De novo generalized periodic discharges related to anesthetic withdrawal resolve spontaneously.

Pentobarbital and propofol are used for the treatment of refractory status epilepticus or elevated intracranial pressure, typically with continuous EEG monitoring. We report a series of patients who developed generalized periodic discharges related to anesthetic withdrawal (GRAWs), different from previous seizure activity. At times, this pattern was misinterpreted as recurrent seizure activity, leading to reinstitution of drug-induced coma, but resolved spontaneously without additional treatment.We identified five patients who developed GRAWs during pentobarbital or propofol withdrawal. Two patients received pentobarbital for increased intracranial pressure. One patient received pentobarbital and propofol for encephalopathy accompanied by a rhythmic EEG pattern erroneously thought to be ictal. Two patients received pentobarbital for refractory partial status epilepticus. In all cases, anesthetic agents were withdrawn after 24 to 48 hours of burst suppression on EEG. We analyzed the course of GRAWs on EEG and the associated clinical outcomes.All five patients developed GRAWs, consisting of periodic 1 to 4 Hz generalized periodic discharge, not previously seen on EEG. In all cases, the pattern eventually resolved spontaneously, over 12 to 120 hours. However, in three cases, the pattern was initially thought to represent ictal activity, and drug-induced coma was reinitiated. The pattern recurred during repeated anesthetic withdrawal, was then recognized as nonictal, and then resolved without further treatment. In all cases but one, the patients exhibited improvement to near-baseline mentation.Generalized periodic discharges related to anesthetic withdrawal may occur de novo after pentobarbital or propofol withdrawal. They should resolve spontaneously without treatment and without recurrence of clinical seizure activity. However, GRAWs are not likely to represent status epilepticus and should not prompt resumption of drug-induced coma, unless there is reappearance of original electrographic seizure activity.

Treatment of refractory complex partial seizures: role of vigabatrin.

Vigabatrin (VGB) is an antiepileptic drug that was designed to inhibit GABA-transaminase, and increase levels of gamma-amino-butyric acid (GABA), a major inhibitory neurotransmitter in the brain. VGB has demonstrated efficacy as an adjunctive antiepileptic drug for refractory complex partial seizures (CPS) and for infantile spasms (IS). This review focuses on its use for complex partial seizures. Although VGB is well tolerated, there have been significant safety concerns about intramyelinic edema and visual field defects. VGB is associated with a risk of developing bilateral concentric visual field defects. Therefore, the use of VGB for complex partial seizures should be limited to those patients with seizures refractory to other treatments. Patients must have baseline and follow-up monitoring of visual fields, early assessment of its efficacy, and ongoing evaluation of the benefits and risks of VGB therapy.

Conversions between monotherapies in epilepsy: expert consensus.

To develop expert consensus for conversion between antiepileptic drug (AED) monotherapies, an 11-member panel used the Delphi Technique over three rounds to: (1) identify relevant issues, (2) vote on the issues, and (3) develop consensus. The panel agreed on the basic principle to taper the existing AED only after a presumably efficacious dose of the planned AED was reached. Application is modified by adverse effects possibly attributable to the existing drug, in which case earlier or more rapid tapering of the existing drug should be considered. Patients with uncontrolled seizures, as well as seizure-free patients for whom driving privileges are a consideration, may benefit from slower tapering by smaller dosage decrements of the existing AED. For 10 of the 12 AEDs considered, the panel made titration recommendations concerning initial and target doses for the planned AED, supplementing limited data in the prescribing information. This expert guidance will aid in the period of transitional polytherapy with AEDs from monotherapy to monotherapy.

Status Epilepticus.

Status epilepticus (SE) is a common neurologic emergency with a high mortality. Immediate recognition and rapid treatment are essential. After initial stabilization of airway and circulation, the patient should be treated as soon as possible with an intravenous (IV) benzodiazepine, followed immediately by IV fosphenytoin. If SE persists, general anesthesia should be initiated, with intubation and cardiac monitoring. Electroencephalogram must also be monitored to ensure suppression of all seizures. Etiology of SE should be assessed through history, examination, blood tests, and brain imaging.