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A middle-aged woman became unresponsive while speaking to her son on the phone and was subsequently found at home unconscious with foam around her mouth. En route to the emergency department, paramedics witnessed a generalised tonic-clonic seizure with left eye deviation and left arm flexion. In the emergency department, she remained unresponsive, was intubated, received a loading dose of levetiracetam and was transferred to the neurosciences intensive care unit. On examination, she was drowsy. There was an increased tone in all four limbs but particularly in the right arm, failure of the left arm to withdraw to pain and generally brisk reflexes. Pertinent results included significant lactic acidosis (plasma lactate 19.6 mmol/L (0.6–1.8)) and elevated serum creatine kinase at 1181 U/L (24–170). CT/CT angiogram/CT venogram head showed a small sulcal subarachnoid haemorrhage in the right precentral sulcus and a small arteriovenous malformation in the same region. Cerebrospinal fluid examination found no evidence of infection or xanthochromia. She remained intubated and sedated in the intensive care unit for several hours, where continuous video electroencephalography showed diffuse delta waves due to sedative effect with no …
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