Refractory Acute Symptomatic Seizures in Critically Ill Adults from a Multicenter Cohort Study
Abstract number :
1.159
Submission category :
3. Neurophysiology / 3B. ICU EEG
Year :
2022
Submission ID :
2204856
Source :
www.aesnet.org
Presentation date :
12/3/2022 12:00:00 PM
Published date :
Nov 22, 2022, 05:26 AM
Authors :
Zachary McKee, MD – Charles Shor Epilepsy Center, Cleveland Clinic; Pradeep Chandan, MD – Charles Shor Epilepsy Center, Cleveland Clinic; Clio Rubinos, MD – University of North Carolina, Chapel Hill; Monica Dhakar, MD – Rhode Island Hospital, Brown University; Sahar Zafar, MD – Massachusetts General Hospital, Harvard University; Adithya Sivaraju, MD – Yale New Haven Hospital, Yale University; Vineet Punia, MD, MS – Charles Shor Epilepsy Center, Cleveland Clinic
This abstract is a recipient of the Grass Young Investigator Award
This abstract has been invited to present during the Neurophysiology platform session
Rationale: Acute symptomatic seizures (ASyS) can be recurrent and require multiple anti-seizure medications (ASMs). We lack information on patients who develop refractory ASyS, defined here as use of two or more non-benzodiazepine ASMs. Our goal was to address this knowledge gap using a multicenter cohort study.
Methods: After IRB approval, the five-member institutes of Post-Acute Symptomatic Seizure Investigations and Outcomes Network (PASSION) collected demographical, electro-clinical, neuroimaging, ASM use and outcomes data on all adults undergoing continuous electroencephalogram (cEEG) monitoring from July 1, 2021, to September 30, 2021. cEEG is performed at the PASSION centers on all hospitalized patients with clinical concern for ASyS. Patients with history of epilepsy were excluded. All patients with convulsive ASyS received 1-4 mg of IV Lorazepam. Only ASMs used for >48 hours were included. The predictors of development of refractory ASyS were analyzed by multivariable logistic regression modeling using a backward stepwise elimination approach based on the Akaike Information Criterion (AIC). The variables included in the multivariable model include: age, sex, primary etiology [acute brain injury (ABI), progressive brain injury (PBI), cardiac arrest (CA), inflammatory/autoimmune (I/A), toxic/metabolic/infectious encephalopathy (TMIE)], acute traumatic brain injury (TBI), cortical involvement with ABI, prior cortical injury, convulsive ASyS prior to cEEG, time from admission to cEEG start, mental status at cEEG start (Glasgow coma scale), intubation status, status epilepticus (convulsive/electrographic), electrographic ASyS, epileptiform abnormalities (EAs) on cEEG, neurology team involvement (not involved, consult, primary). Computations were performed in R, version 4.0.2.
Results: A total of 955 patients (45.9% females; median age 64 years; Cleveland Clinic = 466, Massachusetts General Hospital = 166, Yale University = 96, UNC Chapel Hill = 106, Rhode Island Hospital = 121) were included. Among them, 416 (43.6%) patients were treated with ASMs and 96 patients (10.1%; 23.1% of patients on ASM) developed refractory ASyS. The most common first-line ASM was levetiracetam (97.6%) and second-line ASMs was lacosamide (40; 41.6%). Table 1 compares patients with ASyS concerns who developed refractory ASyS with the rest of the study population. On multivariable analysis, significant predictors of patient developing refractory ASyS included age [odds ratio (OR) = 0.98 (95% CI = 0.97-0.99)], ABI [OR = 2.3 (1.06-5.03)], CA [OR = 3.4 (1.4-8.2)], I/A disorder [OR = 5.9 (1.5-21.4)], acute TBI [OR = 3.2 (1.63-6.2)], convulsive ASyS [OR = 2.23 (1.31-3.79)], status epilepticus [OR = 7.97 (3.55-18.1)], EAs on cEEG [OR = 3.2 (1.94-5.3)].
Conclusions: In first of its kind analysis, we found that 10% of patients with ASyS concerns develop refractory ASyS. Apart from electro-clinical findings like convulsive ASyS, status epilepticus and EAs on cEEG, we found that underlying etiology independently predicts the development of refractory ASyS. These findings could inform future clinical trials investigating ASyS treatment.
Funding: American Epilepsy Society Infrastructure Grant
Neurophysiology