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Busl KM, Fong MWK, Newcomer Z, Patel M, Cohen SA, Jadav R, Smith CN, Mitropanopoulos S, Bruzzone M, Hella M, Eisenschenk S, Robinson CP, Roth WH, Ameli PA, Babi MA, Pizzi MA, Gilmore EJ, Hirsch LJ, Maciel CB. Pregabalin for Recurrent Seizures in Critical Illness: A Promising Adjunctive Therapy, Especially for cyclic Seizures. Neurocrit Care 2022; 37:140-148. [PMID: 35217998 DOI: 10.1007/s12028-022-01459-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/27/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pregabalin (PGB) is an effective adjunctive treatment for focal epilepsy and acts by binding to the alpha2-delta subunit of voltage-gated calcium channels to reduce excitatory neurotransmitter release. Limited data exist on its use in the neurocritical care setting, including cyclic seizures-a pattern of recurrent seizures occurring at nearly regular intervals. Although the mechanism underpinning cyclic seizures remains elusive, spreading excitation linked to spreading depolarizations may play a role in seizure recurrence and periodicity. PGB has been shown to increase spreading depolarization threshold; hence, we hypothesized that the magnitude of antiseizure effect from PGB is more pronounced in patients with cyclic versus noncyclic seizures in a critically ill cohort with recurrent seizures. METHODS We conducted a retrospective case series of adults admitted to two academic neurointensive care units between January 2017 and March 2019 who received PGB for treatment of seizures. Data collected included demographics, etiology of brain injury, antiseizure medications, and outcome. Continuous electroencephalogram recordings 48 hours before and after PGB administration were reviewed by electroencephalographers blinded to the administration of antiseizure medications to obtain granular data on electrographic seizure burden. Cyclic seizures were determined quantitatively (i.e., < 50% variation of interseizure intervals for at least 50% of consecutive seizures). Coprimary outcomes were decrease in hourly seizure burden in minutes and decrease in seizure frequency in the 48 hours after PGB initiation. We used nonparametric tests for comparison of seizure frequency and burden and segmented linear regression to assess PGB effect. RESULTS We included 16 patients; the median age was 69 years, 11 (68.7%) were women, three (18.8%) had undergone a neurosurgical procedure, and five (31%) had underlying epilepsy. All seizures had focal onset; ten patients (62.5%) had cyclic seizures. The median hourly seizure burden over the 48 hours prior to PGB initiation was 1.87 min/hour (interquartile range 1.49-8.53), and the median seizure frequency was 1.96 seizures/hour (interquartile range 1.06-3.41). In the 48 hours following PGB (median daily dose 300 mg, range 75-300 mg), the median number of seizures per hour was reduced by 0.80 seizures/hour (95% confidence interval 0.19-1.40), whereas the median hourly seizure burden decreased by 1.71 min/hour (95% confidence interval 0.38-3.04). When we compared patients with cyclic versus noncyclic seizures, there was a relative decrease in hourly seizure frequency (- 86.7% versus - 2%, p = 0.04) and hourly seizure burden (- 89% versus - 7.8%, p = 0.03) at 48 hours. CONCLUSIONS PGB was associated with a relative reduction in seizure burden in neurocritically ill patients with recurrent seizures, especially those with cyclic seizures, and may be considered in the therapeutic arsenal for refractory seizures. Whether this effect is mediated via modulation of spreading depolarization requires further study.
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Affiliation(s)
- Katharina M Busl
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Michael W K Fong
- Westmead Comprehensive Epilepsy Unit, Westmead Hospital, University of Sydney, Sydney, Australia.,Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | | | - Mitesh Patel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Scott A Cohen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| | - Rakesh Jadav
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Christine N Smith
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Maria Bruzzone
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Stephan Eisenschenk
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Christopher P Robinson
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - William H Roth
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Pouya Alexander Ameli
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Marc-Alain Babi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Michael A Pizzi
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Emily J Gilmore
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Carolina B Maciel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA. .,Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA. .,Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, New Haven, CT, USA. .,Department of Neurology, University of Utah, Salt Lake City, UT, 81432, USA. .,Neurocritical Care, McKnight Brain Institute, 1149 Newell Drive, L3-100, Gainesville, FL, 32610, USA.
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