Intravenous valproate is well tolerated in unstable patients with status epilepticus

Aphasic Status Epilepticus Associated with Alzheimer's Disease: Clinical and Electrographic Characteristics

In aphasic status epilepticus (ASE), aphasia is the sole manifestation of seizure in patients with this disorder. Alzheimer's disease (AD) is one of neurological disorders causing ASE. Herein, we report two cases of ASE associated with AD, and discuss their clinical characteristics. Patient 1 presented Broca's aphasia, and patient 2 presented global aphasia during the ictal period. Both patients exhibited atypical ictal electroencephalographic (EEG) patterns, which improved after antiepileptic drug administration. ASE was the presenting symptom of AD in patient 1. ASE can develop at any stage of AD. Alterations in clinical symptoms and EEG patterns after treatment with antiepileptic drug are the key to diagnosis. Prompt diagnosis and treatment are critical for preventing further consciousness dysfunction.

Epilepsy in the elderly: Unique challenges in an increasingly prevalent population

Elderly individuals (aged at least 60 or 65 years) represent a rapidly growing segment of the population. The incidence and prevalence of epilepsy is higher in this age group than in any other. Diagnosing epilepsy in the elderly can be challenging because the causes and clinical manifestations of seizures often differ as compared with younger individuals. Particular differential diagnoses, such as syncope and amyloid spells, are commonly encountered in the elderly population. A diagnosis of epilepsy has important implications in the older adult, many of which already present a variety of concomitant complex medical problems, such as cognitive impairment, comorbid cerebrovascular disease, and frailty. The treatment of epilepsy in the elderly is complicated by a variety of factors related to aging, including physiological changes, medical comorbidities, and polypharmacy. In this narrative review, we will address the descriptive epidemiology, clinical presentation, differential diagnosis, diagnostic evaluation, treatment, and prognosis of epilepsy in the elderly individual.

Emergency Neurological Life Support: Status Epilepticus

Patients with prolonged or rapidly recurring convulsions lasting more than 5 min should be considered to be in status epilepticus (SE) and receive immediate resuscitation. Although there are few randomized clinical trials, available evidence and experience suggest that early and aggressive treatment of SE improves patient outcomes, for which reason this was chosen as an Emergency Neurological Life Support protocol. The current approach to the emergency treatment of SE emphasizes rapid initiation of adequate doses of first line therapy, as well as accelerated second line anticonvulsant drugs and induced coma when these fail, coupled with admission to a unit capable of neurological critical care and electroencephalography monitoring. This protocol will focus on the initial treatment of SE but also review subsequent steps in the protocol once the patient is hospitalized.

Management of status epilepticus

Status epilepticus is a neurologic and medical emergency manifested by prolonged seizure activity or multiple seizures without return to baseline. It is associated with substantial medical cost, morbidity, and mortality. There is a spectrum of severity dependent on the type of seizure, underlying pathology, comorbidities, and appropriate and timely medical management. This chapter discusses the evolving definitions of status epilepticus and multiple patient and clinical factors which influence outcome. The pathophysiology of status epilepticus is reviewed to provide a better understanding of the mechanisms which contribute to status epilepticus, as well as the potential long-term effects. The clinical presentations of different types of status epilepticus in adults are discussed, with emphasis on the hospital course and management of the most dangerous type, generalized convulsive status epilepticus. Strategies for the evaluation and management of status epilepticus are provided based on available evidence from clinical trials and recommendations from the Neurocritical Care Society and the European Federation of Neurological Societies.

Emergency Neurological Life Support: Status Epilepticus

Patients with prolonged or rapidly recurring convulsions lasting more than 5 min are in status epilepticus (SE) and require immediate resuscitation. Although there are relatively few randomized clinical trials, available evidence and experience suggest that early and aggressive treatment of SE improves patient outcomes, for which reason this was chosen as an Emergency Neurological Life Support protocol. The current approach to the emergency treatment of SE emphasizes rapid initiation of adequate doses of first-line therapy, as well as accelerated second-line anticonvulsant drugs and induced coma when these fail, coupled with admission to a unit capable of neurological critical care and electroencephalography monitoring. This protocol will focus on the initial treatment of SE but also review subsequent steps in the protocol once the patient is hospitalized.

Steady-state pharmacokinetic simulation of intermittent vs. continuous infusion valproic acid therapy in non-critically ill and critically ill patients

OBJECTIVES

Valproic acid (VPA) is a broad-spectrum antiepileptic drug used for a variety of neurologic disorders. The relatively short half-life seen with intermittent intravenous bolus doing may lead to serum concentration variability. Continuous infusion VPA therapy is an approach to mitigate these effects. The objective of this study is to characterize the pharmacokinetics of continuous infusion of VPA in acutely ill patients and to determine dosing regimens that most frequently obtain goal steady-state serum concentrations.

METHODS

This is a retrospective pharmacokinetics study in adult patients receiving continuous infusion VPA per institutional protocol for seizure or status migrainosus. Pharmacokinetic parameters were reviewed for 234 patients (25 critically ill) and compared between the two groups (non-critically ill vs. critically ill). Intermittent and continuous infusion dosing strategies were modeled utilizing Monte Carlo simulations for both cohorts. Frequencies of serum concentration attainment were reported.

RESULTS

The percent target attainment for the non-critically ill group and critically ill group were 69.4 and 58.3% (p = 0.282) post-loading dose and 69.7 and 37.5% (p = 0.004) steady state, respectively. The volume of distribution was significantly different between the two groups (0.35 vs. 0.68 L/kg, p = < 0.0001). Highest frequency of target attainment (50-100 mcg/ml) occurred in the continuous infusion 2 mg/kg/h simulation for both critically ill (45.19%) and acutely ill (48.16%) groups.

DISCUSSION

Critically ill patients have an increased volume of distribution. Increasing the volume of distribution requires higher loading doses of VPA to obtain desired therapeutic concentrations. Continuous infusion VPA provides more consistent serum steady-state concentrations while mitigating pharmacokinetic variability.

Pharmacotherapy Overview of Seizure Management in the Adult Emergency Department

Seizures are a common cause of emergency department visits, and approximately 28% of epilepsy patients present to an emergency department annually for treatment. This article will provide an overview of the pharmacotherapeutic management of seizures and anticonvulsant therapy for patients who present to the adult emergency department, including practical information for pharmacists covering or cross-covering this practice area. The benzodiazepines are reviewed as a class, including dosing strategies, pharmacodynamic considerations, and advantages and disadvantages of lorazepam, diazepam, and midazolam. Indications for the use of phenytoin and fosphenytoin will be reviewed, as well as dosing, adverse effects, and cost-effectiveness data. In addition, dosing, administration, pharmacokinetics, and adverse effects of phenobarbital, carbamazepine, and valproate will be discussed. Clinical indications for serum anticonvulsant concentration monitoring and subsequent calculation of loading doses from serum concentrations are reviewed. Since status epilepticus is a life-threatening emergency, its therapeutic management is reviewed, including the use of continuous infusion midazolam, pentobarbital, and propofol. There are many opportunities for clinical pharmacists to collaborate with other members of the health care team to optimize efficacy and minimize adverse effects of anticonvulsant agents in the emergency department setting.

Pharmacokinetics and Clinical Utility of Valproic Acid Administered via Continuous Infusion

INTRODUCTION

Valproic acid is a versatile antiepileptic drug that is often used in the acute care setting. Intravenous valproic acid lends itself well to a continuous infusion as it exhibits a relatively short half-life. We evaluated the pharmacokinetics and clinical efficacy of continuous infusion valproic acid in hospitalized patients with migraine and seizures.

METHODS

A retrospective cohort study was performed utilizing information from the medical records of patients receiving an intravenous continuous infusion of valproic acid. Patients were included if they were aged 1 month to 85 years and they received a continuous infusion of valproic acid. Therapeutic response, common adverse effects, and the pharmacokinetic profile of valproic acid were evaluated.

RESULTS

Continuous infusion valproic acid led to a concentration within the desired range (50-100 μg/ml) in 83.4% of patients, a rate that was higher in pediatric patients. The clinical response rate was also higher in pediatric patients with seizures or migraines and appeared to be better when the concentration was >75 μg/ml. Analysis of safety parameters suggests similar safety considerations to valproic acid when administered via intermittent infusion.

CONCLUSIONS

Continuous infusion valproic acid appears to be a safe, effective, and predictable manner by which to administer valproic acid to pediatric and adult patients admitted to the hospital.

Pharmacotherapy for Status Epilepticus

Status epilepticus (SE) represents the most severe form of epilepsy. It is one of the most common neurologic emergencies, with an incidence of up to 61 per 100,000 per year and an estimated mortality of 20 %. Clinically, tonic-clonic convulsive SE is divided into four subsequent stages: early, established, refractory, and super-refractory. Pharmacotherapy of status epilepticus, especially of its later stages, represents an "evidence-free zone," due to a lack of high-quality, controlled trials to inform clinical decisions. This comprehensive narrative review focuses on the pharmacotherapy of SE, presented according to the four-staged approach outlined above, and providing pharmacological properties and efficacy/safety data for each antiepileptic drug according to the strength of scientific evidence from the available literature. Data sources included MEDLINE and back-tracking of references in pertinent studies. Intravenous lorazepam or intramuscular midazolam effectively control early SE in approximately 63-73 % of patients. Despite a suboptimal safety profile, intravenous phenytoin or phenobarbital are widely used treatments for established SE; alternatives include valproate, levetiracetam, and lacosamide. Anesthetics are widely used in refractory and super-refractory SE, despite the current lack of trials in this field. Data on alternative treatments in the later stages are limited. Valproate and levetiracetam represent safe and effective alternatives to phenobarbital and phenytoin for treatment of established SE persisting despite first-line treatment with benzodiazepines. To date there are no class I data to support recommendations for most antiepileptic drugs for established, refractory, and super-refractory SE. Limiting the methodologic heterogeneity across studies is required and high-class randomized, controlled trials to inform clinicians about the best treatment in established and refractory status are needed.

Efficacy and safety of intravenous valproate for status epilepticus: a systematic review

INTRODUCTION

The effectiveness of valproate (VPA) in the treatment of focal and generalized epilepsies is well established. The drug has a wide spectrum of action, good tolerability, and has been available as an injectable formulation since 1993. Despite the lack of class A evidence, it has been used extensively in various forms of status epilepticus (SE).

AIM

Our aim was to present a systematic review of data from randomized and non-randomized controlled trials to evaluate the efficacy and safety of intravenous VPA for the treatment of SE.

METHODS

Data sources included MEDLINE, back tracing of references in pertinent studies, and contact with the manufacturer of VPA (Sanofi-Aventis).

RESULTS

Overall, the search strategy yielded 433 results (425 MEDLINE, seven congress abstracts, one unpublished study); after excluding duplicate publications and case reports, 30 studies were identified (the earliest was published in 1993, the most recent in 2012); ten were controlled (six randomized controlled trials, four non-randomized controlled studies), and 20 uncontrolled trials (eight prospective observational studies, 12 retrospective case series). The cumulative literature describes the experiences of 860 patients with various forms of SE treated with intravenous VPA. The overall response rate to abrogate SE was 70.9% (601/848; 95% confidence interval [CI] 67.8-73.9). Response rates to intravenous VPA were better in children than in adults and did not differ between the SE types. The most commonly reported effective doses were between 15 and 45 mg/kg in bolus (6 mg/kg/min) followed by 1-3 mg/kg/h infusion. Safety studies of intravenous VPA administration in patients with SE showed a low incidence of adverse events overall (<10%), mainly dizziness, thrombocytopenia, and mild hypotension, which was independent of infusion rates. Of note, good cardiovascular and respiratory tolerability was observed in these studies, even at high doses and fast infusion rates (up to 30 mg/kg at 10 mg/kg/min), despite multiple morbidities or other antiepileptic drugs. The most serious concern relates to the possibility of acute encephalopathy, sometimes related to hepatic abnormalities or hyperammonemia.

CONCLUSIONS

The published experience is consistent with VPA being a safe and effective therapeutic option for patients with established SE who have previously failed conventional first-line treatment with benzodiazepines, but high-quality randomized controlled trials are needed to inform clinicians on its comparative effectiveness in SE.

Status epilepticus: current treatment strategies

Status epilepticus is a neurological emergency that is commonly encountered by the neurohospitalist. Successful treatment depends upon the recognition of prolonged seizure activity and the acute mobilization of available resources. Pharmacologic treatment regimens have been shown to decrease the time needed for successful control of seizures and have provided for the rapid administration of anticonvulsant medications. Treatment strategies have evolved so that clinicians can administer effective doses of medication by whatever routes of administration are immediately available. Traditional algorithms for the treatment of status epilepticus have used a stepwise approach to the administration of first-, second-, and third-order medications. More recent options have included aggressive anesthetic doses of medications while second-line medications are being titrated.

The effect of levetiracetam on status epilepticus-induced neuronal death in the rat hippocampus

PURPOSE

Levetiracetam has been reported to be well tolerated and effective in status epilepticus (SE) refractory to benzodiazepine. Because of little preclinical or clinical data concerning the outcomes of LEV in SE-induced neuronal death and vasogenic edema, we investigated the effect of LEV on SE-induced injury in comparison to diazepam (DZP), and valproate (VPA).

METHODS

Two hours after pilocarpine-induced SE, rats were given one of the following drugs; (1) DZP, (2) LEV, (3) VPA, (4) DZP+LEV, (5) DZP+VPA, and (6) DZP+oxiracetam. Three-four days after SE, neuronal damage and vasogenic edema were evaluated by Fluoro-Jade B (FJB) staining and serum-protein extravasation, respectively.

RESULTS

LEV (≥50 mg/kg) was effective to protect neuronal damage from SE in comparison to DZP and VPA. LEV as an add-on drug with DZP could not alleviate neuronal damage as compared to LEV alone. VPA (≥100 mg/kg) was effective to protect neuronal damage from SE, as compared to DZP. VPA as an add-on drug with DZP reduced neuronal damage, as compared to DZP alone.

CONCLUSION

These findings suggest that LEV may negatively interact with DZP, and be more effective to prevent SE-induced neuronal death as a first line drug than as a second line therapy after BDZ treatment.

Emergency neurological life support: status epilepticus

Patients with prolonged or rapidly recurring convulsions lasting more than 5 min are in status epilepticus (SE) and require immediate resuscitation. Although there are relatively few randomized clinical trials, available evidence and experience suggest that early and aggressive treatment of SE improves patient outcomes, for which reason it was chosen as an Emergency Neurologic Life Support protocol. The current approach to the emergency treatment of SE emphasizes rapid initiation of adequate doses of first line therapy, as well as accelerated second line anticonvulsant drugs and induced coma when these fail, coupled with admission to a unit capable of neurologic critical care and electroencephalography monitoring. This protocol not only will focus on the initial treatment of SE but also review subsequent steps in the protocol once the patient is hospitalized.

Guidelines for the evaluation and management of status epilepticus

Status epilepticus (SE) treatment strategies vary substantially from one institution to another due to the lack of data to support one treatment over another. To provide guidance for the acute treatment of SE in critically ill patients, the Neurocritical Care Society organized a writing committee to evaluate the literature and develop an evidence-based and expert consensus practice guideline. Literature searches were conducted using PubMed and studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using standardized assessment methods from the American Heart Association and Grading of Recommendations Assessment, Development, and Evaluation systems, as well as expert opinion when sufficient data were lacking.

Efficacy and safety of intravenous sodium valproate versus phenobarbital in controlling convulsive status epilepticus and acute prolonged convulsive seizures in children: a randomised trial

Status epilepticus and acute prolonged seizures are the most commonly occurring neurological emergencies in children. Such events have high morbidity and mortality rates along with poor long-term outcomes, depending on their duration and causes. Therefore, such seizures warrant urgent treatment using appropriate doses of anticonvulsants. Benzodiazepines, phenobarbital, and phenytoin are the most commonly used anticonvulsants for controlling status epilepticus and acute prolonged seizures. However, these medications have several well-known adverse effects. Previous studies on both adults and children have shown the efficacy and safety of rapid infusion of valproate in controlling status epilepticus. However, few well-designed randomised trials have been carried out in children, and there remains a paucity of data regarding intravenous sodium valproate use in children. Therefore, our aim was to compare the efficacy and safety of rapid loading of valproate with those of intravenous phenobarbital in children with status epilepticus and acute prolonged seizures. Sixty children (30 in each group) with convulsive status epilepticus and acute prolonged seizures were enrolled and randomly assigned to receive either valproate or phenobarbital. The main outcome variable was termination of all convulsive activity within 20 min of starting anticonvulsant infusion. Intravenous rapid loading of valproate was successful in seizure termination in (27/30, 90%) of patients compared to phenobarbital (23/30, 77%) (p = 0.189). Clinically significant adverse effects occurred in 74% patients of the phenobarbital group and 24% patients of the valproate group (p < 0.001). In conclusion, rapid loading of valproate is effective and safe in controlling convulsive status epilepticus and acute prolonged convulsive seizures in children. Intravenous valproate should be considered as a suitable choice for terminating status epilepticus and acute prolonged seizures in children.

IV Valproate in generalized convulsive status epilepticus: a systematic review

Aim of this review was to evaluate efficacy and safety of intravenous valproate (IV VPA) in the treatment of generalized convulsive status epilepticus (GCSE) in patients of any age, synthesizing available evidences from randomized controlled trials (RCTs). RCTs on IV VPA administered in patients (no age restriction) for GCSE at any stage were searched in MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials. Studies were selected and data independently extracted. Following outcomes were considered: clinical seizure cessation after drug administration, seizure freedom at 24 h, and adverse effects. Outcomes were assessed using standard methods to calculate risk ratio (RR) with 95% confidence intervals. Five trials met inclusion criteria. Two different comparisons were available (IV VPA versus phenytoin (PHT), IV VPA versus IV Diazepam), but only the former included more than one study with enough information to permit a meta-analysis. Compared with PHT, VPA had statistically lower risk of adverse effects (RR 0.31, 95% CI 0.12-0.85), with no differences in GCSE cessation after drug administration (RR 1.31, 95% CI 0.93-1.84) and in seizure freedom at 24 h (RR 0.96, 95% CI 0.88-1.06). This review suggests that IV VPA has a better tolerability than PHT in treatment of GCSE, without any statistically significant differences in terms of efficacy. More rigorous RCTs of VPA versus an appropriate comparator, in a well-defined population with a systematic definition of SE, are however required to conclude about efficacy and tolerability of VPA in clinical practice.

Comparative efficacy and safety of intravenous valproate and phenytoin in children

Intravenous loading is required to reach therapeutic levels of antiepileptic drugs. Valproate, the drug of choice for most epilepsy, may be a better option than phenytoin. In total, 100 children (aged 3-12 years) with motor focal seizures or generalized seizures (second episode) were randomized to receive valproate (20 mg/kg) or phenytoin (20 mg/kg). Patients convulsing at presentation received diazepam. Pulse rate, respiratory rate, blood pressure, oxygen saturation, consciousness, and recurrence of seizures were monitored. The primary outcome measure was control of seizures for 24 hours. Secondary outcome measures comprised variations in cardiorespiratory parameters. The primary endpoint efficacy was 93% and 97%, respectively, in the two groups (P = 0.345). Sixteen children in the valproate group and 17 in the phenytoin group received diazepam, with time to cessation of seizures at 25.44 ± 10.34 and 24.76 ± 12.60 seconds, respectively (P = 0.90). The percentages of children with drug levels in therapeutic range at 4 hours and 24 hours were comparable (P > 0.05). Among children unconscious at presentation, time to regain consciousness was 58.33 ± 28.50 minutes in the valproate only group, and 135.00 ± 62.10 minutes in the phenytoin only group (P = 0.010). Changes in cardiorespiratory parameters were not significantly different (P > 0.05). Hence intravenous valproate is safe and efficacious, with less time to regain consciousness. Valproate can be included in treatment protocols for acute seizures.

Recent and future advances in the treatment of status epilepticus

Status epilepticus (SE) is one of the most frequent neurological emergencies with an incidence of 20/100,000 per year and a mortality between 3% and 40% depending on etiology, age, SE type and duration. Generalized convulsive forms of SE (GTCSE), in particular, require aggressive treatment. Presently, only 55-80% of cases of GTCSE are controlled by initial therapy. Therefore, there is a need for new options for the treatment of SE. Here we review the current standard treatment including recent advances and provide a summary of preclinical and clinical data regarding treatment options which may become available in the near future. The initial treatment of SE usually consists of a benzodiazepine (preferably lorazepam 0.1 mg/kg) followed by phenytoin or fosphenytoin or valproic acid (where approved for SE therapy). With intravenous formulations of levetiracetam, available since 2006, and lacosamide, which is expected for autumn of 2008, new treatment options have become available, that should be evaluated in prospective controlled trials. If SE remains refractory, the induction of general anaesthesia using propofol, midazolam, thiopental, or pentobarbital is warranted in GTCSE.

Evaluation of the subjective and reinforcing effects of diphenhydramine, levetiracetam, and valproic acid

Few unscheduled sedating medications have been evaluated for their subjective and reinforcing effects in humans. To increase the information available about unscheduled sedating medications and to evaluate the ability of human laboratory measures to discriminate between scheduled and unscheduled sedating drugs, 24 subjects with a history of experience with several classes of drugs of abuse, including sedatives and/or alcohol, and who reported liking a test dose of pentobarbital 300 mg, were randomized to single doses of diphenhydramine 400 mg, levetiracetam 4000 mg, valproic acid 1500 mg, diazepam 30 mg or placebo in a double-blind, 5-way crossover study. On the Addiction Research Center Inventory-Morphine-Benzedrine Group and the Next Day Questionnaire measures 'Take Again' and 'Willing to Pay', diazepam produced a significantly greater effect than placebo; all three other active drugs did not. Levetiracetam significantly increased the crossover point on the Multiple Choice Procedure, whereas diazepam did not. For the doses studied, the rank order of statistically significant findings suggestive of abuse potential was diazepam (9/10 measures significant) > levetiracetam (6/10) > diphenhydramine (5/10) > valproic acid (2/10).

Valproate versus diazepam for generalized convulsive status epilepticus: a pilot study

BACKGROUND AND PURPOSE

Evidence-based data to guide the management of status epilepticus (SE) after failure of primary treatment are still scarce and the alternate needs to be found when phenytoin (PHT) is not available or contraindicated. Comparison of intravenous (IV) valproate (VPA) and diazepam (DZP) infusion has not been conducted in adults with SE. This prospective randomized controlled trial is thus designed to evaluate the relative efficacy and safety of IV VPA and continuous DZP infusion as second-line anticonvulsants.

METHODS

After failure of first-line anticonvulsants treatment, patients with generalized convulsive status epilepticus (GCSE) were randomized to receive either IV VPA or continuous DZP infusion. Primary outcome was the proportion of patients with effective control. Side effects were also evaluated.

RESULTS

There were 66 cases enrolled, with the mean age of 41 ± 21 years. Seizure was controlled in 56% (20/36) of the DZP group and 50% (15/30) of the VPA group (P = 0.652). No patient in the VPA group developed respiratory depression, hypotension, or hepatic dysfunction, whereas in the DZP group, 5.5% required ventilation and 5.5% developed hypotension. Time (hour) for regaining consciousness after control was near-significantly longer in the DZP group [13(3.15-21.5)] than in the VPA group [3(0.75-11)] (P = 0.057). Virus encephalitis and long duration of GCSE were independent risk factors of drug resistance.

CONCLUSIONS

  Both IV VPA and continuous DZP infusion are effective second-line anticonvulsants for GCSE. IV VPA was well tolerated and free of respiratory depression and hypotension, which may develop in the DZP group. Outcome parameters were not significantly different between groups.

Second-line status epilepticus treatment: comparison of phenytoin, valproate, and levetiracetam

PURPOSE

Phenytoin (PHT), valproic acid (VPA), or levetiracetam (LEV) are commonly used as second-line treatment of status epilepticus (SE), but comparative studies are not available.

METHODS

Among 279 adult SE episodes identified prospectively in our tertiary care hospital over 4 years, we retrospectively identified 187 episodes in which PHT, VPA, or LEV were given after benzodiazepines. Patients with postanoxic SE were not included. Demographics, clinical SE features, failure of second-line treatment to control SE, new handicap, and mortality at hospital discharge were assessed. Uni- and multivariable statistical analyses were applied to compare the three agents.

KEY FINDINGS

Each compound was used in about one third of SE episodes. VPA failed to control SE in 25.4%, PHT in 41.4%, and LEV in 48.3% of episodes in which these were prescribed. A deadly etiology was more frequent in the VPA group, whereas SE episodes tended to be more severe in the PHT group. After adjustment for these known SE outcome predictors, LEV failed more often than VPA [odds ratio (OR) 2.69; 95% confidence interval (CI) 1.19-6.08]; 16.8% (95% CI: 6.0-31.4%) of second-line treatment failures could be attributed to LEV. PHT was not statistically different from the other two compounds. Second-line treatment did not seem to influence new handicap and mortality, whereas etiology and the SE Severity Score (STESS) were robust independent predictors.

SIGNIFICANCE

Even without significant differences on outcome at discharge, LEV seems less efficient than VPA to control SE after benzodiazepines. A prospective comparative trial is needed to address this potentially concerning finding.

Antiepileptic drugs: the old and the new

During the past decade several new antiepileptic drugs (AEDs) have become available, including new formulations of some of the older medications. Understanding the pharmacokinetics of the new AEDs is important because they are primarily used for adjunctive therapy and interactions with other medications can result in significant toxicities. The new-generation AEDs do not cause serious morbidity in overdose, and treatment is primarily supportive. Specific medications should be chosen based on the patient's history and presentation.

The diagnosis and management of seizures and status epilepticus in the prehospital setting

Seizure is one of the most common complaints encountered in the prehospital setting. In this review the authors discuss the prehospital management of seizures and review the evidence for specific treatment approaches. Specific attention is devoted to prehospital care of the pediatric seizure patient. Topics of interest to Emergency Medical Services directors such as patient refusal, resource allocation, and dispatch priority are also addressed.

Medical treatment of pediatric status epilepticus

Status epilepticus (SE) is a common pediatric neurologic emergency that refers to a prolonged seizure or recurrent seizures without a return to baseline mental status between seizures. Appropriate treatment strategies are necessary to prevent prolonged SE and its associated morbidity and mortality. This review discusses the importance of a rapid and organized management approach, reviews data related to commonly utilized medications including benzodiazepines, phenytoin, phenobarbital, valproate sodium, and levetiracetam, and then provides a sample SE management algorithm.

Intravenous valproate for status epilepticus ... An effective, yet still merely empirical alternative!

Valproate Is an Effective, Well-Tolerated Drug for Treatment of Status Epilepticus/Serial Attacks in Adults. Olsen KB, Taubøll E, Gjerstad L. Acta Neurol Scand Suppl 2007;187:51–54. OBJECTIVE: Status epilepticus (SE) and serial attacks (SA) represent neurological emergencies, and mortality rate for SE/SA is high, ranging from 3% to 25%, depending on cause and co-morbidity. As SE/SA become more refractory to treatment over time, rapid, appropriate treatment is extremely important. Here, we report a prospective registration of the effect of intravenous (IV) valproate (VPA) on SE/SA in a group of Norwegian patients. PATIENTS AND METHODS: Forty-one adult patients (18 males, 23 females) were included in the study. All had previously been unsuccessfully treated with diazepam. For 19, the main SE/SA seizure type was generalized tonic-clonic, while 16 had complex-partial seizures. Six had seizures that were difficult to classify. The treatment protocol recommended 25 mg/kg of VPA loading dose over 30 min, followed by continuous infusion of 100 mg/h for at least 24 h, then per oral administration. If seizures persisted after the loading dose, general anaesthesia (barbiturates/propofol/midazolam) was administered. RESULTS: No serious side effects were reported. In 76% of the cases (31 of 41), SE/SA stopped and anaesthesia was not required. Of the patients treated within 3 h, only 5% needed anaesthesia, whereas of those treated after 3–24 h, 38% needed anaesthesia. Of those who waited for more than 24 h before treatment, 60% required anaesthesia. Furthermore, 60% of the patients who needed anaesthesia were given loading doses below 2100 mg. CONCLUSIONS: VPA seems to be a safe, effective treatment of SE/SA, but efficacy is dependent on time lapse between symptoms and VPA treatment, and administration of a sufficiently high loading dose.

The status of intravenous valproate for status

Sodium Valproate vs Phenytoin in Status Epilepticus: A Pilot Study. Misra UK, Kalita J, Patel R. Neurology 2006;67(2):340–342. Sixty-eight patients with convulsive status epilepticus (SE) were randomly assigned to two groups to study the efficacy of sodium valproate (VPA) and phenytoin (PHT). Seizures were aborted in 66% in the VPA group and 42% in the PHT group. As a second choice in refractory patients, VPA was effective in 79% and PHT was effective in 25%. The side effects in the two groups did not differ. Sodium valproate may be preferred in convulsive SE because of its higher efficacy.

Management of refractory status epilepticus at a tertiary care centre in a developing country

BACKGROUND

Refractory status epilepticus (RSE) is a common Neurological Emergency with increased mortality and morbidity in developing countries where facilities of intubation, adequate ventilation, Intensive Care Units (ICUs) and general anaesthesia are not ubiquitously available. Treatment protocols use antiepileptic drugs (AEDs) and need ICU facilities after failure of standard AEDs. Our aim was to see the response to two additional drugs in the armamentarium against refractory status, that is, valproate and levetiracetam.

METHODS

Patients with generalized RSE admitted in neurology and neurosurgery services at AIIMS during December 2006 to June 2008 were included in the study. The patients were allotted to two groups based on certain criteria. Demographic details, reason for delay, etiology precipitating status, ongoing AEDs therapy, duration of status, the time taken for cessation along with clinical, EEG and MRI correlates were noted. Outcome parameters were analyzed by an independent blinded observer.

RESULTS

82 patients with RSE were studied out of which 41 patients were given IV valproate (Group A) and 41 patients were given IV levetiracetam (Group B). Cessation of status failed in 13 patients in valproate group and 11 patients in levetiracetam group. Majority of the patients did not require ICU settings despite being classified as refractory.

CONCLUSION

RSE can be controlled with intravenous loading and maintenance of valproate or levetiracetam which do not cause respiratory depression, hypotension, need of intubation and ICU care. These must always be considered in a developing country scenario where ICU facilities are not always available or while transporting to centres where these facilities are available.

Intravenous levetiracetam as treatment for status epilepticus

There are established drugs for the treatment of status epilepticus (SE) but their potentially hazardous side-effects are well known. Levetiracetam (LEV) is a novel anticonvulsant available for intravenous (i.v.) application. It could be an alternative when standard drugs fail or should be avoided. We retrospectively identified patients from two German teaching hospitals who were treated with LEV i.v. for SE. Their charts were reviewed regarding sociodemographic data, type, etiology, onset and duration of SE, dose of LEV, concurrent antiepileptic drugs (AED) treatment, tolerability, and outcome. Thirty-two patients (15 female) were found who were treated with i.v. LEV for SE (median age 71 years). Two patients were exclusively treated with LEV. Eight received a low and further 20 patients a high dose of benzodiazepines before LEV. Two patients were treated with LEV to enable discontinuation of narcosis. SE was generalized convulsive in five, nonconvulsive in 20, and simple focal in seven patients. Etiology was acute 13 times and remote symptomatic 16 times; three SE were of unknown etiology. Therapy was initiated within a median time of 3 h and LEV i.v. was applied within a median time of 6 h. Median LEV bolus was 2,000 mg; median total dose on day 1 was 3,500 mg. Benzodiazepines plus i.v. LEV terminated SE in 23 patients without application of additional anticonvulsants, 10 within 30 min. LEV could not terminate SE in seven patients. We documented nausea and emesis in one and elevation of liver enzymes in another patient that were likely to be attributed to LEV. LEV i.v. seems to be safe with relevant efficiency for the treatment of SE in elderly and multimorbid patients when comorbidity and respiratory insufficiency precludes high doses of benzodiazepines or phenytoin.

Status epilepticus: a critical review

Status epilepticus (SE) is a major neurological emergency with an incidence of about 20/100,000 and a mortality between 3 and 40% depending on etiology, age, status type, and status duration. Generalized tonic-clonic SE, in particular, requires immediate, aggressive, and effective treatment to stop seizure activity, and to prevent neuronal damage and systemic complications and death. Benzodiazepines and phenytoin/fosphenytoin are traditionally used as first-line drugs and are effective in about 60% of all episodes. However, a notable portion of patients remain in SE. For those, narcotics and induction of general anesthesia are used as second-line treatment. Therefore, there is a need for more effective first-line treatment options. Recently, valproic acid was approved for the treatment of status epilepticus in some European countries, and two of the newer antiepileptic drugs have become available for intravenous use: Levetiracetam (LEV) and lacosamide (LCM) should be evaluated in prospective controlled trials as possible treatment options. Standardized protocols for the management of SE are useful to improve immediate care.

Mechanistic and pharmacologic aspects of status epilepticus and its treatment with new antiepileptic drugs

We review recent advances in our understanding and treatment of status epilepticus (SE). Repeated seizures cause an internalization of gamma-aminobutyric acid (GABA)(A) receptors, together with a movement of N-methyl-d-aspartate (NMDA) receptors to the synapse. As a result, the response of experimental SE to treatment with GABAergic drugs (but not with NMDA antagonists) fades with increasing seizure duration. Prehospital treatment, which acts before these changes are established, is finding increased acceptance, and solid evidence of its efficacy is available, particularly in children. Rational polypharmacy aims at multiple receptors or ion channels to increase inhibition and simultaneously reduce excitation. Combining GABA(A) agonists with NMDA antagonists and with agents acting at other sites is successful in treating experimental SE, and in reducing SE-induced brain damage and epileptogenesis. The relevance of these experimental data to clinical SE is actively debated. Valproate and levetiracetam have recently become available for intravenous use, and the use of ketamine and of other agents (topiramate, felbamate, etc.) have seen renewed interest. A rapidly increasing but largely anecdotal body of literature reports success in seizure control at the price of relatively few complications with the clinical use of those agents in refractory SE.

Nonconvulsive status epilepticus in terminally ill patients-a diagnostic and therapeutic challenge

Nonconvulsive status epilepticus (NCSE) is rarely considered as a cause of confusion in terminally ill patients. The clinical presentation varies from altered mental status to coma, without visible convulsions. Electroencephalogram is the most important diagnostic tool to identify epileptiform activity. Treatment should be initiated following a stepwise model, avoiding intubation and transfer to the intensive care unit. Although mortality rates are high, in some patients NCSE can be reversed by treatment. NCSE should be considered in a differential diagnosis of all terminally ill patients with sudden mental status changes. We present two cases and discuss treatment options and the borders of therapy.

Loss of astrocytic domain organization in the epileptic brain

Gliosis is a pathological hallmark of posttraumatic epileptic foci, but little is known about these reactive astrocytes beyond their high glial fibrillary acidic protein (GFAP) expression. Using diolistic labeling, we show that cortical astrocytes lost their nonoverlapping domain organization in three mouse models of epilepsy: posttraumatic injury, genetic susceptibility, and systemic kainate exposure. Neighboring astrocytes in epileptic mice showed a 10-fold increase in overlap of processes. Concurrently, spine density was increased on dendrites of excitatory neurons. Suppression of seizures by the common antiepileptic, valproate, reduced the overlap of astrocytic processes. Astrocytic domain organization was also preserved in APP transgenic mice expressing a mutant variant of human amyloid precursor protein despite a marked upregulation of GFAP. Our data suggest that loss of astrocytic domains was not universally associated with gliosis, but restricted to seizure pathologies. Reorganization of astrocytes may, in concert with dendritic sprouting and new synapse formation, form the structural basis for recurrent excitation in the epileptic brain.

Treatment of acute seizures and status epilepticus

Overt status epilepticus and persistent obtundation after a witnessed clinical seizure are neurologic emergencies. Early recognition and intervention in the electroclinical syndrome of status epilepticus reduces morbidity, although treatment of the underlying etiology is also critical. This review outlines key concepts related to status epilepticus, delineates an approach to the early management of status epilepticus, and highlights novel but practical approaches in the evaluation and treatment of refractory status epilepticus, emphasizing the use of a treatment algorithm. This review is written from the perspective of the intensive care unit clinician, and the approach and opinions expressed stem from clinical experience and review of the current literature. Particular attention is given to an overall approach to the management of convulsive status epilepticus in adults and older children as well as exploring novel approaches and diagnostic tools that may prove useful in difficult-to-control status epilepticus.

Randomized study of intravenous valproate and phenytoin in status epilepticus

INTRODUCTION

The evidence based data to guide management in patients of benzodiazepine refractory status epilepticus (SE) is still lacking. We conducted a randomized study to evaluate the comparative effect of intravenous (IV) phenytoin and intravenous valproate (IV VA) in patients of benzodiazepine refractory SE.

BACKGROUND AND METHODS

Hundred, age and sex matched, patients of benzodiazepine refractory SE were randomly divided into Group A (50 patients), treated with IV VA and Group B (50 patients) treated with IV phenytoin. Twelve patients, in whom SE was not controlled with a single drug, were switched over to the other group. Treatment was considered successful when all motor or EEG seizure activity ceased within 20 min after the beginning of the drug infusion and no return of seizure activity during the next 12h. Secondary study end points were adverse events to treatment, in-hospital complications and the neurological outcome at discharge.

RESULTS

In this study, IV VA was successful in 88% and IV phenytoin in 84% (p>0.05) of patients of SE with a significantly better response in patients of SE <2h (p<0.05). The total number of adverse events did not differ significantly between the two groups (p>0.05). There were no differences among the treatments with respect to recurrence after 12-h study period or the outcome at 7 days.

CONCLUSION

IV VA is as effective as IV phenytoin. It is easy to use, better tolerated and can be used as an alternative to IV phenytoin in patients of benzodiazepine refractory SE, especially in patients of cardio-respiratory disease. The better outcome in patients having shorter duration of SE (<2h) suggests need of immediate treatment.

The management of refractory status epilepticus: an update

Refractory status epilepticus (RSE) is an important and serious clinical problem that typically requires prolonged and high-level intensive care, and is often associated with poor outcome. This review addresses some of the current issues concerning the management of RSE, including recent definitions used for clinical studies, epidemiology, clinical course, and outcome. Current approaches to treatment, including the now relatively standard use of intravenous anesthetic agents, as well as emerging therapies utilizing drugs such as valproate and topiramate, are discussed as well.

Advances in the management of seizures and status epilepticus in critically ill patients

Seizures and status epilepticus are common in critically ill patients. They can be difficult to recognize because most are non-convulsive and require electroencephalogram monitoring to detect; hence, they are currently underdiagnosed. Early recognition and treatment are essential to obtain maximal response to first-line treatment and to prevent neurologic and systemic sequelae. Anti-seizure medication should be combined with management of the underlying cause and reversal of factors that can lower the seizure threshold, including many medications, fever, hypoxia, and metabolic imbalances. This article discusses specific treatments and specific situations, such as hepatic and renal failure patients and organ transplant patients.

Comparative Efficacy and Safety of Antiepileptic Drugs for the Treatment of Status Epilepticus

Status epilepticus (SE) is a medical emergency with high mortality rate. Common causes of SE include noncompliance with antiepileptic medications, drug- and alcohol-related etiologies, and central nervous system (CNS) infections. Because prolonged seizures can cause neuronal damage, treatment should be initiated promptly to avoid potential complications. Previous studies support intravenous (IV) lorazepam as first-line therapy and IV phenytoin or fosphenytoin as a second-line medication. If first-and second-line medications fail to control SE, further treatment with propofol, pentobarbital, midazolam, or other medications should be considered. Many of the drugs currently used to control SE are associated with sedation, respiratory suppression, hypotension, cardiac dysrhythmia, and anaphylactic reactions. Therefore, IV valproate or other newer antiepileptic drugs may be considered as an alternative third-line therapy for those who cannot tolerate the hypotensive effects of other anticonvulsants. This paper reviews comparative effectiveness and safety concerns among frequently used medications for SE.