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Dunn EJ, Willis DD. Ketamine for Super-Refractory Status Epilepticus in Palliative Care. A Case Report and Review of the Literature. Am J Hosp Palliat Care 2024; 41:1252-1257. [PMID: 37982530 DOI: 10.1177/10499091231215491] [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] [Indexed: 11/21/2023] Open
Abstract
We report a case of super refractory status epilepticus uncontrolled by multiple anti-seizure medications in an individual with acute liver failure due to hepatic cirrhosis and an obstructive ileocecal mass plus multiple bilateral lung lesions presumed to be metastatic. A ketamine infusion was initiated late in his hospitalization which eliminated the convulsive seizures in less than an hour. The abatement of convulsive seizures allowed his grieving wife to return to her husband's bedside to witness the withdrawal of life sustaining treatment and be present during the final 24 hours of his life. We review the medical literature on the role of Intravenous (IV) Ketamine in the treatment of super refractory status epilepticus.
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Affiliation(s)
- Edward J Dunn
- U of L Health - Jewish Hospital Palliative Care, Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA
- U of L Health - Jewish Hospital, University of Louisville School of Medicine, Louisville, KY, USA
| | - David D Willis
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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2
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Chiriboga N, Spentzas T, Abu-Sawwa R. A systematic review and meta-analysis of ketamine in pediatric status epilepticus. Epilepsia 2024; 65:2200-2212. [PMID: 38881333 DOI: 10.1111/epi.18035] [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: 12/01/2023] [Revised: 05/22/2024] [Accepted: 05/22/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVE Status epilepticus (SE) is a common neurological medical emergency in the pediatric population, with 10%-40% of cases progressing to refractory SE (RSE), requiring treatment with anesthetic infusions. We present a systematic review and meta-analysis of the use of ketamine for the treatment of pediatric SE and its potential advantages over other anesthetic infusions. METHODS This review follows the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Electronic databases, including PubMed, Cochrane Library, Ovid, Embase, and Google Scholar, were searched with the keywords "pediatrics," "status epilepticus," and "ketamine treatment." Randomized trials, prospective and retrospective cohort studies, and case reports were considered for inclusion. RESULTS Eighteen publications met the initial inclusion criteria. The 18 publications comprise 11 case reports, one nonconclusive clinical trial, two case series, and four retrospective cohorts. After excluding the case reports because of reporting bias, only the six case series and cohorts were included in the final analysis. There were 172 patients in the six included studies. The weighted age was 9.93 (SD = 10.29) years. The weighted maximum dose was 7.44 (SD = 9.39) mg/kg/h. SE cessation was attained in 51% (95% confidence interval = 43-59) of cases with the addition of ketamine. The heterogeneity was I2 = 0%, t2 = 0, χ2 (5) = 3.39 (p = .64). SIGNIFICANCE Pediatric RSE is difficult to treat, resulting in increased morbidity and mortality. Without strong recommendations and evidence regarding preferred agents, this review provides evidence that ketamine may be considered in managing SE in the pediatric population.
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Affiliation(s)
- Nicolas Chiriboga
- Pediatric Intensive Care Unit Le Bonheur Children's Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Thomas Spentzas
- Pediatric Intensive Care Unit Le Bonheur Children's Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Renad Abu-Sawwa
- Department of Anatomy and Cell Biology, Rush Medical College, Chicago, Illinois, USA
- Department of Pediatric Neurology, Rush University Children's Hospital, Chicago, Illinois, USA
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3
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Shehata IM, Kohaf NA, ElSayed MW, Latifi K, Aboutaleb AM, Kaye AD. Ketamine: Pro or antiepileptic agent? A systematic review. Heliyon 2024; 10:e24433. [PMID: 38293492 PMCID: PMC10826813 DOI: 10.1016/j.heliyon.2024.e24433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/01/2024] Open
Abstract
Purpose of Review: This evidence-based systematic review evaluated the safety of ketamine as regard the potential to provoke epilepsy to help better guide anesthesiologists in their practice. Recent findings Ketamine, originally developed as a dissociative anesthetic, has gained attention for its potential therapeutic applications in various medical conditions, including epilepsy. Ketamine is generally well-tolerated and widely used in anesthesia, however, conflicting data are confusing the anesthesiologists regarding the potential risk of seizures associated with its use. The literature that claimed the proepileeptic property are inconsistent and the mechanism of action is unclear. Moreover, the case reports had been in same certain contexts, such as procedural sedation where ketamine was used as a single agent. On the other hand, the retrospective data analysis confirmed the positive role ketamine plays as antiepileptic agent. Summary Many studies have shown promising results for the use of ketamine as antiepileptic agent. In case of epileptic patients, there is no contraindication for using ketamine, however, combining with benzodiazepine or propofol may enhance the safety.
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Affiliation(s)
| | - Neveen A. Kohaf
- Department of Clinical Pharmacy, Alazhar, University, Cairo, 11651, Egypt
| | - Mohamed W. ElSayed
- Geisel School of Medicine at Dartmouth, New Hampshire Hospital, SUNY School of Graduate Studies, USA
| | - Kaveh Latifi
- Department of Anesthesiology and Pain Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Alan David Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
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4
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Buratti S, Giacheri E, Palmieri A, Tibaldi J, Brisca G, Riva A, Striano P, Mancardi MM, Nobili L, Moscatelli A. Ketamine as advanced second-line treatment in benzodiazepine-refractory convulsive status epilepticus in children. Epilepsia 2023; 64:797-810. [PMID: 36792542 DOI: 10.1111/epi.17550] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
Status epilepticus (SE) is one of the most common neurological emergencies in children. To date, there is no definitive evidence to guide treatment of SE refractory to benzodiazepines. The main objectives of treatment protocols are to expedite therapeutic decisions and to use fast- and short-acting medications without significant adverse effects. Protocols differ among institutions, and most frequently valproate, phenytoin, and levetiracetam are used as second-line treatment. After failure of first- and second-line medications, admission to the intensive care unit and continuous infusion of anesthetics are usually indicated. Ketamine is a noncompetitive N-methyl-D-aspartate receptor antagonist that has been safely used for the treatment of refractory SE in adults and children. In animal models of SE, ketamine demonstrated antiepileptic and neuroprotective properties and synergistic effects with other antiseizure medications. We reviewed the literature to demonstrate the potential role of ketamine as an advanced second-line agent in the treatment of SE. Pharmacological targets, pathophysiology of SE, and the receptor trafficking hypothesis are reviewed and presented. The pharmacology of ketamine is outlined with related properties, advantages, and side effects. We summarize the most recent and relevant publications on experimental and clinical studies on ketamine in SE. Key expert opinion is also reported. Considering the current knowledge on SE pathophysiology, early sequential polytherapy should include ketamine for its wide range of positive assets. Future research and clinical trials on SE pharmacotherapy should focus on the role of ketamine as second-line medication.
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Affiliation(s)
- Silvia Buratti
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Emanuele Giacheri
- Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Antonella Palmieri
- Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Jessica Tibaldi
- Emergency Medicine Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Giacomo Brisca
- Intermediate Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Antonella Riva
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy
| | - Pasquale Striano
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy.,Pediatric Neurology and Muscular Disease Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | | | - Lino Nobili
- Department of Neuroscience (DINOGMI), University of Genoa, Genoa, Italy.,Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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5
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Treatment of refractory status epilepticus with intravenous anesthetic agents: A systematic review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.1016/j.tacc.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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6
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Defining and overcoming the therapeutic obstacles in canine refractory status epilepticus. Vet J 2022; 283-284:105828. [DOI: 10.1016/j.tvjl.2022.105828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/08/2022] [Accepted: 04/09/2022] [Indexed: 11/20/2022]
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Gale JR, Kosobucki GJ, Hartnett-Scott KA, Aizenman E. Imprecision in Precision Medicine: Differential Response of a Disease-Linked GluN2A Mutant to NMDA Channel Blockers. Front Pharmacol 2021; 12:773455. [PMID: 34776984 PMCID: PMC8581401 DOI: 10.3389/fphar.2021.773455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022] Open
Abstract
Mutations in N-methyl-d-aspartate receptors (NMDAR) subunits have been implicated in a growing number of human neurodevelopmental disorders. Previously, a de novo mutation in GRIN2A, encoding the GluN2A subunit, was identified in a patient with severe epilepsy and developmental delay. This missense mutation, which leads to GluN2A-P552R, produces significant dendrotoxicity in transfected rodent cortical neurons, as evidenced by pronounced dendritic blebbing. This injurious process can be prevented by treatment with the NMDA antagonist memantine. Given the increasing use of FDA approved NMDA antagonists to treat patients with GRIN mutations, who may have seizures refractory to traditional anti-epileptic drugs, we investigated whether additional NMDA antagonists were effective in attenuating neurotoxicity associated with GluN2A-P552R expression. Intriguingly, we found that while treatment with memantine can effectively block GluN2A-P552R-mediated dendrotoxicity, treatment with ketamine does not, despite the fact that both drugs work as open NMDAR channel blockers. Interestingly, we found that neurons expressing GluN2A-P552R were more vulnerable to an excitotoxic insult-an effect that, in this case, could be equally rescued by both memantine and ketamine. These findings suggest that GluN2A-P552R induced dendrotoxicity and increased vulnerability to excitotoxic stress are mediated through two distinct mechanisms. The differences between memantine and ketamine in halting GluN2A-P552R dendrotoxicity could not be explained by NMDA antagonist induced changes in MAP or Src kinase activation, previously shown to participate in NMDA-induced excitotoxicity. Our findings strongly suggest that not all NMDA antagonists may be of equal clinical utility in treating GRIN2A-mediated neurological disorders, despite a shared mechanism of action.
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Affiliation(s)
- Jenna R Gale
- Department of Neurobiology and Pittsburgh Institute for Neurodegenerative Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Gabrielle J Kosobucki
- Department of Neurobiology and Pittsburgh Institute for Neurodegenerative Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Karen A Hartnett-Scott
- Department of Neurobiology and Pittsburgh Institute for Neurodegenerative Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Elias Aizenman
- Department of Neurobiology and Pittsburgh Institute for Neurodegenerative Diseases, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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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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9
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Kim D, Kim JM, Cho YW, Yang KI, Kim DW, Lee ST, No YJ, Seo JG, Byun JI, Kang KW, Kim KT. Antiepileptic Drug Therapy for Status Epilepticus. J Clin Neurol 2021; 17:11-19. [PMID: 33480193 PMCID: PMC7840311 DOI: 10.3988/jcn.2021.17.1.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 12/31/2022] Open
Abstract
Status epilepticus (SE) is one of the most serious neurologic emergencies. SE is a condition that encompasses a broad range of semiologic subtypes and heterogeneous etiologies. The treatment of SE primarily involves the management of the underlying etiology and the use of antiepileptic drug therapy to rapidly terminate seizure activities. The Drug Committee of the Korean Epilepsy Society performed a review of existing guidelines and literature with the aim of providing practical recommendations for antiepileptic drug therapy. This article is one of a series of review articles by the Drug Committee and it summarizes staged antiepileptic drug therapy for SE. While evidence of good quality supports the use of benzodiazepines as the first-line treatment of SE, such evidence informing the administration of second- or third-line treatments is lacking; hence, the recommendations presented herein concerning the treatment of established and refractory SE are based on case series and expert opinions. The choice of antiepileptic drugs in each stage should consider the characteristics and circumstances of each patient, as well as their estimated benefit and risk to them. In tandem with the antiepileptic drug therapy, careful searching for and treatment of the underlying etiology are required.
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Affiliation(s)
- Daeyoung Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae Moon Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea.
| | - Yong Won Cho
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea.
| | - Kwang Ik Yang
- Department of Neurology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Dong Wook Kim
- Department of Neurology, Konkuk University School of Medicine, Seoul, Korea
| | - Soon Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Young Joo No
- Department of Neurology, Samsung Noble County, Yongin, Korea
| | - Jong Geun Seo
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jung Ick Byun
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Keun Tae Kim
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
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10
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Pribish A, Wood N, Kalava A. A Review of Nonanesthetic Uses of Ketamine. Anesthesiol Res Pract 2020; 2020:5798285. [PMID: 32308676 PMCID: PMC7152956 DOI: 10.1155/2020/5798285] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 02/07/2020] [Accepted: 03/05/2020] [Indexed: 12/20/2022] Open
Abstract
Ketamine, a nonselective NMDA receptor antagonist, is used widely in medicine as an anesthetic agent. However, ketamine's mechanisms of action lead to widespread physiological effects, some of which are now coming to the forefront of research for the treatment of diverse medical disorders. This paper aims at reviewing recent data on key nonanesthetic uses of ketamine in the current literature. MEDLINE, CINAHL, and Google Scholar databases were queried to find articles related to ketamine in the treatment of depression, pain syndromes including acute pain, chronic pain, and headache, neurologic applications including neuroprotection and seizures, and alcohol and substance use disorders. It can be concluded that ketamine has a potential role in the treatment of all of these conditions. However, research in this area is still in its early stages, and larger studies are required to evaluate ketamine's efficacy for nonanesthetic purposes in the general population.
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Affiliation(s)
- Abby Pribish
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Nicole Wood
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Arun Kalava
- Department of Anesthesiology, University of Central Florida College of Medicine, Orlando, FL, USA
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11
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Talahma M, Sabharwal V, Bukovskaya Y, Khan F. Ketamine Infusion Used to Successfully Control Refractory Status Epilepticus in a Pregnant Patient. Case Rep Neurol Med 2018; 2018:3041279. [PMID: 30498609 PMCID: PMC6222219 DOI: 10.1155/2018/3041279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/30/2018] [Indexed: 11/18/2022] Open
Abstract
The management of SE during pregnancy is especially challenging to the treating physician. While antiepileptic medications might cause teratogenicity, SE can have significant morbidity and mortality on both the mother and the developing fetus. This case report demonstrated the successful use of ketamine infusion in the management of RSE in pregnancy without affecting the immediate outcome of pregnancy. The fetus survived this complicated ICU stay and outpatient follow-up was generally uncomplicated. The pregnancy was ended with a delivery of a normal female newborn.
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Affiliation(s)
- Murad Talahma
- Department of Neurocritical Care, Ochsner Health System, New Orleans, LA, USA
| | - Vivek Sabharwal
- Department of Neurocritical Care, Ochsner Health System, New Orleans, LA, USA
| | - Yana Bukovskaya
- Department of Neurocritical Care, Ochsner Health System, New Orleans, LA, USA
| | - Fawad Khan
- Department of Neurocritical Care, Ochsner Health System, New Orleans, LA, USA
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12
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Amengual-Gual M, Sánchez Fernández I, Wainwright MS. Novel drugs and early polypharmacotherapy in status epilepticus. Seizure 2018; 68:79-88. [PMID: 30473267 DOI: 10.1016/j.seizure.2018.08.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 08/05/2018] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Rescue medications for status epilepticus (SE) have a relatively high rate of failure. The purpose of this review is to summarize the evidence for the efficacy of novel drugs and early polypharmacotherapy for SE. METHOD Literature review. RESULTS New drugs and treatment strategies aim to target the pathophysiology of SE in order to improve seizure control and outcomes. Changes at the synapse level during SE include a progressive decrease in synaptic GABAA receptors and increase in synaptic NMDA receptors. These changes tend to promote self-sustaining seizures. Current SE guidelines recommend a rapid stepwise treatment using benzodiazepines in monotherapy as the first-line treatment, targeting GABAA synaptic receptors. Novel treatment approaches target GABAA synaptic and extrasynaptic receptors with allopregnanolone, and NMDA receptors with ketamine. Novel rescue treatments used for SE include topiramate, brivaracetam, and perampanel, which are already marketed in epilepsy. Some available drugs not marketed for use in epilepsy have been used in the treatment of SE, and other agents are being studied for this purpose. Early polytherapy, most frequently combining a benzodiazepine with a second-line drug or an NMDA receptor antagonist, might potentially increase seizure control with relatively minor increase in side effects. Although many preclinical studies support novel drugs and early polytherapy in SE, human studies are scarce and inconclusive. Currently, evidence is lacking to recommend specific combinations of these new agents. CONCLUSIONS Novel drugs and strategies target the underlying pathophysiology of SE with the intent to improve seizure control and outcomes.
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Affiliation(s)
- Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Pediatric Neurology Unit, Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain.
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Child Neurology, Hospital Sant Joan de Déu, Universidad de Barcelona, Spain
| | - Mark S Wainwright
- Department of Neurology, Division of Pediatric Neurology. University of Washington School of Medicine, Seattle, WA, USA
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13
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Tao H, Zhou X, Xie Q, Ma Z, Sun F, Cui L, Cai Y, Ma G, Fu J, Liu Z, Li Y, Zhou H, Zhao J, Chen Y, Mai H, Chen Y, Chen J, Qi W, Sun C, Zhao B, Li K. SRR intronic variation inhibits expression of its neighbouring SMG6 gene and protects against temporal lobe epilepsy. J Cell Mol Med 2018; 22:1883-1893. [PMID: 29363864 PMCID: PMC5824374 DOI: 10.1111/jcmm.13473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 10/30/2017] [Indexed: 01/05/2023] Open
Abstract
D‐serine is a predominant N‐methyl‐D‐aspartate receptor co‐agonist with glutamate, and excessive activation of the receptor plays a substantial role in epileptic seizures. Serine racemase (SRR) is responsible for transforming L‐serine to D‐serine. In this study, we aimed to investigate the genetic roles of SRR and a neighbouring gene, nonsense‐mediated mRNA decay factor (SMG6), in temporal lobe epilepsy (TLE). Here, a total of 496 TLE patients and 528 healthy individuals were successfully genotyped for three SRR tag single nucleotide polymorphisms. The frequencies of the GG genotype at rs4523957 T > G were reduced in the TLE cases in the initial cohort (cohort 1) and were confirmed in the independent cohort (cohort 2). An analysis of all TLE cases in cohort 1 + 2 revealed that the seizure frequency and drug‐resistant incidence were significantly decreased in carriers of the GG genotype at rs4523957. Intriguingly, the activity of the SMG6 promoter with the mutant allele at rs4523957 decreased by 22% in the dual‐luciferase assay, and up‐regulated expression of SMG6 was observed in an epilepsy rat model. This study provides the first demonstration that the GG genotype is a protective marker against TLE. In particular, variation at rs4523957 likely inhibits SMG6 transcription and plays a key role against susceptibility to and severity of TLE. The significance of SMG6 hyperfunction in epileptic seizures deserves to be investigated in future studies.
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Affiliation(s)
- Hua Tao
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China.,Guangdong Key Laboratory of Age-related Cardiac and Cerebral Diseases, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Xu Zhou
- Clinical Research Center, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Qian Xie
- Emergency Department, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Zhonghua Ma
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Fuhai Sun
- Department of Neurology, the First People's Hospital of Pingdingshan, Pingdingshan, Hebei, China
| | - Lili Cui
- Guangdong Key Laboratory of Age-related Cardiac and Cerebral Diseases, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Yujie Cai
- Guangdong Key Laboratory of Age-related Cardiac and Cerebral Diseases, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Guoda Ma
- Guangdong Key Laboratory of Age-related Cardiac and Cerebral Diseases, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Jiawu Fu
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Zhou Liu
- Guangdong Key Laboratory of Age-related Cardiac and Cerebral Diseases, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - You Li
- Guangdong Key Laboratory of Age-related Cardiac and Cerebral Diseases, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Haihong Zhou
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Jianghao Zhao
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Yanyan Chen
- Guangdong Key Laboratory of Age-related Cardiac and Cerebral Diseases, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Hui Mai
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Ying Chen
- Department of Neurology, Central People's Hospital of Zhanjiang, Zhanjiang, Guangdong, China
| | - Jun Chen
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Wei Qi
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Chaowen Sun
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Bin Zhao
- Guangdong Key Laboratory of Age-related Cardiac and Cerebral Diseases, Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Keshen Li
- Institute of Neurology, Guangdong Medical University, Zhanjiang, Guangdong, China.,Stroke Center, Neurology& Neurosurgery Division, Clinical Medicine Research Institute & the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China
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14
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Ciccone O, Mathews M, Birbeck GL. Management of acute seizures in children: A review with special consideration of care in resource-limited settings. Afr J Emerg Med 2017; 7:S3-S9. [PMID: 30505668 PMCID: PMC6246874 DOI: 10.1016/j.afjem.2017.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 08/14/2017] [Accepted: 09/15/2017] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION We sought to review recent evidence-based guidelines and where applicable, primary data to extrapolate insights into the appropriate management of acute seizures in children in resource-limited settings. METHODS PubMed and Google scholar searches were conducted with attention to publications from the last three to five years, including a focused search for acute seizure management guidelines relevant to resource limited settings. Since all guidelines to date, except the World Health Organization's, assume ready access to invasive ventilation and advanced diagnostic testing, guidelines and primary data were used to propose management appropriate for resource-limited settings where respiratory suppression from treatment presents a major challenge in management. RESULTS Acute seizures are among the commonest medical emergencies encountered in the African settings. Seizure management must occur simultaneously with the diagnostic assessment, which should include addressing life threatening causes (e.g. hypoglycaemia, malaria) and with attention given to the most likely aetiology in a particular region or setting. For ongoing seizures, initial treatment with benzodiazepines is indicated. There is evidence of efficacy for several agents and delivery modes. Longer-acting antiepileptic drugs (AEDs) should be on hand if acute seizures fail to respond to two doses of benzodiazepines. There is little direct evidence comparing the relative efficacy of different long-acting AEDs for acute seizure management in African children. Findings suggest that generalising data from Western settings, where different aetiologies and risk factors for seizures prevail, may be inappropriate. DISCUSSION Though treatment options and diagnostics may be dictated by available medications and capacity, it is possible for virtually any healthcare setting to develop a relevant and feasible local guideline for seizure management. Clear specifications on when to refer to a higher level of care should be part of the care plan.
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Affiliation(s)
- Ornella Ciccone
- The University of Zambia, School of Medicine, Lusaka, Zambia
- University Teaching Hospital, 1 Nationalist Road, P.O. Box 50440, Ridgeway, Lusaka, Zambia
| | - Manoj Mathews
- University Teaching Hospital, 1 Nationalist Road, P.O. Box 50440, Ridgeway, Lusaka, Zambia
| | - Gretchen L. Birbeck
- Chikankata Epilepsy Care Team, Chikankata Hospital, Private Bag S2, Mazabuka, Zambia
- Strong Epilepsy Center, Department of Neurology, University of Rochester, 265 Crittenden Blvd, Rochester, NY 14641, United States
- Corresponding author.
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15
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Beg JM, Anderson TD, Francis K, Meckley LM, Fitzhenry D, Foster T, Sukhtankar S, Kanes SJ, Moura LMVR. Burden of illness for super-refractory status epilepticus patients. J Med Econ 2017; 20:45-53. [PMID: 27556834 DOI: 10.1080/13696998.2016.1223680] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To provide an estimate of the annual number of super-refractory status epilepticus (SRSE) cases in the US and to evaluate utilization of hospital resources by these patients. METHODS The Premier Hospital Database was utilized to estimate the number of SRSE cases based on hospital discharges during 2012. Discharges were classified as SRSE cases based on an algorithm using seizure-related International Classification of Diseases-9 (ICD-9) codes, Intensive Care Unit (ICU) length of stay (LOS), and treatment protocols (e.g. benzodiazepines, anti-epileptic drugs (AEDs), and ventilator use). Secondary analyses were conducted using more restrictive algorithms for SRSE. RESULTS A total of 6,325 hospital discharges were classified as SRSE cases from a total of 5,300,000 hospital discharges. Applying a weighting based on hospital characteristics and 2012 US demographics, this projected to an estimated 41,156 cases of SRSE in the US during 2012, an estimated incidence rate of ∼13/100,000 annually for SRSE in the US. Secondary analyses using stricter SRSE algorithms resulted in estimated incidence rates of ∼11/100,000 and 8/100,000 annually. The mean LOS for SRSE hospitalizations was 16.5 days (median =11; interquartile range [IQR] = 6-20), and the mean ICU LOS was 9.3 days (median =6; IQR =3-12). The mean cost of an SRSE hospitalization was $51,247 (median = $33,294; 95% CI = $49,634-$52,861). LIMITATIONS The analysis uses ICD-9 diagnostic codes and claims information, and there are inherent limitations in any methodology based on treatment protocol, which created challenges in distinguishing with complete accuracy between SRSE, RSE, and SE on the basis of care patterns in the database. CONCLUSION SRSE is associated with high mortality and morbidity, which place a high burden on healthcare resources. Projections based upon the findings of this study suggest an estimated 25,821-41,959 cases of SRSE may occur in the US each year, but more in-depth studies are required.
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Affiliation(s)
- Jamil M Beg
- a Sage Therapeutics, Inc. , Cambridge , MA , USA
| | | | | | | | | | | | | | | | - Lidia M V R Moura
- c Department of Neurology , Massachusetts General Hospital , Boston , MA , USA
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16
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Abstract
Nonconvulsive status epilepticus (NCSE) is a state of continuous or repetitive seizures without convulsions. Owing to the nonspecific symptoms and considerable morbidity and mortality associated with NCSE, clinical research has focused on early diagnosis, risk stratification and seizure termination. The subtle symptoms and the necessity for electroencephalographic confirmation of seizures result in under-diagnosis with deleterious consequences. The introduction of continuous EEG to clinical practice, and the characterization of electrographic criteria have delineated a number of NCSE types that are associated with different prognoses in several clinical settings. Epidemiological studies have uncovered risk factors for NCSE; knowledge of these factors, together with particular clinical characteristics and EEG observations, enables tailored treatment. Despite these advances, NCSE can be refractory to antiepileptic drugs, necessitating further escalation of treatment. The presumptive escalation to anaesthetics, however, has recently been questioned owing to an association with increased mortality. This Review compiles epidemiological, clinical and diagnostic aspects of NCSE, and considers current treatment options and prognosis.
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17
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A Potential Role for Felbamate in TSC- and NF1-Related Epilepsy: A Case Report and Review of the Literature. Case Rep Neurol Med 2015; 2015:960746. [PMID: 26579319 PMCID: PMC4633543 DOI: 10.1155/2015/960746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 09/23/2015] [Accepted: 10/05/2015] [Indexed: 12/31/2022] Open
Abstract
A 15-year-old girl with maternal inheritance of neurofibromatosis type 1 (NF1) and paternal inheritance of tuberous sclerosis complex (TSC) developed intractable epilepsy at age 5. Her seizures were refractory to adequate doses of four antiepileptic medications until felbamate was initiated at age 7. She has since remained seizure-free on felbamate monotherapy. Although felbamate has multiple mechanisms of action, it is thought to have its most potent antiepileptic effects through inhibition of the N-methyl-D-aspartate receptor (NMDAR). Previous studies have shown that the NMDAR is altered in varying epilepsy syndromes and notably in the cortical tubers found in TSC. The aim of this paper is to examine how felbamate monotherapy was able to achieve such robust antiepileptic effects in a unique patient and possibly offer a novel therapeutic approach to patients suffering from TSC- and NF-related epilepsy.
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18
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Chen HY, Albertson TE, Olson KR. Treatment of drug-induced seizures. Br J Clin Pharmacol 2015; 81:412-9. [PMID: 26174744 DOI: 10.1111/bcp.12720] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 07/03/2015] [Accepted: 07/07/2015] [Indexed: 01/01/2023] Open
Abstract
Seizures are a common complication of drug intoxication, and up to 9% of status epilepticus cases are caused by a drug or poison. While the specific drugs associated with drug-induced seizures may vary by geography and change over time, common reported causes include antidepressants, stimulants and antihistamines. Seizures occur generally as a result of inadequate inhibitory influences (e.g., gamma aminobutyric acid, GABA) or excessive excitatory stimulation (e.g. glutamate) although many other neurotransmitters play a role. Most drug-induced seizures are self-limited. However, status epilepticus occurs in up to 10% of cases. Prolonged or recurrent seizures can lead to serious complications and require vigorous supportive care and anticonvulsant drugs. Benzodiazepines are generally accepted as the first line anticonvulsant therapy for drug-induced seizures. If benzodiazepines fail to halt seizures promptly, second line drugs include barbiturates and propofol. If isoniazid poisoning is a possibility, pyridoxine is given. Continuous infusion of one or more anticonvulsants may be required in refractory status epilepticus. There is no role for phenytoin in the treatment of drug-induced seizures. The potential role of ketamine and levetiracetam is promising but not established.
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Affiliation(s)
- Hsien-Yi Chen
- California Poison Control System, Department of Clinical Pharmacy, University of California, San Francisco, USA.,Department of Emergency Medicine, Chang-Gung Memorial Hospital, Taoyuan, Taiwan.,Division of Clinical Pharmacology & Toxicology, San Francisco General Hospital, San Francisco, USA
| | - Timothy E Albertson
- California Poison Control System, Department of Clinical Pharmacy, University of California, San Francisco, USA.,Department of Internal Medicine, University of California Davis School of Medicine and Veterans Administration Northern California Health Care System, California
| | - Kent R Olson
- California Poison Control System, Department of Clinical Pharmacy, University of California, San Francisco, USA.,Division of Clinical Pharmacology & Toxicology, San Francisco General Hospital, San Francisco, USA
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