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Nakai M, Nishimoto S, Higashibeppu Y, Inoue Y. Efficacy of perampanel by etiology in Japanese patients with epilepsy-subpopulation analysis of a prospective post-marketing observational study. Epilepsia Open 2024. [PMID: 38963336 DOI: 10.1002/epi4.13002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/27/2024] [Accepted: 06/17/2024] [Indexed: 07/05/2024] Open
Abstract
OBJECTIVE To examine the efficacy and safety of perampanel (PER) in patients with post-stroke epilepsy (PSE), brain tumor-related epilepsy (BTRE), and post-traumatic epilepsy (PTE) using Japanese real-world data. METHODS The prospective post-marketing observational study included patients with focal seizures with or without focal to bilateral tonic-clonic seizures who received PER combination therapy. The observation period was 24 or 52 weeks after the initial PER administration. The safety and efficacy analysis included 3716 and 3272 patients, respectively. This post hoc analysis examined responder rate (50% reduction in seizure frequency), seizure-free rate (proportion of patients who achieved seizure-free), and safety in patients included in the post-marketing study who had PSE, BTRE, and PTE in the 4 weeks prior to the last observation. RESULTS Overall, 402, 272, and 186 patients were included in the PSE, BTRE, and PTE subpopulations, and 2867 controls in the "Other" population (etiologies other than PSE, BTRE, or PTE). Mean modal dose (the most frequently administered dose) values at 52 weeks were 3.38, 3.36, 3.64, and 4.04 mg/day for PSE, BTRE, PTE, and "Other," respectively; PER retention rates were 56.2%, 54.0%, 52.6%, and 59.7%, respectively. Responder rates (% [95% confidence interval]) were 82% (76.3%-86.5%), 78% (70.8%-83.7%), 67% (56.8%-75.6%), and 50% (47.9%-52.7%) for PSE, BTRE, PTE, and "Other," respectively, and seizure-free rates were 71% (64.5%-76.5%), 62% (54.1%-69.0%), 50% (40.6%-60.4%), and 28% (25.8%-30.1%), respectively. Adverse drug reactions tended to occur less frequently in the PSE (14.7%), BTRE (16.5%), and PTE (16.7%) subpopulations than in the "Other" population (26.3%). SIGNIFICANCE In real-world clinical conditions, efficacy and tolerability for PER combination therapy were observed at low PER doses for the PSE, BTRE, and PTE subpopulations. PLAIN LANGUAGE SUMMARY To find out how well the medication perampanel works and whether it is safe for people who have epilepsy after having had a stroke, brain tumor, or head injury, we used information from real-life medical situations in Japan. We looked at the data of about 3700 Japanese patients with epilepsy who were treated with perampanel. We found that perampanel was used at lower doses and better at controlling seizures, and had fewer side effects for patients with epilepsy caused by these etiologies than the control group.
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Affiliation(s)
- Miku Nakai
- Neurology Department, Medical Headquarters, Eisai Co., Ltd., Tokyo, Japan
| | - Shohei Nishimoto
- Neurology Department, Medical Headquarters, Eisai Co., Ltd., Tokyo, Japan
| | - Yoichi Higashibeppu
- Clinical Planning and Development Department, Medical Headquarters, Eisai Co., Ltd., Tokyo, Japan
| | - Yushi Inoue
- National Epilepsy Center, NHO Shizuoka Institute of Epilepsy and Neurological Disorders, Shizuoka, Japan
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Zhao L, Wu YP, Qi JL, Liu YQ, Zhang K, Li WL. Efficacy of levetiracetam compared with phenytoin in prevention of seizures in brain injured patients: A meta-analysis. Medicine (Baltimore) 2018; 97:e13247. [PMID: 30508910 PMCID: PMC6283080 DOI: 10.1097/md.0000000000013247] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 10/19/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Early and/or late onset in patients with brain injury (BI) is associated with a poorer prognosis, and phenytoin (PHT) is standard of care to prevent seizures. Levetiracetam (LEV), an alternative antiepileptic drug, is associated with less cognitive disruption. The purpose of this study was to evaluate the safety and efficacy of LEV in the prevention of brain traumatic seizures with the standard drug PHT. METHODS Search the publications on comparison the safety and efficacy of LEV against the standard agent PHT in prevention of traumatic seizures in BI to January 2018. After rigorous reviewing on quality, the data were extracted from eligible trials. All trials analyzed the summary hazard ratios of the endpoints of interest. RESULTS LEV was found not more effective than PHT in terms of overall seizure (odds ratio [OR] = 0.73; 95% confidence interval [CI] = 0.51-1.05; P = .09), and late seizure (OR = 0.64; 95% CI = 0.34-1.19; P = .16) occurrence. However, there is significant difference in terms of early seizure (OR = 0.63; 95% CI = 0.40-0.99; P = .04). Moreover, there were no significant differences in terms of mortality (OR = 0.67; 95% CI = 0.43-1.05; P = .08), or side effects (OR = 1.31; 95% CI = 0.80-2.15; P = .29) between groups. CONCLUSION The meta-analysis showed that LEV prevention of seizures was associated with early seizure rates that were lower than the PHT-prolonged course of treatment. There is no statistically significant difference in the efficacy and safety profile of PHT and LEV in cases of traumatic BI.
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Affiliation(s)
- Lin Zhao
- Department of Neurosurgery, the Second Hospital of Hebei Medical University
| | - Yu-Peng Wu
- Department of Neurosurgery, the Second Hospital of Hebei Medical University
| | - Jin-Long Qi
- Department of Pharmacology, Hebei Medical University
| | - Yong-Qiang Liu
- Department of Orthopedics, The No 1 Hospital of Shijiazhuang City
| | - Kai Zhang
- College of Pharmacy, Hebei Medical University, Shijiazhuang, China
| | - Wen-Ling Li
- Department of Neurosurgery, the Second Hospital of Hebei Medical University
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A Systematic Appraisal of Neurosurgical Seizure Prophylaxis: Guidance for Critical Care Management. J Neurosurg Anesthesiol 2017; 28:233-49. [PMID: 26192247 DOI: 10.1097/ana.0000000000000206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Clinical decisions are often made in the presence of some uncertainty. Health care should be based on a combination of scientific evidence, clinical experience, economics, patient value judgments, and preferences. Seizures are not uncommon following brain injury, surgical trauma, hemorrhage, altered brain metabolism, hypoxia, or ischemic events. The impact of seizures in the immediate aftermath of injury may be a prolonged intensive care stay or compounding of the primary injury. The aim of brain injury management is to limit the consequences of the secondary damage. The original intention of seizure prophylaxis was to limit the incidence of early-onset seizures. However, clinical trials have been equivocal on this point, and there is concern about the adverse effects of antiepileptic drug therapy. This review of the literature raises concerns regarding the arbitrary division of seizures into early onset (7 d) and late onset (8 d and beyond). In many cases it would appear that seizures present within 24 hours of the injury or after 7 days, which would be outside of the scope of current seizure prophylaxis guidance. There also does not appear to be a pathophysiological reason to divide brain injury-related seizures into these timeframes. Therefore, a solution to the conundrum is to reevaluate current practice. Prophylaxis could be offered to those receiving intensive care for the primary brain injury, where the impact of seizure would be detrimental to the management of the brain injury, or other clinical judgments where prophylaxis is prudent. Neurosurgical seizure management can then focus attention on which agent has the best adverse effect profile and the duration of therapy. The evidence seems to support levetiracetam as the most appropriate agent. Although previous reviews have identified an increase cost associated with the use of levetiracetam, current cost comparisons with phenytoin demonstrate a marginal price differential. The aim of this review is to assimilate the applicable literature regarding seizure prophylaxis. The final guidance is a forum upon which further clinical research could evaluate a new seizure prophylaxis paradigm.
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Chou SHY, Latorre JGS, Alpargu G, Ogilvy CS, Sorond FA, Rordorf G. Outcomes after Early Anticonvulsant Discontinuation in Aneurysmal Subarachnoid Hemorrhage. JOURNAL OF VASCULAR MEDICINE & SURGERY 2015; 3. [PMID: 34568512 PMCID: PMC8460122 DOI: 10.4172/2329-6925.1000173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Background: Empiric use of anticonvulsant (AED) for seizure prophylaxis in aneurysmal subarachnoid hemorrhage (SAH) remains controversial and may be associated with worse SAH outcome. We determined the safety and feasibility of early discontinuation of empiric AED in a select cohort of SAH patients. Methods: In a cohort of 166 consecutive SAH patients, a subset underwent early AED discontinuation if they were awake and following commands after aneurysm treatment. We examined the effect of AED discontinuation on seizure incidence, mortality and functional outcome at discharge using logistic regression and validated results using 70%-30% data partition. Results: Seventy-three subjects underwent AED discontinuation. Patient groups had similar gender, age, Fisher grade, incidence of craniotomy, vasospasm, ischemic infarct, intraventricular and intraparenchymal hemorrhages. Hunt-Hess (HH) grade were lower in AED-discontinuation group. Clinical or electrographic seizure occurred in 1/93 (1%) patients on AED and 0/73 patient in AED-discontinuation group. Crude mortality was 24% in patients on AED and 2.7% off AED. After adjusting for age, HH grade, vasospasm, ischemic infarct, intracerebral, and intraventricular hemorrhage, AED discontinuation remains independently associated with lower mortality and higher odds of discharge to home (p=0.0002). AED use is not associated with angiographic vasospasm on exploratory analysis. Conclusion: AED discontinuation in SAH patients who are awake and following commands post aneurysm treatment is safe, feasible, and associated with better outcome at hospital discharge. A larger, prospective study is necessary to determine if empiric AED use in SAH leads to poorer functional status.
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Affiliation(s)
- Sherry Hsiang-Yi Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh School of Medicine, USA
| | | | - Gulhan Alpargu
- Department of Statistics, California State University Fullerton, USA
| | - Christopher S Ogilvy
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, USA
| | - Farzaneh A Sorond
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, USA
| | - Guy Rordorf
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, USA
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Lai LT, O'Donnell J, Morgan MK. The risk of seizures during the in-hospital admission for surgical or endovascular treatment of unruptured intracranial aneurysms. J Clin Neurosci 2013; 20:1498-502. [PMID: 23896547 DOI: 10.1016/j.jocn.2013.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Accepted: 02/23/2013] [Indexed: 10/26/2022]
Abstract
Few studies detail the risk of in-hospital seizures following elective surgical or endovascular treatment of unruptured intracranial aneurysms (UIA). We compared the peri-procedural seizure incidence for clipping and coiling of UIA. A retrospective cohort study using the Australian National Hospital Morbidity Database from 1998 to 2008 was conducted. Treatment modalities were compared for the combined primary end point related to seizure. Putative risk factors were investigated with univariate and multivariate logistic regression analysis to identify independent predictors of outcome. A total of 5922 hospitalisations for UIA (3098 clipping, 2824 coiling) were identified. Overall, surgery was associated with a 2.7% (95% confidence interval [CI] 2.2-3.4) incidence of peri-operative seizures, compared to a 0.6% (95% CI 0.4-1.0) incidence following endovascular treatment (adjusted odds ratio [OR] 4.40; 95% CI 2.64-7.33; p<0.001). The incidences of seizures declined over the 11 year study period in both treatment groups, from 4.2% to 2.0% for surgery and from 2.8% to 0.3% for endovascular. Haemorrhagic complication with intracerebral haemorrhage predicted occurrence of a seizure (OR 3.41; 95% CI 1.20-9.66; p=0.021), whereas endovascular coiling was associated with a better seizure outcome (OR 0.23; 95% CI 0.14-0.39; p<0.001). Overall, elective surgical treatment of UIA is associated with a higher risk of seizure occurrence compared to endovascular coiling. Contrary to conventional thinking, the risk of seizures following endovascular treatment is not entirely absent. Current recommendations must be considered in relation to the issue of driving after elective intracranial aneurysm treatment.
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Affiliation(s)
- Leon T Lai
- Australian School of Advanced Medicine, 2 Technology Place, Macquarie University, NSW 2109, Australia.
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Raper DM, Starke RM, Komotar RJ, Allan R, Connolly ES. Seizures After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review of Outcomes. World Neurosurg 2013; 79:682-90. [DOI: 10.1016/j.wneu.2012.08.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 08/08/2012] [Accepted: 08/15/2012] [Indexed: 10/27/2022]
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Arango JI, Deibert CP, Brown D, Bell M, Dvorchik I, Adelson PD. Posttraumatic seizures in children with severe traumatic brain injury. Childs Nerv Syst 2012; 28:1925-9. [PMID: 22843174 DOI: 10.1007/s00381-012-1863-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 07/10/2012] [Indexed: 01/30/2023]
Abstract
PURPOSE Traumatic brain injury (TBI) remains a leading cause of childhood death and disability worldwide. Seizures are a common complication of TBI and they are particularly common in pediatric populations. The proper management of children sustaining severe TBI is still controversial. Our study aims to share our experience contributing to build evidence for better care. METHODS Retrospective chart review was performed on individuals ages 0 to <18 who presented to a level 1 trauma center during a 10-year period with the diagnosis of severe TBI. Data analyzed included patient's demographics, event information, clinical and radiological presentation, management, and midterm follow-up. Presence of seizures was tracked through EEG monitoring, staff witnessing, or guardian referral. RESULTS The incidence of early posttraumatic seizures (EPTS) observed in our population (19 %) exceeds those previously reported. Such findings likely reflect the importance of close monitoring including EEG. An association between the presence of EPTS and the development of late posttraumatic seizures (LPTS) was evidenced (p=0.001; 95 % CI 2.2, 16.5), while this association should not be assumed as a measure of causality, it should be considered for the management of patients presenting EPTS. Non-accidental trauma and young age were identified as independent predictors for the development of seizures. CONCLUSIONS Seizures are a common complication of severe TBI among children aged 0-3 years. Given the detrimental effects that seizures produce on the injured brain, close observation and appropriate monitoring with EEG are essential for the management of children sustaining severe TBI.
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Affiliation(s)
- Jorge I Arango
- Department of Neurosurgery and Neuroscience Research, Barrow Neurological Institute at Phoenix Children's Hospital, Ambulatory Building B, 1919 East Thomas Road, Phoenix, AZ 85016, USA
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Lanzino G, D'Urso PI, Suarez J. Seizures and anticonvulsants after aneurysmal subarachnoid hemorrhage. Neurocrit Care 2012; 15:247-56. [PMID: 21751102 DOI: 10.1007/s12028-011-9584-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Seizures and seizure-like activity may occur in patients experiencing aneurysmal subarachnoid hemorrhage. Treatment of these events with prophylactic antiepileptic drugs remains controversial. An electronic literature search was conducted for English language articles describing the incidence and treatment of seizures after aneurysmal subarachnoid hemorrhage from 1980 to October 2010. A total of 56 articles were included in this review. Seizures often occur at the time of initial presentation or aneurysmal rebleeding before aneurysm treatment. Seizures occur in about 2% of patients after invasive aneurysm treatment, with a higher incidence after surgical clipping compared with endovascular repair. Non-convulsive seizures should be considered in patients with poor neurological status or deterioration. Seizure prophylaxis with antiepileptic drugs is controversial, with limited data available for developing recommendations. While antiepileptic drug use has been linked to worse prognosis, studies have evaluated treatment with almost exclusively phenytoin. When prophylaxis is used, 3-day treatment seems to provide similar seizure prevention with better outcome compared with longer-term treatment.
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Affiliation(s)
- Giuseppe Lanzino
- Department of Neurologic Surgery, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA.
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Murphy-Human T, Welch E, Zipfel G, Diringer MN, Dhar R. Comparison of short-duration levetiracetam with extended-course phenytoin for seizure prophylaxis after subarachnoid hemorrhage. World Neurosurg 2011; 75:269-74. [PMID: 21492729 DOI: 10.1016/j.wneu.2010.09.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 09/10/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND The optimal regimen for seizure prophylaxis after subarachnoid hemorrhage (SAH) remains uncertain. Based on data suggesting that a short course may be adequate, coupled with an association between phenytoin exposure and poor cognitive outcome, our institution modified their seizure prophylaxis protocol for patients with SAH from an extended course of phenytoin to 3 days of levetiracetam. This study sought to compare the incidence of seizures before and after this change to evaluate whether a short course of levetiracetam would be as effective in preventing in-hospital seizures. METHODS This study analyzed 442 consecutive patients admitted with SAH between January 2003 and January 2008, including 297 patients treated before the protocol change (PHT group) and 145 treated afterward (LEV group). Occurrence of all seizures was extracted from a prospectively collected intensive care unit database and further review of medical records. In-hospital seizures were divided into early (occurring on or before day 3, all patients on prophylaxis) and those occurring late (after day 3, LEV group off prophylaxis). RESULTS In-hospital seizures occurred in 3.4% of the PHT group and 8.3% of the LEV group (P = 0.03). Although the rate of early seizures was not different (1.4% PHT vs. 2.8% LEV, P = 0.45), there was a higher rate of late seizures (2% PHT vs. 5.5% LEV, P = 0.05). CONCLUSIONS The use of short-duration levetiracetam for seizure prophylaxis after SAH was associated with a higher rate of in-hospital seizures than an extended course of phenytoin, mainly related to an increase in late seizures, when the levetiracetam had been discontinued. This suggests that a longer duration of prophylaxis may be required to minimize seizures in patients with SAH, although confirmatory studies are required.
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Anticonvulsant drug therapy after aneurysmal subarachnoid hemorrhage: a critically appraised topic. Neurologist 2011; 16:397-9. [PMID: 21150393 DOI: 10.1097/nrl.0b013e3181efc92f] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Seizures are a complication of aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE To evaluate whether antiepileptic drug (AED) prophylaxis after aSAH reduces seizure risk and whether it is associated with improved neurological outcomes. METHODS The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom line conclusions. Neurology consultants and residents, a medical librarian, clinical epidemiologists, and content experts in the fields of epilepsy, neurosurgery, and critical care contributed to the review and placed the evidence in clinical context. RESULTS There were no relevant randomized, controlled trials that addressed the question. A post hoc analysis of data from 4 trials of tirilazad for aSAH showed that prophylactic AED therapy was associated with worse Glasgow Outcome Scale scores at 3 months (odds ratio 1.56, 95% confidence interval 1.16-2.10; P = 0.003) but numerous confounders limit data interpretation. CONCLUSIONS There are insufficient data to support or refute the prophylactic use of AED therapy after aSAH. Randomized, controlled trials are needed to address the efficacy and risks of AEDs in this setting and should take into account factors such as aneurysmal factors (location, hemorrhage grade, degree of parenchymal injury), type of aneurysm surgery (clip vs. coil), and evaluate the timing and duration of AED use.
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Tesoro EP, Brophy GM. Pharmacological management of seizures and status epilepticus in critically ill patients. J Pharm Pract 2010; 23:441-54. [PMID: 21507848 DOI: 10.1177/0897190010372321] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Seizures are serious complications seen in critically ill patients and can lead to significant morbidity and mortality if the cause is not identified and treated quickly. Uncontrolled seizures can lead to status epilepticus (SE), which is considered a medical emergency. The first-line treatment of seizures is an intravenous (IV) benzodiazepine followed by anticonvulsant therapy. Refractory SE can evolve into a nonconvulsive state requiring IV anesthetics or induction of pharmacological coma. To prevent seizures and further complications in critically ill patients with acute neurological disease or injury, short-term seizure prophylaxis should be considered in certain patients.
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Affiliation(s)
- Eljim P Tesoro
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Abstract
Seizures are common in pediatric emergency care units, either as the main medical issue or in association with an additional neurological problem. Rapid treatment prolonged and repetitive seizures or status epilepticus is important. Multiple anti-convulsant medications are useful in this setting, and each has various indications and potential adverse effects that must be considered in regard to individual patients. This review discusses new data regarding anticonvulsants that are useful in these settings, including fosphenytoin, valproic acid, levetiracetam, and topiramate. A status epilepticus treatment algorithm is suggested, incorporating changes from traditional algorithms based on these new data. Treatment issues specific to complex medical patients, including patients with brain tumors, renal dysfunction, hepatic dysfunction, transplant, congenital heart disease, and anticoagulation, are also discussed.
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