Abstracts

Rationale: Super-refractory status epilepticus (SRSE) is a condition that continues 24 hours or more after initiation of anesthetic medications and recurs with medication reduction and is associated with high morbidity and mortality. There are no proven therapies for these patients. Methods: We report here a patient with recurrent SRSE who was treated with anterior temporal lobectomy. Results: A 61-yr-old woman with no previous history of epilepsy transferred due to hypokalemia, hypercalcemia, confusion, and a brief seizure (eye and head deviation) was found to be in non-convulsive status epilepticus (NCSE), originating from the right temporal area. Brain MRI showed right frontotemporal meningioma with adjacent mass effect and midline shift of 3 mm. She was treated with intravenous lorazepam, fosphenytoin loading dose, and was started on maintenance antiepileptic (AED) therapy. The patient was intubated and admitted to the neuro-ICU. Burst-suppression pattern was achieved with propofol, midazolam, and ketamine in less than 24 hours. Intravenous levetiracetam and later lacosamide were added due to very frequent bursts of rhythmic epileptiform discharges. She underwent resection of right frontotemporal mass which was proven to be WHO grade I meningioma. Postoperatively, she remained minimally responsive and was discharged to a long term care facility. After discharge she had significant improvement. She had normal memory, attention, and language functions two months after discharge. Two weeks later she presented again with left face twitching and confusion. EEG showed continuous right hemispheric spike and wave activity consistent with focal status epilepticus. She was loaded with valproic acid and continued on preadmission AEDs. Video EEG monitoring showed NCSE. Burst-suppression pattern was achieved with propofol, ketamine, midazolam and pentobarbital. Brain MRI showed encephalomalacia and gliosis along the right superior temporal gyrus. EEG showed SRSE despite four antiepileptic medications. Eight days later, she underwent right temporal lobectomy with removal of the superior middle and inferior temporal gyri and hippocampectomy guided by intraoperative electrocorticography. Postoperatively scalp EEG continued to show frequent PLEDs from right posterior temporal region for another 15 days with no improvement in clinical condition. Patient was restarted on continued burst suppression with propofol and midazolam for two days after which the EEG showed significant decrease in epileptiform discharges. She was transferred to a long term care facility on five AEDs. She has been seizure free since then. At nine month follow up, she was living at home in a state of static encephalopathy, requiring 24 hour care. Conclusions: Surgery with continued anesthetic agents may help to break the super-refractory status epilepticus however the functional status stays poor. Most patients get surgical intervention after one week of medical therapy, it remains to be seen if early surgery may lead to a better functional outcome.