Abstracts

Rationale: Status epilepticus (SE) is a neurological emergency and often does not respond to initial treatment. Algorithms to treat SE with well established medications such as phenytoin (PHT) and phenobarbital exist, but treatment of SE when these medications fail is less clear. Several newer antiepileptics (AEDs) are available in intravenous (IV) formulations (such as levitiracetam (LEV) and lacosamide (LCM)), but their safety profiles and efficacies are not well established. Several case reports, small case series, and animal models have suggested efficacy for LCM in SE. The purpose of this study was to examine the safety of IV LCM in a critically-ill population and obtain an estimate of efficacy in patients with refractory SE on continuous video EEG (cEEG) in a large, retrospective case series. Methods: Retrospective review of prospectively collected data of patients in SE on cEEG treated with IV LCM located in the electronic medical record and epilepsy database of the Cleveland Clinic from June 2009 to April 2011. GraphPad InStat (San Diego, CA) was used for statistical analyses. Results: Eighty-four patients in SE (59.6 yrs, 43F/41M ) were identified over a two-year period treated with LCM of which 59.5% had nonconvulsive SE. 38.1% had prior history of seizures with 8.3% having prior SE. Suspected etiologies of the SE included ischemic stroke (16.7%), hemorrhagic strokes (15.5%), tumor (14.3%), epilepsy (14.3%), anoxia (9.5%), and other (29.7%). Safety parameters included measurement of blood pressure change, PR interval on EKG, LFTs, and renal function. There was no significant change in serial blood pressure monitoring prior to LCM and 1, 4 and 24 hrs after LCM; 19 patients were on pressors prior to LCM and four patients required pressors following LCM. No significant change in PR interval was seen before or after LCM on EKG, but 1l patients with non-symptomatic PR prolongations were noted. Serum creatinine was used to follow renal function pre-LCM and 1 and 7 days post-LCM with no significant change. There was no significant change in AST/ALT at 1 and 7 days although there was a lot of variability in this population. Fifty one patients were treated with LCM after the onset of SE on cEEG and the time to seizure termination after LCM dose was used as an estimate of efficacy in this retrospective series. Cessation of SE after LCM occurred in 15.7% (8) by 4 hrs, 25.5% (13) by 12 hours, 58.8% (30) by 24 hours and 82.4% (42) by 48 hrs. The mean length of SE until cessation was 31.1 hrs. Cessation of SE after PHT and levetiracetam (LEV) were also analyzed. Mean number of IV AEDs prior to LCM was 2.4 (range 0-4). An average of 0.9 AEDs were required after LCM. Conclusions: IV LCM appears safe in our series of 84 critically-ill patients with SE. The retrospective estimate of efficacy for LCM appears promising for SE and comparable to PHT and LEV. Prospective, randomized controlled studies are needed to better determine the role of LCM in treating SE.