Therapeutic difficulties in recurrent, multidrug-resistant epilepsy and vagal nerve stimulation, with recent traumatic brain complications needing iterative neurosurgical interventions

Abstract

Introduction: Focal epilepsy (possible with secondary generalization) may be a secondary complication to any brain damage (traumatic, vascular, infectious), and is characterized by abnormal excessive neuronal activity with motor, cognitive and psychosocial manifestations. About one third of the patients who suffer from epilepsy have a refractory, multidrug clinical form. Falls are one of the most common medical complications in neurologic patients, occurring during paroxysmal epileptic attacks, or due to sequelary gait limitations. Physical injuries are common, and about 47% patients with epilepsy report at least one injury in the past 12 months. Case presentation: We present a 36-years-old male patient with a medical history of right frontal congenital arteriovenous malformation, ruptured and operated at the age of eight, complicated with left spastic hemiplegia and refractory epilepsy, needing three antiepileptic drugs (AED) and vagus nerve-stimulation (VNS).This presentation was approved by THEBA Bioethics Committee (No.17464/14.06.2019). During a recent epileptic seizure he suffered a severe traumatic brain injury with coma (GCS 5), needing iterative neurosurgical interventions, intensive care supervision, and orotracheal intubation. CT cerebral scan revealed right hemispheric subdural hematoma, operated (on the 2nd May 2019). Rebleeding occurred seven days later, due to an extradural hematoma, and neurosurgical intervention was performed again. The patient was transferred in our neurorehabilitation clinic with left spastic hemiplegia (global motor score was 65/100, and functional independence measure (FIM) 24/91. Neuropsychological assessment revealed an obtunded level of consciousness, depression and dysmnesia for recent events, MMSE 9/30. During hospitalization the patient has continued his previous daily AED treatment with: levetiracetamum 2000 mg + clonazepamum 1mg + carbamazepinum retard 600 mg, associated with VNS. During hospitalization emerged three new short jacksonian seizures, who gave up spontaneously. The overall evolution was favorable with rehabilitation program and psychological support, with improvement of the global motor score, FIM (44/91), and partial restoration of walking ability, but still needing human help. Discussion: The pathophysiological mechanism of relapsed seizures has complex, multiple causes: imbalance of the local brain metabolism and /or a dysfunctional VNS procedure (a possible technical issue due to an impaired electronic device or a bioelectrical one, due to local fibrosis and increased impedance at the contact level between the electrode and the vagal nerve). Specialized technical control disclosed normal electric parameters provided by the electronic device. Other neuromodulatory devices and related technologies, such as deep brain stimulation (DBS) immediately demonstrate their effect control (motor correction) of Parkinson's or dystonic movements. Unfortunately VNS has not the possibility of immediate clinical feed-back control. The AED schedule was modified, by increasing clonazepamum to 2 mg daily. Video-EEG monitoring was recommended. The quod ad vitam prognosis might be unfavorable, because seizures can relapse anytime and evolution is uncontrolled. Furthermore, new brain injures may exacerbate the severity of the epilepsy, any new seizure may worsen the neurologic evolution. The quod ad functionem rehabilitation outcome might be precarious. The family support is essential in the therapeutic efforts. This clinical case underlines the necessity to implement a fall prevention program in patients with epilepsy, the importance of therapeutically tailoring AED for different pathophysiological stages of the disease, and emphasizes the limits of the modern techniques for seizures control. A multi-/ interdisciplinary team management of a such complex clinical case is mandatory. Key words: cerebral arteriovenous malformation, multidrug-resistant (refractory) epilepsy, vagal nerve electrostimulation (VNS), falls, traumatic brain injury,