Abstracts

Rationale: Animal studies have shown very high glutamate levels in status epilepticus (SE). Vigabatrin (VGB) irreversibly inhibits γ-amino butyric acid-transaminase (GABA-T), increases GABA, and may indirectly lower glutamate levels. Theoretically, this effect could reduce excitatory states and help control SE. Our aims were to report the control rate of refractory status epilepticus (RSE) associated with VGB administration as an adjunct to other anti-epileptic drugs. We previously described the use of VGB in RSE in a two patient case study. (1)Methods: After IRB approval, we reviewed charts of patients admitted to the Neurological ICU for management of RSE between the years of 2012 and 2015 at Ochsner Medical Center. This is a single center, retrospective analysis of cases of RSE in which VGB was used adjunctively in the treatment of RSE.Results: We identified 24 patients diagnosed with RSE treated with VGB. Patient demographics were 16 females and 8 males. Ages ranged from 3 months to 79 years (average 43 years, median 48). Non-convulsive SE (NCSE) occurred in 22. Etiologies included cerebral anoxia due to cardiac arrest (5), genetic/structural (4), cerebral hemorrhage (4), metabolic derangement (4), autoimmune disease (3/24), systemic infection (1), and unclear (3). SE resolved after the addition of VGB in 20 (83%) patients. Three patients were controlled but relapsed when anesthetics were reduced. Addition of VGB prevented relapse when anesthetics were again discontinued. Five patients (21%) suffered in hospital mortality due to multisystem organ failure (3), and cardiac arrest (1) and withdrawal of care (one uncontrolled SE). Maximal dose of VGB ranged from 200-3000 mg per day which was reached within 24 hours of initiation in 20/24 patients. Anesthetics were used in 22/24 (92%) patients. Of these, 14/22 received both propofol and ketamine infusions and 8 received propofol only. SE in these 22 patients can be characterized as super-refractory. Other anti-epileptic drugs used prior to initiation of VGB were levetiracetum 24, lacosamide 23, clobazam 12/24, depakote 8, lorazepam 4, topiramate 3, lamotrigine 2, perampanel 2, fosphenytoin 2, oxcarbazepine 2, clonazepam 2, and midazolam 1. VGB was the last agent added prior to control in 18/24 (75%). Clobazam and perampanel were the final agents added prior to control in 4 and 1, respectively. The time from diagnosis of SE to VGB initiation ranged from 0 to 10 days (average 5.5 days, median 4.5). The duration of VGB treatment before SE was controlled ranged from 1 to 140 hours (average= 38.3, median= 28).Conclusions: The use of VGB has shown to be extremely important in achieving and maintaining control in the management of many patients with refractory and super-refractory SE. Reference: 1. McCormick J, Jonas N, Ramsay R, Sabharwal V. Vigabatrin: A Novel Approach for Treatment of Super Refractory Status Epilepticus, a Case Study of 2 Patients (P01.079). Neurology. 2012;78:P01-P01.079.