Authors :
First Author: Nicholas Fearns, MD – University of Munich (LMU), University Hospital
Presenting Author: Selina Trapp, MD – Department of Neurology, University of Munich (LMU), University Hospital
Selina Trapp, MD – Department of Neurology – University of Munich (LMU), University Hospital; Katharina Ernst, MD – Department of Neurology – University of Munich (LMU), University Hospital; Stefanie Quach, MD – Department of Neurosurgery – University of Munich (LMU), University Hospital; Christian Vollmar, MD, PhD – Department of Neurology – University of Munich (LMU), University Hospital; Jan Rémi, MD – Department of Neurology – University of Munich (LMU), University Hospital
Rationale:
Even though there is a growing body of evidence that
lacosamide is a safe and effective drug in the treatment of status epilepticus, it is still considered second-line and not approved for this scenario in most countries. This case report documents the termination of a super-refractory focal status epilepticus with lacosamide by stereo-EEG. Methods: This is a case report.
Results:
A 54-year-old male patient presented with focal status epilepticus after severe traumatic brain injury with acute left hemispheric subdural hemorrhage, bilateral subarachnoid hemorrhages, and multiple hemorrhagic contusions in the left frontal and temporal lobes. Clinically the patient was stuporous and had a right arm clonic status epilepticus. Scalp EEG showed generalized slowing, left central continuous slowing and a left central status pattern.
Intravenous benzodiazepines (lorazepam and midazolam) and anti-seizure medication (levetiracetam, valproic acid) did not lead to cessation of the status. Due to drug-drug-interactions with the patient’s HIV-medication, phenytoin was avoided. Therapy was escalated but neither deep sedation (midazolam, thiopental) nor ketogenic diet could terminate the status. Additional phenobarbital treatment improved vigilance but the right arm clonic status remained.
To evaluate the option of resective epilepsy surgery, nine intracranial EEG-electrodes were implanted stereotactically in the lesional regions: three left frontal, three left temporal, two left central, and one right frontal. After implantation, status epilepticus was temporarily interrupted, likely due to a disturbance of the epileptic network as a direct effect of the intracranial electrodes. After several days, status epilepticus resumed. Invasive EEG showed a left temporal status pattern.
200mg Lacosamide were administered intravenously and the invasive EEG status pattern ceased after 20 minutes. The patient had two more seizures the following day, one arising from the left central region, the other from the left frontoorbital region. These seizures did not progress into status epilepticus.
The electrodes were removed two weeks after implantation. The patient remained seizure-free on a combination of oral lacosamide (600mg) and brivaracetam (200mg) and could be discharged from the intensive care unit in an alert and responsive state. Epilepsy surgery was not required at this point.
Conclusions:
1) Though in this case it was not necessary, resective epilepsy surgery should be considered in all patients with focal super-refractory status epilepticus.
2) The implantation of invasive EEG electrodes itself seemed to have a positive effect. Further studies should evaluate this "disturbance of the epileptic network" effect in status epilepticus.
3)
Lacosamide is an effective drug in the treatment of status epilepticus and should be considered in super-refractory cases.Funding: None.