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Bitar R, Khan UM, Rosenthal ES. Utility and rationale for continuous EEG monitoring: a primer for the general intensivist. Crit Care 2024; 28:244. [PMID: 39014421 PMCID: PMC11251356 DOI: 10.1186/s13054-024-04986-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/09/2024] [Indexed: 07/18/2024] Open
Abstract
This review offers a comprehensive guide for general intensivists on the utility of continuous EEG (cEEG) monitoring for critically ill patients. Beyond the primary role of EEG in detecting seizures, this review explores its utility in neuroprognostication, monitoring neurological deterioration, assessing treatment responses, and aiding rehabilitation in patients with encephalopathy, coma, or other consciousness disorders. Most seizures and status epilepticus (SE) events in the intensive care unit (ICU) setting are nonconvulsive or subtle, making cEEG essential for identifying these otherwise silent events. Imaging and invasive approaches can add to the diagnosis of seizures for specific populations, given that scalp electrodes may fail to identify seizures that may be detected by depth electrodes or electroradiologic findings. When cEEG identifies SE, the risk of secondary neuronal injury related to the time-intensity "burden" often prompts treatment with anti-seizure medications. Similarly, treatment may be administered for seizure-spectrum activity, such as periodic discharges or lateralized rhythmic delta slowing on the ictal-interictal continuum (IIC), even when frank seizures are not evident on the scalp. In this setting, cEEG is utilized empirically to monitor treatment response. Separately, cEEG has other versatile uses for neurotelemetry, including identifying the level of sedation or consciousness. Specific conditions such as sepsis, traumatic brain injury, subarachnoid hemorrhage, and cardiac arrest may each be associated with a unique application of cEEG; for example, predicting impending events of delayed cerebral ischemia, a feared complication in the first two weeks after subarachnoid hemorrhage. After brief training, non-neurophysiologists can learn to interpret quantitative EEG trends that summarize elements of EEG activity, enhancing clinical responsiveness in collaboration with clinical neurophysiologists. Intensivists and other healthcare professionals also play crucial roles in facilitating timely cEEG setup, preventing electrode-related skin injuries, and maintaining patient mobility during monitoring.
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Affiliation(s)
- Ribal Bitar
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA
| | - Usaamah M Khan
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, 55 Fruit St., Lunder 644, Boston, MA, 02114, USA.
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2
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Almohaish S, Cook AM, Brophy GM, Rhoney DH. Personalized antiseizure medication therapy in critically ill adult patients. Pharmacotherapy 2023; 43:1166-1181. [PMID: 36999346 DOI: 10.1002/phar.2797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 04/01/2023]
Abstract
Precision medicine has the potential to have a significant impact on both drug development and patient care. It is crucial to not only provide prompt effective antiseizure treatment for critically ill patients after seizures start but also have a proactive mindset and concentrate on epileptogenesis and the underlying cause of the seizures or seizure disorders. Critical illness presents different treatment issues compared with the ambulatory population, which makes it challenging to choose the best antiseizure medications and to administer them at the right time and at the right dose. Since there is a paucity of information available on antiseizure medication dosing in critically ill patients, therapeutic drug monitoring is a useful tool for defining each patient's personal therapeutic range and assisting clinicians in decision-making. Use of pharmacogenomic information relating to pharmacokinetics, hepatic metabolism, and seizure etiology may improve safety and efficacy by individualizing therapy. Studies evaluating the clinical implementation of pharmacogenomic information at the point-of-care and identification of biomarkers are also needed. These studies may make it possible to avoid adverse drug reactions, maximize drug efficacy, reduce drug-drug interactions, and optimize medications for each individual patient. This review will discuss the available literature and provide future insights on precision medicine use with antiseizure therapy in critically ill adult patients.
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Affiliation(s)
- Sulaiman Almohaish
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
- Department of Pharmacy Practice, Clinical Pharmacy College, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Aaron M Cook
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Gretchen M Brophy
- Department of Pharmacotherapy & Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Denise H Rhoney
- Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
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Holla SK, Krishnamurthy PV, Subramaniam T, Dhakar MB, Struck AF. Electrographic Seizures in the Critically Ill. Neurol Clin 2022; 40:907-925. [PMID: 36270698 PMCID: PMC10508310 DOI: 10.1016/j.ncl.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Identifying and treating critically ill patients with seizures can be challenging. In this article, the authors review the available data on patient populations at risk, seizure prognostication with tools such as 2HELPS2B, electrographic seizures and the various ictal-interictal continuum patterns with their latest definitions and associated risks, ancillary testing such as imaging studies, serum biomarkers, and invasive multimodal monitoring. They also illustrate 5 different patient scenarios, their treatment and outcomes, and propose recommendations for targeted treatment of electrographic seizures in critically ill patients.
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Affiliation(s)
- Smitha K Holla
- Department of Neurology, UW Medical Foundation Centennial building, 1685 Highland Avenue, Madison, WI 53705, USA.
| | | | - Thanujaa Subramaniam
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, 15 York Street, Building LLCI, 10th Floor, Suite 1003 New Haven, CT 06520, USA
| | - Monica B Dhakar
- Department of Neurology, The Warren Alpert Medical School of Brown University, 593 Eddy St, APC 5, Providence, RI 02903, USA
| | - Aaron F Struck
- Department of Neurology, UW Medical Foundation Centennial building, 1685 Highland Avenue, Madison, WI 53705, USA; William S Middleton Veterans Hospital, Madison WI, USA
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Singu BS, Morrison H, Irengeya L, Verbeeck RK. Therapeutic drug monitoring of phenytoin and valproic acid in critically ill patients at Windhoek Central Hospital, Namibia. Afr J Lab Med 2022; 11:1628. [PMID: 35937763 PMCID: PMC9350491 DOI: 10.4102/ajlm.v11i1.1628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 04/14/2022] [Indexed: 11/19/2022] Open
Abstract
Background Phenytoin and valproic acid, anticonvulsants, have a low therapeutic index and are highly plasma protein bound, mainly to albumin. Hypoalbuminaemia is common in critically ill patients and increases the unbound drug concentration. Thus, monitoring unbound rather than total plasma drug concentrations is recommended to optimise the dosing of these drugs. Objective This retrospective study determined unbound plasma concentrations of phenytoin and valproic as a more accurate value of drug levels than total plasma drug concentrations. Methods Total plasma concentrations were retrieved for 56 Intensive Care Unit patients for phenytoin and 93 for valproic acid. Total drug concentrations were converted to unbound concentrations using a serum albumin-based normalising equation. Results Total phenytoin plasma concentration was below (41.1% of patients), within (46.4%) or above (12.5%) the therapeutic range (10 μg/mL – 20 μg/mL). However, the predicted unbound plasma concentration of phenytoin was above the therapeutic range (1 μg/mL – 2 μg/mL) in the majority of patients (57.1%). For valproic acid, the total plasma concentration of most patients (87.1%) was below the therapeutic range (50 μg/mL – 100 μg/mL); among remaining patients (12.9%), it was within the therapeutic range. In the majority of patients (91.4%), the predicted unbound plasma concentration of valproic acid was between 2.5 μg/mL and 20 μg/mL. Conclusion The usefulness of monitoring the total phenytoin or valproic acid levels for dose optimisation is limited as it is an inaccurate indicator of a patient’s drug therapeutic state. Thus, the unbound plasma drug concentrations should be quantified experimentally or predicted in resource-limited settings.
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Affiliation(s)
- Bonifasius S Singu
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Helen Morrison
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Lydia Irengeya
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
| | - Roger K Verbeeck
- School of Pharmacy, Faculty of Health Sciences, University of Namibia, Windhoek, Namibia
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Piwowarczyk L, Tomczak S, Antkowiak P, Jelińska A, Stawny M. Sodium Valproate Incompatibility with Parenteral Nutrition Admixtures—A Risk to Patient Safety: An In Vitro Evaluation Study. Pharmaceutics 2022; 14:pharmaceutics14020371. [PMID: 35214103 PMCID: PMC8876349 DOI: 10.3390/pharmaceutics14020371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 11/16/2022] Open
Abstract
Epilepsy is defined as a group of concerning problems related to the nervous system; its defining feature is a predisposition to epileptic seizures. The frequency of seizures in intensive care units (ICU) ranges from 3.3% to 34%, and ICU antiepileptic treatment is routine practice. The administration of drugs through the same infusion line is not recommended but is common clinical practice, especially in ICU. Incompatibilities between parenteral drugs and between drugs and parenteral nutrition admixtures (PNAs) are common medical errors and pose risks to patient safety. The co-administration of drugs must always be confirmed and clearly defined. The simultaneous infusion of sodium valproate (VPA, drug used to treat seizures and epilepsy) with parenteral PNAs has not yet been studied. During the experiment reported in this study, a visual control, pH, osmolality, zeta potential, particle size, polydispersity index, and turbidity were measured. The conducted research shows that the lipid emulsion composition has a significant influence on drug–PN (drug–parenteral nutrition) compatibility. The acceptance criteria were met only for PNs containing omega-3-acid-triglycerides (Omegaflex special and peri). The second fraction of particles above 1000 nm was observed for most of the tested PNAs (Lipoflex special, Lipoflex peri, Kabiven, SmofKabiven, Kabiven Peripheral, and Olimel Peri N4E), which disqualifies their simultaneous administration with VPA.
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Abstract
Purpose of this review This review presents current therapy for seizures in the intensive care unit. The reader is provided with recent evidence regarding the use of EEG in determining treatment for acute seizures. Proposed treatment approaches for seizures and status epilepticus are provided. Controversies and complexity of selecting treatments are discussed. Recent findings Critical Care EEG Monitoring Research Consortium analyzed the association of periodic and rhythmic electroencephalographic patterns with seizures and found that lateralized and generalized periodic discharges and lateralized rhythmic delta were associated with increased seizure risk. Applications using modified EEG techniques have demonstrated more rapid feedback to the ICU than was previously possible. Summary Accurate diagnosis and efficient treatment of seizures in the ICU is challenging due to patient factors, complexities of antiepileptic drug therapy, and the required expertise for EEG interpretation. Selection of optimally effective therapy for seizures or status epilepticus depends on multiple factors, making collaboration between neurophysiologists and the ICU team of paramount importance.
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Affiliation(s)
- Jane G Boggs
- Comprehensive Epilepsy Center, Wake Forest University, Winston-Salem, NC USA
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Schaidle S, Greathouse K, McConnell D. Safety and efficacy of lacosamide versus phenytoin for refractory seizures in neurosurgical patients. BMJ Neurol Open 2021; 3:e000144. [PMID: 34250484 PMCID: PMC8231016 DOI: 10.1136/bmjno-2021-000144] [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: 02/24/2021] [Accepted: 06/06/2021] [Indexed: 11/24/2022] Open
Abstract
Background Postoperative neurosurgical patients have increased risk of seizures. Traditional anti-epileptics, such as phenytoin, are not always effective and cause adverse effects. Levetiracetam is the first-line therapy due to its similar efficacy and more favourable side effect profile. However, many patients continue to seize despite adequate dosing. Lacosamide has been used for refractory seizures and may offer similar seizure control without the negative aspects of traditional agents. The purpose of this study is to evaluate if lacosamide is as safe and effective as phenytoin in terminating seizures in neurosurgical patients already on levetiracetam. Methods This retrospective, single-centre cohort study identified neurosurgical intensive care unit (ICU) patients ≥18 years old who had received levetiracetam plus either phenytoin or lacosamide at Northwestern Memorial Hospital between 1 January 2016 and 31 August 2017. The primary endpoint was treatment failure and the secondary endpoint was safety assessed by liver function tests, blood pressure, heart rate and ECG. Results 70 patients were included in this study, 52 in the phenytoin group and 18 in the lacosamide group. Both phenytoin and lacosamide groups had similar treatment failure rates (25% vs 22% respectively, p=1). Phenytoin use resulted in a mean decrease in systolic blood pressure of 20.9 mm Hg compared with 9.8 mm Hg in the lacosamide group (p=0.019). There were no statistically significant differences in the rates of other adverse effects. Conclusions The use of lacosamide for refractory seizures in neurosurgical ICU patients was associated with similar failure rates, but fewer adverse effects when compared with phenytoin.
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Affiliation(s)
- Sarah Schaidle
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Kasey Greathouse
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Deepika McConnell
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
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Farrokh S, Tahsili-Fahadan P, Ritzl EK, Lewin JJ, Mirski MA. Antiepileptic drugs in critically ill patients. Crit Care 2018; 22:153. [PMID: 29880020 PMCID: PMC5992651 DOI: 10.1186/s13054-018-2066-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 05/14/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The incidence of seizures in intensive care units ranges from 3.3% to 34%. It is therefore often necessary to initiate or continue anticonvulsant drugs in this setting. When a new anticonvulsant is initiated, drug factors, such as onset of action and side effects, and patient factors, such as age, renal, and hepatic function, should be taken into account. It is important to note that the altered physiology of critically ill patients as well as pharmacological and nonpharmacological interventions such as renal replacement therapy, extracorporeal membrane oxygenation, and target temperature management may lead to therapeutic failure or toxicity. This may be even more challenging with the availability of newer antiepileptics where the evidence for their use in critically ill patients is limited. MAIN BODY This article reviews the pharmacokinetics and pharmacodynamics of antiepileptics as well as application of these principles when dosing antiepileptics and monitoring serum levels in critically ill patients. The selection of the most appropriate anticonvulsant to treat seizure and status epileptics as well as the prophylactic use of these agents in this setting are also discussed. Drug-drug interactions and the effect of nonpharmacological interventions such as renal replacement therapy, plasma exchange, and extracorporeal membrane oxygenation on anticonvulsant removal are also included. CONCLUSION Optimal management of antiepileptic drugs in the intensive care unit is challenging given altered physiology, polypharmacy, and nonpharmacological interventions, and requires a multidisciplinary approach where appropriate and timely assessment, diagnosis, treatment, and monitoring plans are in place.
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Affiliation(s)
- Salia Farrokh
- Department of Pharmacy, The Johns Hopkins Hospital, 600 N. Wolfe Street, Carnegie 180, Baltimore, MD 21287 USA
| | - Pouya Tahsili-Fahadan
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD USA
- Department of Medicine, Virginia Commonwealth University School of Medicine, INOVA Campus, Falls Church, VA USA
| | - Eva K. Ritzl
- Department of Neurology, The Johns Hopkins Hospital, Baltimore, MD USA
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD USA
| | - John J. Lewin
- Department of Pharmacy, The Johns Hopkins Hospital, 600 N. Wolfe Street, Carnegie 180, Baltimore, MD 21287 USA
| | - Marek A. Mirski
- Department of Pharmacy, The Johns Hopkins Hospital, 600 N. Wolfe Street, Carnegie 180, Baltimore, MD 21287 USA
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Tu B, Young GB, Kokoszka A, Rodriguez-Ruiz A, Varma J, Eerikäinen LM, Assassi N, Mayer SA, Claassen J, Särkelä MOK. Diagnostic accuracy between readers for identifying electrographic seizures in critically ill adults. Epilepsia Open 2017; 2:67-75. [PMID: 29750214 PMCID: PMC5939393 DOI: 10.1002/epi4.12034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2016] [Indexed: 01/17/2023] Open
Abstract
Objective Electrographic seizures in critically ill patients are often equivocal. In this study, we sought to determine the diagnostic accuracy of electrographic seizure annotation in adult intensive care units (ICUs) and to identify affecting factors. Methods To investigate diagnostic accuracy, interreader agreement (IRA) measures were derived from 5,769 unequivocal and 6,263 equivocal seizure annotations by five experienced electroencephalogram (EEG) readers after reviewing 74 days of EEGs from 50 adult ICU patients. Factors including seizure equivocality (unequivocal vs. equivocal) and laterality (generalized, partial, or bilaterally independent), cyclicity (cyclic vs. noncyclic), persistency (occurrence of status epilepticus), and patient consciousness level (coma vs. noncoma) were further investigated for their influence on IRA measures. Results On average, 70% of seizures marked by a reference reader overlapped, at least in part, with those marked by a test reader (any-overlap sensitivity, AO-Sn). Agreed seizure duration between reader pairs (overlap-integral sensitivity, OI-Sn) was 62%, while agreed nonseizure duration (overlap-integral specificity, OI-Sp) was 99%. A test reader would annotate one additional seizure not overlapping with a reference reader's annotation in every 11.7 h of EEG, that is, the false-positive rate (FPR) was 0.0854/h. Classifying seizure patterns into unequivocal and equivocal improved specificity and FPR (unequivocal patterns) but compromised sensitivity only for equivocal patterns. Sensitivity of all and unequivocal annotations was higher for patients with status epilepticus. Specificity was higher for partial than for bilaterally independent unequivocal seizure patterns, and lower for cyclic all seizure patterns. Significance Diagnosing electrographic seizures in critically ill adults is highly specific and moderately sensitive. Improved criteria for diagnosing electrographic seizures in the ICU are needed.
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Affiliation(s)
- Bin Tu
- Columbia University Comprehensive Epilepsy Center New York New York U.S.A
| | | | | | | | - Jay Varma
- Barrow Neurological Institute Phoenix Arizona U.S.A
| | | | - Nadege Assassi
- New York University Pre-Medicine Neural Science Program New York New York U.S.A
| | - Stephan A Mayer
- Institute for Critical Care Medicine Icahn School of Medicine at Mount Sinai New York New York U.S.A
| | - Jan Claassen
- Division of Neurocritical Care Columbia University New York New York U.S.A
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Czosnyka M, Pickard J, Steiner L. Principles of intracranial pressure monitoring and treatment. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:67-89. [DOI: 10.1016/b978-0-444-63600-3.00005-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Sokolova EY, Savin IA, Kadasheva AB, Gavryushin AV, Pitskhelauri DI, Kozlov AV, Lapteva KN, Podlepich VV. [The management of patients with new epileptic seizures in the early period after resection of hemispheric tumors: two case reports and a literature review]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2017; 81:96-103. [PMID: 29076473 DOI: 10.17116/neiro201781596-103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Epileptic seizures developing for the first time after a neurosurgical intervention (de novo seizures) are a challenge for choosing an optimal treatment. The pathogenesis of these seizures is often associated with factors that become inactive in the early postoperative period. These seizures can not serve the basis for diagnosing symptomatic epilepsy and should be regarded as a brain response to surgery, and patients do not need anticonvulsant therapy that reduces the quality of life. But in some situations, new early postoperative seizures serve the onset of symptomatic epilepsy and require prolonged anticonvulsant therapy. To date, one of the main techniques to identify the nature of newly developed seizure and to plan further treatment (whether or not to use anticonvulsant therapy) is video EEG monitoring. We present two clinical cases of patients who developed de novo convulsive seizures in the early postoperative period in similar situations after resection of intracerebral tumors. The use of video EEG monitoring allowed avoiding unreasonable use of anticonvulsant therapy in one of the patients.
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Affiliation(s)
| | - I A Savin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | | | | | - A V Kozlov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - K N Lapteva
- Burdenko Neurosurgical Institute, Moscow, Russia
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