Epilepsy
Philip B. Gorelick, Fernando D. Testai, Graeme J. Hankey, Joanna M. Wardlaw in Hankey's Clinical Neurology, 2020
At the completion of the benzodiazepine load, and within 30 minutes of the start of therapy, the patient is concurrently started on a second-line therapy for prevention of withdrawal. Most algorithms suggest: Levetiracetam at a dose of 40–60 mg/kg.Lacosamide at a dose of 400–600 mg/day.Valproic acid at a dose of 30–40 mg/kg, if seizures continue, an additional 10 mg/kg may be given.Phenytoin (usually administered as fosphenytoin due to the lower risk of cardiovascular side effects) at 20 mg/kg loading dose.
Posttraumatic epilepsy and neurorehabilitation
Mark J. Ashley, David A. Hovda in Traumatic Brain Injury, 2017
In general, all AEDs should be introduced slowly to avoid problems with neurotoxicity, including somnolence and altered mental status. If introduced too quickly, carbamazepine may cause severe dizziness, and lamotrigine may precipitate a serious rash. However, when multiple seizures or status epilepticus occur, loading with phenytoin is often effective in controlling seizures. For intravenous use, fosphenytoin is better tolerated than phenytoin. Valproic acid is also available for intravenous use and can be used in relatively high doses, acutely, if necessary. Levetiracetam and lacosamide are also available for intravenous administration and appear to be well tolerated at therapeutic starting doses. The intravenous preparations of these drugs may be useful for patients who are unable to take oral medications, for instance, after surgical procedures. With all AEDs, clinical efficacy and tolerability determine appropriate dosing. Most of the newer AEDs do not have well-established therapeutic plasma levels, but nevertheless, the presence of significant traumatic encephalopathy may make determination of AED plasma levels appropriate. Drug plasma levels may be utilized to provide a rough guideline for therapy but should not be used as the sole indicator of therapy or toxicity.60 It should be noted that plasma steady state is not achieved for up to seven half-lives of a medication so that levels are rarely useful acutely after dosing changes.
Epilepsy
Hani Ts Benamer in Essential Revision Notes in Clinical Neurology, 2017
➤ The following are the general principles of treating status (each hospital should have its own protocol and all staff should be familiar with it): ➣ Maintain the airway, assess the breathing and give oxygen, maintain the circulation, establishing intravenous (IV) access; take blood for emergency investigation (full blood count, glucose, renal and liver function tests, calcium level and AEDs level).➣ Give dextrose if there is a possibility of hypoglycaemia or thiamine if there is a history of alcohol abuse.➣ Lorazepam as IV bolus should be given initially (diazepam intravenously or rectally could be used), followed by phenytoin infusion. IV fosphenytoin infusion is an alternative. IV valproate infusion is considered to be as effective. ECG, blood pressure monitoring and pulse oximetry are needed.➣ If status continues the patient should be transferred to the intensive care unit and propofol, thiopental or midazolam should be started after discussion with the intensivist. EEG monitoring is needed in anaesthetised patients.➣ If the patient is known to have epilepsy the regular AEDs should be given orally or through a nasogastric tube. Maintenance AEDs should be started in patients not known to have seizures.
A Case Study on Differential Diagnosis of Episodic Left Arm Numbness
Published in The Neurodiagnostic Journal, 2021
Adam Shugan
The patient was initially given levetiracetam (1 gram), but it was discontinued the following morning due to fear of adverse effects with CKD. He was then given a valproic acid infusion of 450 mg TID. A CT of the head without contrast demonstrated no acute intracranial hemorrhages. An MRI without contrast was also unremarkable and did not locate any lesions that might help to identify a seizure focus. Another long-term EEG was ordered to monitor for seizure activity. With the cessation of the fosphenytoin, the patient was able to tolerate that EEG keeping it on for a full 48 hours, and no further electrographic seizures were recorded. After 4 days in the hospital, the patient was discharged with a prescription for valproic acid, 250 mg TID. The focus of the seizures was never determined.
Critical care
Published in Canadian Journal of Respiratory, Critical Care, and Sleep Medicine, 2021
Ricardo Teijeiro Paradis, Ghislaine Douflé, John Granton
Status epilepticus is a neurological emergency where prompt interventions can achieve early termination of seizures and improve outcomes. Up to ⅓ of patients will have seizures refractory to benzodiazepines. The standard algorithm recommends fosphenytoin, levetiracetam or valproate as the antiepileptics of choice in benzodiazepine refractory seizures. However, only fosphenytoin/phenytoin has been approved by the FDA for this indication. The ESETT trial,22 a multicenter, randomized, adaptive comparative-effectiveness trial, compared the efficacy and safety of intravenous levetiracetam, valproate and fosphenytoin in adults and children with benzodiazepine refractory status. The trial was stopped during the interim analysis for futility of finding superior or inferior drugs. The primary outcome of achieving resolution of seizures and recovery in the level of consciousness at 1 hour occurred in equal proportion of patients amongst the 3 drugs (45-47%). Posterior probability analysis showed levetiracetam as potentially the most effective drug. The incidence of adverse events was similar between groups. The trial findings compare to prior literature and meta-analysis achieving 50% termination of seizures, and confirm the utility of alternate antiepileptics, with a potentially safer administration profile.
Ellen Grass Memorial Lecture: Clinical Neurophysiology in the Treatment of Disease
Published in The Neurodiagnostic Journal, 2018
Aatif M. Husain
One of the first times cEEG was used as a biomarker to determine successful treatment of NCS was in the TRENdS (Treatment of Recurrent Nonconvulsive Seizures) study (Husain 2015). The value of cEEG was not only in the diagnosis but also in treatment of the NCSE and NCS. The TRENdS study was a prospective, multicenter, open-label, randomized, interventional study comparing intravenous fosphenytoin (fPHT) and lacosamide (LCM) for the treatment of NCS. CEEG was used to determine the diagnosis and adequacy of treatment. All cEEG-interpreting physicians were blinded to treatment. A noninferiority design was used to test the two ASDs, with fPHT considered the standard treatment. The objective of the study was to evaluate the efficacy of LCM compared with fPHT for the treatment of NCS as measured by cEEG in critically ill subjects. A secondary objective was to determine the change in seizure burden (amount of time in electrographic seizure per hour of EEG recording) with treatment.