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Almohaish S, Tesoro EP, Brophy GM. Status Epilepticus: An Update on Pharmacological Management. Semin Neurol 2024; 44:324-332. [PMID: 38580318 DOI: 10.1055/s-0044-1785503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
Status epilepticus (SE) is a neurological emergency that requires timely pharmacological therapy to cease seizure activity. The treatment approach varies based on the time and the treatment stage of SE. Benzodiazepines are considered the first-line therapy during the emergent treatment phase of SE. Antiseizure medicines such as phenytoin, valproic acid, and levetiracetam are recommended during the urgent treatment phase. These drugs appear to have a similar safety and efficacy profile, and individualized therapy should be chosen based on patient characteristics. Midazolam, propofol, pentobarbital, and ketamine are continuous intravenous infusions of anesthetic medications utilized in the refractory SE (RSE) period. The most efficacious pharmacotherapeutic treatments for RSE and superrefractory status epilepticus are not clearly defined.
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Affiliation(s)
- Sulaiman Almohaish
- Department of Pharmacy Practice, Clinical Pharmacy College, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Eljim P Tesoro
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia
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Winter Y, Sandner K, Vieth T, Gonzalez-Escamilla G, Stuckrad-Barre SV, Groppa S. Third-Generation Antiseizure Medication in the Treatment of Benzodiazepine-Refractory Status Epilepticus in Poststroke Epilepsy: A Retrospective Observational Register-Based Study. CNS Drugs 2023; 37:929-936. [PMID: 37784006 PMCID: PMC10570217 DOI: 10.1007/s40263-023-01039-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Status epilepticus in poststroke epilepsy is a challenging condition because of multiple vascular comorbidities and the advanced age of patients. Data on third-generation antiseizure medication (ASM) in this condition are limited. The aim of this study was to evaluate the efficacy of third-generation ASMs in the second- or third-line therapy of benzodiazepine-refractory status epilepticus in poststroke epilepsy following acute ischemic stroke. METHODS Data on the effectiveness of third-generation ASMs in patients with status epilepticus in poststroke epilepsy were gathered from two German Stroke Registries and the Mainz Epilepsy Registry. We included only cases with epilepsy remote to the ischemic event. No patients with acute symptomatic seizures were included. The following third-generation ASMs were included: brivaracetam, lacosamide, eslicarbazepine, perampanel, topiramate, and zonisamide. The assessment of effectiveness was based on seizure freedom within 48 h since the start of therapy with the respective ASM. Seizure freedom was evaluated both clinically (clinical evaluation at least three times per day) and by daily electroencephalogram records. RESULTS Of the 138 patients aged 70.8 ± 8.1 years with benzodiazepine-refractory status epilepticus in ischemic poststroke epilepsy, 33 (23.9%) were treated with lacosamide, 24 (17.4%) with brivaracetam, 23 (16.7%) with eslicarbazepine, 21 (15.2%) with perampanel, 20 (14.5%) with topiramate, and 17 (12.3%) with zonisamide. Seizure freedom within 48 h was achieved in 66.7% of patients with lacosamide, 65.2% with eslicarbazepine, 38.1% with perampanel, 37.5% with brivaracetam, 35.0% with topiramate, and 35.3% with zonisamide (p < 0.05 for comparison of lacosamide or eslicarbazepine to other ASMs). CONCLUSIONS Based on these data, lacosamide and eslicarbazepine might be more favorable in the treatment of refractory status epilepticus in poststroke epilepsy, when administered as second- or third-line ASMs before anesthesia. Because of the fact that these ASMs share the same mechanism of action (slow inactivation of sodium channels), our findings could motivate further research on the role that this pharmaceutical mechanism of action has in the treatment of poststroke epilepsy. CLINICAL TRIAL REGISTRATION This study was registered at ClinicalTrials.gov (NCT05267405).
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Affiliation(s)
- Yaroslav Winter
- Department of Neurology, Mainz Comprehensive Epilepsy and Sleep Medicine Center, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr 1, 55131 Mainz, Germany
- Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Katharina Sandner
- Department of Neurology, Mainz Comprehensive Epilepsy and Sleep Medicine Center, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr 1, 55131 Mainz, Germany
| | - Thomas Vieth
- Rudolf Frey Educational Clinic, Johannes Gutenberg University, Mainz, Germany
| | - Gabriel Gonzalez-Escamilla
- Focus Program Translational Neuroscience (FTN), Department of Neurology, Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Sergiu Groppa
- Focus Program Translational Neuroscience (FTN), Department of Neurology, Rhine Main Neuroscience Network, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Lai MC, Wu SN, Huang CW. Rufinamide, a Triazole-Derived Antiepileptic Drug, Stimulates Ca 2+-Activated K + Currents While Inhibiting Voltage-Gated Na + Currents. Int J Mol Sci 2022; 23:ijms232213677. [PMID: 36430153 PMCID: PMC9697614 DOI: 10.3390/ijms232213677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/27/2022] [Accepted: 11/03/2022] [Indexed: 11/10/2022] Open
Abstract
Rufinamide (RFM) is a clinically utilized antiepileptic drug that, as a triazole derivative, has a unique structure. The extent to which this drug affects membrane ionic currents remains incompletely understood. With the aid of patch clamp technology, we investigated the effects of RFM on the amplitude, gating, and hysteresis of ionic currents from pituitary GH3 lactotrophs. RFM increased the amplitude of Ca2+-activated K+ currents (IK(Ca)) in pituitary GH3 lactotrophs, and the increase was attenuated by the further addition of iberiotoxin or paxilline. The addition of RFM to the cytosolic surface of the detached patch of membrane resulted in the enhanced activity of large-conductance Ca2+-activated K+ channels (BKCa channels), and paxilline reversed this activity. RFM increased the strength of the hysteresis exhibited by the BKCa channels and induced by an inverted isosceles-triangular ramp pulse. The peak and late voltage-gated Na+ current (INa) evoked by rapid step depolarizations were differentially suppressed by RFM. The molecular docking approach suggested that RFM bound to the intracellular domain of KCa1.1 channels with amino acid residues, thereby functionally affecting BKCa channels' activity. This study is the first to present evidence that, in addition to inhibiting the INa, RFM effectively modifies the IK(Ca), which suggests that it has an impact on neuronal function and excitability.
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Affiliation(s)
- Ming-Chi Lai
- Department of Pediatrics, Chi-Mei Medical Center, Tainan 71004, Taiwan
| | - Sheng-Nan Wu
- Department of Physiology, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Institute of Basic Medical Sciences, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: (S.-N.W.); (C.-W.H.)
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: (S.-N.W.); (C.-W.H.)
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Perez DQ, Espiritu AI, Jamora RDG. Perampanel in achieving status epilepticus cessation: A systematic review. Epilepsy Behav 2022; 128:108583. [PMID: 35151187 DOI: 10.1016/j.yebeh.2022.108583] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/18/2022] [Accepted: 01/18/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Status epilepticus (SE) is a neurological emergency necessitating rapid seizure control to prevent long-term consequences. Perampanel (PER) is a novel selective, noncompetitive alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic (AMPA) receptor antagonist that demonstrated efficacy and safety in lithium-pilocarpine models of SE; however, data in humans are limited. This systematic review was performed to assess the efficacy and safety of PER in patients with SE, RSE, and SRSE. METHODS We searched MEDLINE (accessed through PubMed), Embase, Scopus, Cochrane Library, and ClinicalTrials.gov from inception until May 30, 2021 to identify all human studies on PER for the treatment of SE of any type and etiology. An additional search was performed on DANS Easy Archive, in which OpenGrey data were stored, from inception until January 10, 2022 and conference proceedings by the International League Against Epilepsy from 2011 onward. The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall certainty of the body of evidence. RESULTS Twenty-one studies (7 case reports, 9 case series, and 5 retrospective cohort studies) were included with a total of 369 cases of SE in 368 patients aged 11 months to 99 years, of which 56.2% were female. Seizures of the majority were refractory (n = 220), super refractory SE (n = 70), or either (n = 81) with prominent motor symptoms (n = 284) and are associated with a structural etiology (n = 218). The number of antiseizure medications and/or anesthetics used prior to PER ranged from 1 to 13. PER was administered in 324 cases and was initiated at a dose of 2-36 mg between 30 min to 59 days from SE onset. SE cessation ranged from 1 h to 4 weeks from PER initiation. A total of 119 cases (36.6%) were considered PER responders. According to the GRADE approach, there is very low certainty of evidence for all outcomes. CONCLUSIONS The real-world data of PER as a possible therapeutic option in SE of any type are increasing. However, there is very low certainty of evidence for its use and this requires further clinical studies to establish the appropriate timing, dosing, and titration that are efficacious and safe for SE cessation.
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Affiliation(s)
- Dominique Q Perez
- Department of Clinical Neurosciences, University of the East Ramon Magsaysay Memorial Medical Center Inc., Quezon City, Philippines; Section of Neurology, Department of Internal Medicine, Cardinal Santos Medical Center, San Juan City, Philippines
| | - Adrian I Espiritu
- Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines, Manila, Manila, Philippines; Department of Clinical Epidemiology, College of Medicine, University of the Philippines, Manila, Manila, Philippines; Division of Neurology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Roland Dominic G Jamora
- Section of Neurology, Department of Internal Medicine, Cardinal Santos Medical Center, San Juan City, Philippines; Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines, Manila, Manila, Philippines; Institute for Neurosciences, St. Luke's Medical Center, Global City, Philippines.
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Kirmani BF, Au K, Ayari L, John M, Shetty P, Delorenzo RJ. Super-Refractory Status Epilepticus: Prognosis and Recent Advances in Management. Aging Dis 2021; 12:1097-1119. [PMID: 34221552 PMCID: PMC8219503 DOI: 10.14336/ad.2021.0302] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is a life-threatening neurological emergency with high morbidity and mortality. It is defined as “status epilepticus (SE) that continues or recurs 24 hours or more after the onset of anesthesia, including those cases in which SE recurs on the reduction or withdrawal of anesthesia.” This condition is resistant to normal protocols used in the treatment of status epilepticus and exposes patients to increased risks of neuronal death, neuronal injury, and disruption of neuronal networks if not treated in a timely manner. It is mainly seen in patients with severe acute onset brain injury or presentation of new-onset refractory status epilepticus (NORSE). The mortality, neurological deficits, and functional impairments are significant depending on the duration of status epilepticus and the resultant brain damage. Research is underway to find the cure for this devastating neurological condition. In this review, we will discuss the wide range of therapies used in the management of SRSE, provide suggestions regarding its treatment, and comment on future directions. The therapies evaluated include traditional and alternative anesthetic agents with antiepileptic agents. The other emerging therapies include hypothermia, steroids, immunosuppressive agents, electrical and magnetic stimulation therapies, emergent respective epilepsy surgery, the ketogenic diet, pyridoxine infusion, cerebrospinal fluid drainage, and magnesium infusion. To date, there is a lack of robust published data regarding the safety and effectiveness of various therapies, and there continues to be a need for large randomized multicenter trials comparing newer therapies to treat this refractory condition.
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Affiliation(s)
- Batool F Kirmani
- 1Texas A&M University College of Medicine, College Station, TX, USA.,3Epilepsy and Functional Neurosurgery Program, Department of Neurology, CHI St. Joseph Health, Bryan, TX, USA
| | - Katherine Au
- 2George Washington University, School of Medicine & Health Sciences, Washington DC, USA
| | - Lena Ayari
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Marita John
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Padmashri Shetty
- 4M. S. Ramaiah Medical College, M. S. Ramaiah Nagar, Bengaluru, Karnataka, India
| | - Robert J Delorenzo
- 5Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA
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De Liso A, Ricci L, Bravi MC, Pezzella FR, Anticoli S. An uncommon case of nonconvulsive status epilepticus successfully treated with enteral Brivaracetam. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021156. [PMID: 33944839 PMCID: PMC8142772 DOI: 10.23750/abm.v92is1.9649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIM OF THE WORK We present a case of a woman affected by nonconvulsive status epilepticus (NCSE) caused by cerebral hyperperfusion syndrome (CHS) after carotid endarterectomy (CEA) who was successfully treated with Brivaracetam (BRV) administered via nasogastric tube (NGT). CASE PRESENTATION An 82-years old woman was referred for increasing blood pressure, severe headache and two focal motor seizures on postoperative day four after right CEA. CT scan showed edema of the right hemisphere with a midline shift of 5 mm. The patient underwent daily Electroencephalography (EEG) monitoring which showed continuous epileptiform discharges over the right hemisphere, compatible with a diagnosis of status epilepticus. She was treated with standard antiepileptic drugs (Phenytoin, Lacosamide and Levetiracetam iv) without clinical response. A therapeutic trial with BRV 200mg administered via nasogastric tube (NGT) was tried which resulted in substantial clinical benefit. CONCLUSIONS The administration of new antiepileptic drugs (AEDs) such as BRV may result in significant clinical improvement in refractory cases of status epilepticus. The enteral administration of AEDs via NGT should always be considered for refractory cases of status epilepticus when standard iv treatment has failed or is not possible.
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Affiliation(s)
- Alfredo De Liso
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome.
| | - Lorenzo Ricci
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome.
| | | | | | - Sabrina Anticoli
- Department of Neuroscience, Stroke Unit San Camillo Hospital, Rome.
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Pharmacotherapy for Nonconvulsive Seizures and Nonconvulsive Status Epilepticus. Drugs 2021; 81:749-770. [PMID: 33830480 DOI: 10.1007/s40265-021-01502-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 12/22/2022]
Abstract
Most seizures in critically ill patients are nonconvulsive. A significant number of neurological and medical conditions can be complicated by nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE), with brain infections, hemorrhages, global hypoxia, sepsis, and recent neurosurgery being the most prominent etiologies. Prolonged NCSs and NCSE can lead to adverse neurological outcomes. Early recognition requires a high degree of suspicion and rapid and appropriate duration of continuous electroencephalogram (cEEG) monitoring. Although high quality research evaluating treatment with antiseizure medications and long-term outcome is still lacking, it is probable that expeditious pharmacological management of NCSs and NCSE may prevent refractoriness and further neurological injury. There is limited evidence on pharmacotherapy for NCSs and NCSE, although a few clinical trials encompassing both convulsive and NCSE have demonstrated similar efficacy of different intravenous (IV) antiseizure medications (ASMs), including levetiracetam, valproate, lacosamide and fosphenytoin. The choice of specific ASMs lies on tolerability and safety since critically ill patients frequently have impaired renal and/or hepatic function as well as hematological/hemodynamic lability. Treatment frequently requires more than one ASM and occasionally escalation to IV anesthetic drugs. When multiple ASMs are required, combining different mechanisms of action should be considered. There are several enteral ASMs that could be used when IV ASM options have been exhausted. Refractory NCSE is not uncommon, and its treatment requires a very judicious selection of ASMs aiming at reducing seizure burden along with management of the underlying condition.
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Hung TY, Wu SN, Huang CW. The Integrated Effects of Brivaracetam, a Selective Analog of Levetiracetam, on Ionic Currents and Neuronal Excitability. Biomedicines 2021; 9:biomedicines9040369. [PMID: 33916190 PMCID: PMC8067033 DOI: 10.3390/biomedicines9040369] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/17/2021] [Accepted: 03/26/2021] [Indexed: 12/22/2022] Open
Abstract
Brivaracetam (BRV) is recognized as a novel third-generation antiepileptic drug approved for the treatment of epilepsy. Emerging evidence has demonstrated that it has potentially better efficacy and tolerability than its analog, Levetiracetam (LEV). This, however, cannot be explained by their common synaptic vesicle-binding mechanism. Whether BRV can affect different ionic currents and concert these effects to alter neuronal excitability remains unclear. With the aid of patch clamp technology, we found that BRV concentration dependently inhibited the depolarization-induced M-type K+ current (IK(M)), decreased the delayed-rectifier K+ current (IK(DR)), and decreased the hyperpolarization-activated cation current in GH3 neurons. However, it had a concentration-dependent inhibition on voltage-gated Na+ current (INa). Under an inside-out patch configuration, a bath application of BRV increased the open probability of large-conductance Ca2+-activated K+ channels. Furthermore, in mHippoE-14 hippocampal neurons, the whole-cell INa was effectively depressed by BRV. In simulated modeling of hippocampal neurons, BRV was observed to reduce the firing of the action potentials (APs) concurrently with decreases in the AP amplitude. In animal models, BRV ameliorated acute seizures in both OD-1 and lithium-pilocarpine epilepsy models. However, LEV had effects in the latter only. Collectively, our study demonstrated BRV’s multiple ionic mechanism in electrically excitable cells and a potential concerted effect on neuronal excitability and hyperexcitability disorders.
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Affiliation(s)
- Te-Yu Hung
- Department of Pediatrics, Chi-Mei Medical Center, Tainan 71004, Taiwan;
| | - Sheng-Nan Wu
- Department of Physiology, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: (S.-N.W.); (C.-W.H.)
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 70101, Taiwan
- Correspondence: (S.-N.W.); (C.-W.H.)
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Habermehl L, Mross PM, Krause K, Immisch I, Chiru D, Zahnert F, Gorny I, Strzelczyk A, Rosenow F, Möller L, Menzler K, Knake S. Stiripentol in the treatment of adults with focal epilepsy- a retrospective analysis. Seizure 2021; 88:7-11. [PMID: 33774499 DOI: 10.1016/j.seizure.2021.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/10/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES The aim of the present study was to evaluate the safety and efficacy of the add-on treatment of stiripentol (STP) in adult patients with severely pharmacoresistant focal or multifocal epilepsy. METHODS Data on adult patients treated with STP from March 2007 to July 2020 and with at least one clinical follow-up (FU) were retrospectively reviewed. Data on tolerability, efficacy and concomitant medication were evaluated at baseline, 6 months (5.5 ± 1.6 months (mean ± SD)) and 12 months (13.1 ± 3.9 months (mean ± SD)). RESULTS Data of 22 patients (54.5% male, mean age 34.4 ± 17.79 years (mean ± SD), including mean duration of epilepsy 17.6 ± 25.5 years (mean ± SD), median seizure frequency 30 ± 20 (median ± MAD) per month, and 63.6% being severely intellectually disabled, with 3 to 18 previous anti-seizure-drugs (ASD), were collected. After 6 months, 72.7% of the patients were still taking STP, and 31% of the patients were responders, including 13% who were seizure-free. The 12-month retention rate was 54.4 %, the response rate was 36.4% and 13.6% of patients were seizure-free at the 12-month FU. Reasons for discontinuation were increased seizure frequency, hyperammonaemia and encephalopathy. CONCLUSION STP seems to be a useful option in the treatment of patients with severely pharmacoresistant epilepsy. Prospective trials are necessary to examine the efficacy of STP in adult patients with pharmacoresistant focal epilepsy.
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Affiliation(s)
- L Habermehl
- Department of Neurology, Epilepsy Centre Hessen, Philipps-University Marburg, Marburg, Germany
| | - P M Mross
- Department of Neurology, Epilepsy Centre Hessen, Philipps-University Marburg, Marburg, Germany
| | - K Krause
- Department of Neurology, Epilepsy Centre Hessen, Philipps-University Marburg, Marburg, Germany
| | - I Immisch
- Department of Neurology, Epilepsy Centre Hessen, Philipps-University Marburg, Marburg, Germany
| | - D Chiru
- Department of Acute Medicine, Schweizer Paraplegiker Zentrum, Notwill, Switzerland
| | - F Zahnert
- Department of Neurology, Epilepsy Centre Hessen, Philipps-University Marburg, Marburg, Germany
| | - I Gorny
- Department of Neurology, Epilepsy Centre Hessen, Philipps-University Marburg, Marburg, Germany
| | - A Strzelczyk
- Department of Neurology, Epilepsy Centre Frankfurt Rhine-Main, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - F Rosenow
- Department of Neurology, Epilepsy Centre Frankfurt Rhine-Main, Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - L Möller
- Department of Neurology, Epilepsy Centre Hessen, Philipps-University Marburg, Marburg, Germany
| | - K Menzler
- Department of Neurology, Epilepsy Centre Hessen, Philipps-University Marburg, Marburg, Germany
| | - S Knake
- Department of Neurology, Epilepsy Centre Hessen, Philipps-University Marburg, Marburg, Germany.
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Lim SN, Wu T, Tseng WEJ, Chiang HI, Cheng MY, Lin WR, Lin CN. Efficacy and safety of perampanel in refractory and super-refractory status epilepticus: cohort study of 81 patients and literature review. J Neurol 2021; 268:3744-3757. [PMID: 33754209 DOI: 10.1007/s00415-021-10506-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND The effective dose of perampanel in status epilepticus (SE), refractory SE (RSE), and super-refractory SE (SRSE) in humans is unknown, and the potential of perampanel in treating SE has not been evaluated in a large cohort. METHODS Data of intensive care patients with RSE and SRSE treated with perampanel were retrospectively reviewed and analyzed. RESULTS Eighty-one patients received perampanel, including 39 females with median age 64 [17-91] years, perampanel responders (n = 27), and non-responders (n = 54). The initial perampanel dose was positively associated with treatment response in patients with RSE or SRSE (OR = 1.27, 95% CI 1.03-1.57, p = 0.025), while the maximum dose was negatively associated with treatment response (OR = 0.74, 95% CI 0.58-0.96, p = 0.022). Hypoxia caused seizures in six patients; five died in hospital and one had severe disability. A statistically non-significant tendency toward better response was found in patients with unique SE type and cause, particularly in nonconvulsive status epilepticus (NCSE) without coma (NCSE without coma vs. generalized tonic-clonic seizure: OR = 4.14, 95% CI 0.98-17.47, p = 0.053). In the high-dose (≥ 16 mg/day) groups, although distributions of modified Rankin Scale (mRS) scores were similar between perampanel responders and non-responders at discharge, a greater proportion of perampanel responders had less change in mRS scores from baseline than did perampanel non-responders (median mRS: 0 vs 4, p = 0.064). No cardiorespiratory adverse events or laboratory abnormalities were noted with perampanel treatment. CONCLUSIONS Perampanel is effective and has a satisfactory safety profile in the emergency treatment of established RSE and SRSE.
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Affiliation(s)
- Siew-Na Lim
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fu-Shin Street, Kwei-Shan, Taoyuan, 333, Taiwan.
| | - Tony Wu
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fu-Shin Street, Kwei-Shan, Taoyuan, 333, Taiwan
- Department of Neurology, Xiamen Chang Gung Hospital, Xiamen, Fujian, China
| | - Wei-En Johnny Tseng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fu-Shin Street, Kwei-Shan, Taoyuan, 333, Taiwan
- Biomedical Engineering, Chang Gung University, Taoyuan, Taiwan
| | - Hsing-I Chiang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fu-Shin Street, Kwei-Shan, Taoyuan, 333, Taiwan
| | - Mei-Yun Cheng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fu-Shin Street, Kwei-Shan, Taoyuan, 333, Taiwan
| | - Wey-Ran Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chia-Ni Lin
- Department of Laboratory Medicine, Chang Gung Memorial Hospital at Linkou Medical Center, Taoyuan, Taiwan
- Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
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Mastroianni G, Iannone LF, Roberti R, Gasparini S, Ascoli M, Cianci V, De Sarro G, Gambardella A, Labate A, Brigo F, Russo E, Aguglia U, Ferlazzo E. Management of status epilepticus in patients with liver or kidney disease: a narrative review. Expert Rev Neurother 2020; 21:1251-1264. [PMID: 33297776 DOI: 10.1080/14737175.2021.1862649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Status epilepticus (SE) is a neurologic and medical emergency with significant related morbidity and mortality. Hepatic or renal dysfunction can considerably affect the pharmacokinetics of drugs used for SE through a variety of direct or indirect mechanisms.Areas Covered: This review aims to focus on the therapeutic management of SE in patients with hepatic or renal impairment, highlighting drugs' selection and dose changes that may be necessary due to altered drug metabolism and excretion. The references for this review were identified by searches of PubMed and Google Scholar until May 2020.Expert opinion: According to literature evidence and clinical experience, in patients with renal disease, the authors suggest considering lorazepam as the drug of choice in pre-hospital and intra-hospital early-stage SE, phenytoin in definite SE, propofol in refractory or super-refractory SE. In patients with liver disease, the authors suggest the use of lorazepam as drug of choice in pre-hospital and intra-hospital early-stage SE, lacosamide in definite SE, propofol in refractory or super-refractory SE. A list of preferred drugs for all SE stages is provided.
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Affiliation(s)
- Giovanni Mastroianni
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio, Italy
| | | | - Roberta Roberti
- Science of Health Department, School of Medicine, Magna Græcia University, Catanzaro, Italy
| | - Sara Gasparini
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Michele Ascoli
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Vittoria Cianci
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio, Italy
| | | | - Antonio Gambardella
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
| | - Angelo Labate
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
| | - Francesco Brigo
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, Magna Græcia University, Catanzaro, Italy
| | - Umberto Aguglia
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
| | - Edoardo Ferlazzo
- Regional Epilepsy Centre, Great Metropolitan "Bianchi-Melacrino-Morelli" Hospital, Reggio, Italy.,Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Institute of Molecular Bioimaging and Physiology, National Research Council, Catanzaro, Italy
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13
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Paredes-Aragón EM, Valdéz-Ruvalcaba HE, Santos-Peyret A, Cisneros-Otero M, Medina-Rioja R, Orozco-Suárez S, Hernandez MM, Breda-Yepes MDL, Rivas-Alonso V, Flores-Rivera JJ, Martínez-Juárez IE. Continuous Visual Focal Status Epilepticus as the Primary Presentation of NMDA-R and GAD65-R Autoimmune Epilepsy. Front Neurol 2020; 11:598974. [PMID: 33324338 PMCID: PMC7726346 DOI: 10.3389/fneur.2020.598974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/21/2020] [Indexed: 11/15/2022] Open
Abstract
Epilepsia partialis continua (EPC) has changed in its clinical and pathophysiological definition throughout time. Several etiologies have been described in addition to classic causes of EPC. The following case depicts a young woman who had a peculiar onset of epilepsy with a continuous visual aura becoming a form of chronic recurrent and non-progressive EPC. The patient was initially misdiagnosed as a non-neurological entity (assumed psychiatric in origin), but finally, an immune-mediated epilepsy was diagnosed, and EEG showed focal status epilepticus during evolution. Once the diagnosis was achieved and immune treatment was established, the patient is seizure free. Early identification of an immune basis in patients with epilepsy is important because immunotherapy can reverse the epileptogenic process and reduce the risk of chronic epilepsy. To date, this is the only case reported with EPC manifesting as a continuous visual aura associated with antiglutamic acid decarboxylase 65 (anti-GAD65) and anti-N-methyl-d-aspartate (anti-NMDA) antibodies.
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Affiliation(s)
- Elma M Paredes-Aragón
- Epilepsy Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - Andrea Santos-Peyret
- Epilepsy Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Marcela Cisneros-Otero
- Neuropsychiatry Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Raúl Medina-Rioja
- Neurology Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - Sandra Orozco-Suárez
- Unit of Medical Research in Neurologic Diseases (UIMEN), Medical National Center Century XXI, Mexican Institute of Social Security, Mexico City, Mexico
| | - Miriam M Hernandez
- Neurology Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | | | - Verónica Rivas-Alonso
- Neuroimmunology Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
| | - José J Flores-Rivera
- Neuroimmunology Clinic, National Institute of Neurology and Neurosurgery, Mexico City, Mexico
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14
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Wieruszewski ED, Brown CS, Leung JG, Wieruszewski PM. Pharmacologic Management of Status Epilepticus. AACN Adv Crit Care 2020; 31:349-356. [PMID: 33313702 DOI: 10.4037/aacnacc2020907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Erin D Wieruszewski
- Erin D. Wieruszewski is Clinical Pharmacy Specialist, Emergency Medicine and Neurocritical Care, Mayo Clinic, Department of Pharmacy, 1216 2nd Street SW, Rochester, MN 55902
| | - Caitlin S Brown
- Caitlin S. Brown is Clinical Pharmacy Specialist, Emergency Medicine and Neurocritical Care, Mayo Clinic, Department of Pharmacy, Rochester, Minnesota
| | - Jonathan G Leung
- Jonathan G. Leung is Clinical Pharmacy Specialist, Psychiatry, Mayo Clinic, Department of Pharmacy, Rochester, Minnesota
| | - Patrick M Wieruszewski
- Patrick M. Wieruszewski is Clinical Pharmacy Specialist, Cardiothoracic Surgery and Anesthesia Critical Care, Mayo Clinic, Department of Pharmacy, Rochester, Minnesota
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15
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Moosavi R, Swisher CB. Acute Provoked Seizures-Work-Up and Management in Adults. Semin Neurol 2020; 40:595-605. [PMID: 33155185 DOI: 10.1055/s-0040-1719075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Acute provoked seizures, also known as acute symptomatic seizures, occur secondary to a neurological or systemic precipitant, commonly presenting as a first-time seizure. In this article, we will discuss etiology, emergent protocols, medical work-up, initial treatment, and management of these seizures. The definitions, classifications, and management of convulsive status epilepticus and nonconvulsive status epilepticus in an acute setting will also be reviewed.
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Affiliation(s)
- Rana Moosavi
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Christa B Swisher
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
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16
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Willems LM, Bauer S, Jahnke K, Voss M, Rosenow F, Strzelczyk A. Therapeutic Options for Patients with Refractory Status Epilepticus in Palliative Settings or with a Limitation of Life-Sustaining Therapies: A Systematic Review. CNS Drugs 2020; 34:801-826. [PMID: 32705422 PMCID: PMC8316215 DOI: 10.1007/s40263-020-00747-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Refractory status epilepticus (RSE) represents a serious medical condition requiring early and targeted therapy. Given the increasing number of elderly or multimorbid patients with a limitation of life-sustaining therapy (LOT) or within a palliative care setting (PCS), guidelines-oriented therapy escalation options for RSE have to be omitted frequently. OBJECTIVES This systematic review sought to summarize the evidence for fourth-line antiseizure drugs (ASDs) and other minimally or non-invasive therapeutic options beyond guideline recommendations in patients with RSE to elaborate on possible treatment options for patients undergoing LOT or in a PCS. METHODS A systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focusing on fourth-line ASDs or other minimally or non-invasive therapeutic options was performed in February and June 2020 using the MEDLINE, EMBASE and Cochrane databases. The search terminology was constructed using the name of the specific ASD or therapy option and the term 'status epilepticus' with the use of Boolean operators, e.g. "(brivaracetam) AND (status epilepticus)". The respective Medical Subject Headings (MeSH) and Emtree terms were used, if available. RESULTS There is currently no level 1, grade A evidence for the use of ASDs in RSE. The best evidence was found for the use of lacosamide and topiramate (level 3, grade C), followed by brivaracetam, perampanel (each level 4, grade D) and stiripentol, oxcarbazepine and zonisamide (each level 5, grade D). Regarding non-medicinal options, there is little evidence for the use of the ketogenic diet (level 4, grade D) and magnesium sulfate (level 5, grade D) in RSE. The broad use of immunomodulatory or immunosuppressive treatment options in the absence of a presumed autoimmune etiology cannot be recommended; however, if an autoimmune etiology is assumed, steroid pulse, intravenous immunoglobulins and plasma exchange/plasmapheresis should be considered (level 4, grade D). Even if several studies suggested that the use of neurosteroids (level 5, grade D) is beneficial in RSE, the current data situation indicates that there is formal evidence against it. CONCLUSIONS RSE in patients undergoing LOT or in a PCS represents a challenge for modern clinicians and epileptologists. The evidence for the use of ASDs in RSE beyond that in current guidelines is low, but several effective and well-tolerated options are available that should be considered in this patient population. More so than in any other population, advance care planning, advance directives, and medical ethical aspects have to be considered carefully before and during therapy.
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Affiliation(s)
- Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany.
| | - Sebastian Bauer
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Kolja Jahnke
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Martin Voss
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- Dr. Senckenberg Institute of Neuro-Oncology, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
- Department of Neurology, Epilepsy Center Hessen, Philipps University Marburg, Marburg (Lahn), Germany
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17
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Treatment of status epilepticus with zonisamide: A multicenter cohort study of 34 patients and review of literature. Epilepsy Behav 2020; 109:107139. [PMID: 32417381 DOI: 10.1016/j.yebeh.2020.107139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION We present a summary of clinical cases of oral zonisamide (ZNS) used to treat refractory and super-refractory episodes of status epilepticus (SE). METHODS Zonisamide administration in SE was identified in the clinical records of patients treated in Frankfurt and Marburg between 2011 and 2017. RESULTS Zonisamide was administered during a total of 37 SE episodes in 34 patients with a mean age of 58.7 ± 17.8 years, 21 of them were female (61.7%). The median latency from the onset of SE to administration of ZNS was 6.3 days. Patients had already undergone unsuccessful treatment with a median of three other antiseizure drugs (ASDs). The median initial dose of ZNS was 100 mg/d, titrated to a median maintenance dose of 400 mg/d. Patients underwent ZNS treatment for a median period of 7 days. Zonisamide was the final drug administered in 9 of 37 (24.3%) episodes, with a clinical effect attributed to ZNS observed in 6 of 37 (16.2%) episodes. An effect attributed to ZNS was observed in 5 out of 30 episodes of refractory SE (RSE) and in one out of 7 episodes of super-refractory SE (SRSE). Possible negative side effects of ZNS were observed in two patients (one patient each with ataxia and skin rash). The mortality rate in hospitalized patients was 10.4% (n = 4). CONCLUSION The rate of SE resolution attributed to ZNS treatment (16.2%) can be considered relevant, particularly since ZNS treatment tends to be administered only after several other options have been tried, and has a treatment latency of over six days. Zonisamide may therefore be considered as an alternative oral treatment option in RSE and SRSE.
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18
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Der-Nigoghossian C, Rubinos C, Alkhachroum A, Claassen J. Status epilepticus - time is brain and treatment considerations. Curr Opin Crit Care 2020; 25:638-646. [PMID: 31524720 DOI: 10.1097/mcc.0000000000000661] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Status epilepticus is a neurological emergency associated with high morbidity and mortality. There is a lack of robust data to guide the management of this neurological emergency beyond the initial treatment. This review examines recent literature on treatment considerations including the choice of continuous anesthetics or adjunctive anticonvulsant, the cause of the status epilepticus, and use of nonpharmacologic therapies. RECENT FINDINGS Status epilepticus remains undertreated and mortality persists to be unchanged over the past 30 years. New anticonvulsant choices, such as levetiracetam and lacosamide have been explored as alternative emergent therapies. Anecdotal reports on the use of other generation anticonvulsants and nonpharmacologic therapies for the treatment of refractory and super-refractory status epilepticus have been described.Finally, recent evidence has examined etiology-guided management of status epilepticus in certain patient populations, such as immune-mediated, paraneoplastic or infectious encephalitis and anoxic brain injury. SUMMARY Randomized clinical trials are needed to determine the role for newer generation anticonvulsants and nonpharmacologic modalities for the treatment of epilepticus remains and evaluate the long-term outcomes associated with continuous anesthetics.
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Affiliation(s)
| | - Clio Rubinos
- Division of Neurocritical Care, Department of Neurology, Columbia University, New York, New York, USA
| | - Ayham Alkhachroum
- Division of Neurocritical Care, Department of Neurology, Columbia University, New York, New York, USA
| | - Jan Claassen
- Division of Neurocritical Care, Department of Neurology, Columbia University, New York, New York, USA
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Strein M, Holton-Burke JP, Smith LR, Brophy GM. Prevention, Treatment, and Monitoring of Seizures in the Intensive Care Unit. J Clin Med 2019; 8:E1177. [PMID: 31394791 PMCID: PMC6722541 DOI: 10.3390/jcm8081177] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/30/2019] [Accepted: 08/01/2019] [Indexed: 12/25/2022] Open
Abstract
The diagnosis and management of seizures in the critically ill patient can sometimes present a unique challenge for practitioners due to lack of exposure and complex patient comorbidities. The reported incidence varies between 8% and 34% of critically ill patients, with many patients often showing no overt clinical signs of seizures. Outcomes in patients with unidentified seizure activity tend to be poor, and mortality significantly increases in those who have seizure activity longer than 30 min. Prompt diagnosis and provision of medical therapy are crucial in order to attain successful seizure termination and prevent poor outcomes. In this article, we review the epidemiology and pathophysiology of seizures in the critically ill, various seizure monitoring modalities, and recommended medical therapy.
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Affiliation(s)
- Micheal Strein
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA 23298-0533, USA
| | - John P Holton-Burke
- Department of Neurology, Virginia Commonwealth University Health System, Richmond, VA 23298-0599, USA
| | - LaTangela R Smith
- Department of Neurology, Virginia Commonwealth University Health System, Richmond, VA 23298-0599, USA
| | - Gretchen M Brophy
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, VA 23298-0533, USA.
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20
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Reimers A, Ljung H. An evaluation of zonisamide, including its long-term efficacy, for the treatment of focal epilepsy. Expert Opin Pharmacother 2019; 20:909-915. [DOI: 10.1080/14656566.2019.1595584] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Arne Reimers
- Department of Clinical Chemistry and Pharmacology, Division of Laboratory Medicine, Lund, Sweden
| | - Hanna Ljung
- Department of Neurology and Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
- Department of Clinical Neurosciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
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