Abstracts

Rationale: Refractory status epilepticus (RSE) is a very challenging condition to treat requiring multiple antiepileptic  drugs (AED) and anesthetics.  During RSE the brain is under excessive excitation with increase in the glutamate receptors such as alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and N-methyl-Daspartate (NMDA) receptors in the synaptic membranes. Perampanel (PER), a novel noncompetitive AMPA-receptor antagonist might have a potential role in the treatment of RSE with positive results in different animal models with refractory and diazepam resistant SE.  Methods: Retrospective case series  Results: We reviewed all adult patients with RSE who received PER since the medication became available in our institution. We identified 8 patients over 6 months period with different forms (generalized and focal )  RSE  with different etiologies ( see table 1). One was excluded as the etiology of RSE was anoxic brain injury which carries a very poor prognosis and patient had a withdrawal of care within 24 hours of initiating PER. Three patients had a definite response to PER, which we defined as electroencephalographic resolution of the ictal pattern within 48 hours of PER without adding a new AED. One had a possible response giving the improvement of EEG predate the initiation of PER despite significant improvement after. Recognizing the limited number of patients and the retrospective nature of this review, we describe based on our experience in those who responded to PER that potentially using it earlier in the course of  treatment ( 6th and 7th  vs 9th  and 10th ) , starting at a higher dose ( 8mg   vs 4 mg ) , and escalating to maximum dose within 48 h could potentially increase the response rate. Also we suspected a possible synergistic effect with Ketamine and versed  (2/3 responders ).We did not observe any significant side effects of the medication during the ICU stay and nothing reported with reviewing medical records prior to discharge. However, we did observe some decrease in Dilantin level in one patient which could potentially be related to PER as there is reports of having some enzyme inducing properties.  Conclusions: We observed a good efficacy of PER in patients with focal and generalized RSE without a significant side effects. Further studies are needed to clarify the  dosing, timing and appropriate indications in RSE treatment.  Funding: NA