periodic lateralized epileptiform discharges (PLEDs) were observed predominantly in the right hemisphere, coinciding with the location of the dural graft, the presumed source of the CJD agent and PLEDs seen in this case finally developed into PSDs. A similar case has not been reported in the literature and we believe this case serves to further the understanding of the pathophysiology of CJD. q 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Electroencephalography; Cadaveric dural graft; Computed tomography; Periodic lateralized epileptiform discharges; Periodic synchronous discharges; Creutzfeldt–Jakob disease 1. Introduction According to a nationwide survey commissioned by the Ministry of Health and Welfare and conducted by the Japan Creutzfeldt–Jakob disease (CJD) Surveillance Group, 57 patients with CJD had histories of cadaveric dural grafts in Japan between January 1979 and September 1999 (Sato et al., 1997; Nakamura et al., 1999; Hoshi et al., 2000). Of these 57 CJD patients, 45 fell into the ‘probable’ CJD cate- gory. Periodic synchronous discharges (PSDs) were present in 51 of these patients, but a detailed analysis of electroen- cephaographic (EEG) findings over time in these patients has not yet been reported (Miyashita et al., 1991; Sato et al., 1997; Nakamura et al., 1999; Hoshi et al., 2000). PSDs are a well-known EEG finding associated with CJD (Burger et al., 1972; Au et al., 1980; Lee et al., 2000), but only a few reports have documented the appearance of periodic later- alized epileptiform discharges (PLEDs) in CJD (Au et al., 1980; Lee et al., 2000). In contrast to PSDs, which have been reported in cases of CJD, subacute sclerosing panen- cephalitis (SSPE), anoxic encephalopathy, and metabolic encephalopathy (particularly, hepatic coma), PLEDs are usually associated with acute focal unilateral lesions such as infarcts, tumor, encephalitis (Chatrian et al., 1964; Schwartz et al., 1973; Westmoreland et al., 1986). In addi- tion, PLEDs usually emerge transiently and disappear within a few days or weeks (Au et al., 1980; Westmoreland et al., 1986), whereas PSDs occur over a relatively longer time period. CJD should be suspected on the rare occasions where PLEDs occur persistently (Au et al., 1980). Our case falls into the ‘probable’ CJD category and presumably the grafted dura mater was the source of the CJD agent. PLEDs appeared initially and predominantly in the hemisphere where dura mater was grafted, and were subsequently replaced by PSDs. 2. Case report In February 1983, a 61-year-old man with no history of familial neurologic disease developed a hematoma in the right temporal lobe subsequent to the rupture of an aneur- ysm in the right middle cerebral artery. Surgical treatment consisted of clipping the aneurysm, evacuation of the hema- toma and cranioplasty. Lyophilized dura mater (Lyodura, manufactured by B. Braun Melsungen, Germany, lot number unknown) was used. The patient was discharged at about 2 months after surgery and had no difficulty in performing activities of daily living. There were no epileptic discharges in EEGs and no clinical seizures developed. In December 1997, the patient started to suffer from episodes Clinical Neurophysiology 113 (2002) 1030–1035 1388-2457/02/$ - see front matter q 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S1388-2457(02)00116-5 www.elsevier.com/locate/clinph CLINPH 2001183 * Corresponding author. Tel.: 181-188-846122; fax: 181-188-846445. E-mail address: fushimi@psy.med.akita-u.ac.jp (M. Fushimi).