Abstracts

RATIONALE: To report the effectiveness of topiramate in treating complex partial status epilepticus (1 patient) and refractory generalized status epilepticus (2 patients)
Objective: Readers will become more familiar with the use of topiramate in refractory status epilepticus
METHODS: Two patients with refractory generalized status epilepticus and one patient with end stage liver disease, hepatic encephalopathy and complex partial status epilepticus were treated with topiramate. The patients[ssquote] clinical status and neurologic examinations were followed. Two patients had continuous EEG whereas the third had intermittent prolonged EEG recordings. In all patients topiramate was initiated at 500 mg bid for 2-5 days and the dose gradually tapered thereafter to 200 mg bid.
RESULTS: Patient 1 was admitted for subacute encephalopathy of unclear etiology. Initial EEG showed generalized slow wave activity, Two days after admission he developed recurrent partial seizures with secondary generalization that were resistant to repeated doses of lorazepam and loading with fosphenytoin. He was intubated and pentobarbital coma was induced. Over the next 8 days, continuous EEG showed recurrent ictal discharges with repeated attempts to taper pentobarbital despite optimization of serum phenytoin level and the addition of intravenous valproate. Topiramate 500 mg bid was added and two days later pentobarbital was again tapered with no recurrence of ictal discharges. The patient was eventually extubated and discharged on a combination of phenytoin and topiramate (200 mg bid).
Patient 2 had end stage liver disease, was hospitalized for peritonitis and his course was complicated by hepatic encephalopathy and variceal bleeding. On day 16 of hospitalization, he had four complex partial seizures and encephalopathy worsened. Prolonged EEG showed recurrent ictal discharges arising from the left frontocentral region. Topiramate 500 mg bid was started. Two days later mental status improved and he became more responsive. A repeat EEG study showed improved background activity and no further ictal discharges although periodic epileptiform discharges were seen in the left centroparietal area. Two days later the patient died from recurrent variceal bleeding.
Patient 3 suffered cardiopulmonary arrest after choking on food, and was treated for post anoxic seizures with lorazpam and fosphenytoin. The following day EEG showed recurrent generalized ictal discharges, serum phenytoin level was optimized and intravenous valproate was added. Continuous EEG showed recurrent generalized ictal discharges, propofol coma was induced and topiramate 500 mg bid was started. Two days later propofol was tapered and discontinued and EEG showed generalized slow wave activity and no ictal discharges. Topiramate was mistakenly held for 2 days and EEG showed recurrence of frequent epileptiform discharges but these subsided after reinitiation of topiramate 200 mg bid. The patient was discharged to another facility 2 days later.
CONCLUSIONS: Topiramate was effective in treating two patients with refractory generalized status epilepticus and one with complex partial status epilpticus. It could therefore be considered as an option in treating refractory status epilepticus or when standard antiepileptic medications cannot be used.