Abstract
Introduction Acute symptomatic seizures are frequent in the critically ill patient and can be difficult to treat. The novel anticonvulsant perampanel may be effective in the treatment of status epilepticus considering its mechanism of action of being an AMPA antagonist. We present four cases of super refractory status epilepticus treated with high dose perampanel. Method Case report. Cases Four patients were treated with perampanel for their refractory status epilepticus. One patient had new onset refractory status epilepticus of unknown etiology. Three other patients had status epilepticus as a result of their cardiac arrest. Two of the cardiac arrest patients had myoclonus. In all patients, the additional of perampanel resulted in a reduction of seizure burden without affecting hemodynamics or hepatic or renal function. Conclusion Perampanel may be effective in the treatment of super-refractory status epilepticus of varying etiologies. A larger, prospective study is needed to further assess this therapy.
Highlights
Acute symptomatic seizures are frequent in the critically ill patient and can be difficult to treat. e novel anticonvulsant perampanel may be effective in the treatment of status epilepticus considering its mechanism of action of being an amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) antagonist
The efficacy of GABAergic agents is reduced by the internalization of postsynaptic gamma-aminobutyric acid (GABA)-A receptors allowing for glutamate to promote ictal activity by binding to AMPA receptors [2]
We present four cases of super refractory status epilepticus, in very different clinical settings, treated with high dose perampanel
Summary
Acute symptomatic seizures—convulsive or nonconvulsive— are frequent in the critically ill patient [1]. Case Reports in Critical Care without contrast was unremarkable He was monitored on continuous electroencephalography (CEEG). CEEG showed nonconvulsive seizures from bilateral frontotemporal regions His levetiracetam dose was increased and he was given fosphenytoin. Autoimmune and paraneoplastic encephalitis panels were negative except for elevated anti-thyroid peroxidase antibodies (>1548 IU/mL (range 0–60 IU/mL)) and anti-thyroglobulin antibodies (128 IU/mL (range 0–60 IU/mL)) He was started on intravenous high dose methylprednisolone (1 g/day). Repeat lumbar puncture showed improving pleocytosis (13 cells/mm3) and protein (54 mg/dL) He continued to have nonconvulsive seizures on CEEG. He continued to have breakthrough seizures and required pentobarbital He was subsequently loaded with lacosamide and valproic acid and was eventually started on a ketamine infusion. T 1: Hemodynamic and laboratory values for patients treated with high dose perampenal
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