Abstracts

Rationale: Lacosamide is a broad spectrum agent, approved for both partial and generalized seizures in patients 16 or older. It is available in an i.v. form, but is not approved for status epilepticus. One study reported its safety and efficacy in 24 children less than 4 years old with focal epilepsies, mean age 2.7 (1). Two other reports suggest usefullness in status or ARS (2,3). LAC has not been tested in infants with ARS or status. The author consulted on an infant who had a normal gestation and NSVD ,but on day 2 developed episodes of O2 desaturation with decreased HR. After failing to respond to antacids for GERD, an EEG on day 3 revealed seizures from C3 and spreading to the L hemisphere or to the right parasagittal electrodes. Head ultrasound and CT were normal. Mother denied a family history of epilepsy. The infant was started on phenobarbital and continuous Video-EEG monitoring, with a PB level of 24 mcg/ml on day 5. Routine labs and cultures were normal, CSF was unremarkable, cultures for HSV-1&2 were sent. Frequent seizures continued; PB was increased to 44 mcg/ml. The infant remained able to breathe without ventilation and could feed in between seizures. When the seizures failed to respond on day 6 levetiracetam was started at 14 mg/Kg and increased to 40 mg/Kg on Day 7. Pyridoxine, 50 mg qd was started. Ammonia was normal. Day 7 seizures continued at one per 3 hours and began ""ping-ponging"" from side to side. The background had multifocal independent spikes, primarily on the left. MRI was negative. On day 10, high amplitude polyspikes on a suppressed background appeared and seizures continued and LEV was increased to 50 mg/Kg/day.Methods: EEG monitoring consisted of 21 electrodes, placed with the ILAE10-20 system with a single, digital video and was reviewed 3 times per day. All seizure medications were given i.v. until the day before discharge. The infant was becoming somnolent on day 11, with seizures on the EEG, so LAC was started at 5 mg/Kg/day. i.v, q 12 h.Results: On day 12 frequent PLDs or BiPDs appeared alternating with spike-waves, but no seizures were noted. On day 13 the backgound was improved and there were no seizures; VEEG was discontinued day 14. Daily routine EEGs continued to improve, and the infant was discharged to home on day 16 on PB 5mg/Kg/day, LEV 40 mg/KG/day and LAC 10 mg/Kg/day. After one month she has no clinical seizures and is developing normally. PB has been tapered off. HSV I & II cultures, NMDA receptor, VGKC antibodies, amino and organic acid tests are negative. The mother recently found that the paternal grandfather also had acute repetitive seizures as a neonate.Conclusions: The long term effects of PB and DPH and potential acute toxicity of VPA in infants leaves LEV as a possible treatment for ARS in infants, although without an FDA indication. We suggest a possible role for LAC in infants which warrants further study. References: 1. Grosso, et al. Eur J Paediatr Neurol. 2014 Jan;18(1):55-9. 2. Garcés M, et al. Epilepsy Behav. 2014 Jul;36:144-52. 3. Minatsakanyan L, et al. Seizure. 2012 Apr;21(3):198-201.