We report a case of sustained ventricular tachycardia following the initiation of lacosamide as adjunctive epilepsy treatment. A 49-year-old male with intractable frontal lobe seizures experienced severe ventricular tachycardia following the addition of 400 mg lacosamide to his existing regimen of carbamazepine, lamotrigine, clonazepam, and valproate. The tachycardia occurred during a cardiac stress test; stress tests prior to initiation of lacosamide were normal. Conduction defects, including QRS prolongation, persisted during hospitalization until lacosamide was discontinued. The patient had no prior history of cardiac arrhythmia but did possess cardiac risk factors, including hypertension, hypercholesterolemia, and low heart rate variability. This case represents one part of a growing body of literature suggesting a link between arrhythmia and use of lacosamide, which enhances slow inactivation of sodium channels in both the brain and the heart. We believe further study may be necessary to assess the safety of lacosamide in epilepsy patients with cardiac risk factors.
Background: Platelet inhibitor loading is commonly used in emergent settings for neurondovascular interventions in which permanent device implantation (eg, a stent or a flow-diverter) is planned. Oral/enteral load of antiplatelets may delay time-sensitive intervention in emergency settings, and intravenous glycoprotein inhibitors have a long half-life making them difficult to reverse should the treatment strategy change or complications (eg, bleeding) occur. Objective: To investigate the safety and utility of Cangrelor, an intravenous P2Y12 receptor inhibitor with immediate onset (within 2 min) and rapid offset (elimination half-life of 3-6 min) of antiplatelet activity for acute stenting in patients with ischemic and hemorrhagic stroke. Methods/Patients: A total of seven patients (at the time of this submission) received intravenous Cangrelor intraprocedurally. Of those, three patients had tandem cervical/intracranial occlusions, necessitating carotid stenting; two underwent intracranial stenting for thrombectomy-resistant intracranial large vessel occlusions, and two had flow-diverting stents for aneurysmal subarachnoid hemorrhage where use of traditional endovascular/microsurgical techniques was deemed suboptimal. In each case, the infusion was started five minutes before the device implantation, after selective access had been obtained and stent placement was imminent. Results: Endovascular device implantation was successful in all patients. P2Y12 inhibition testing was conducted intraprocedurally (5-10 minutes after the bolus dose) and showed adequate platelet inhibiton in all seven cases (PRU 60-151). Upon completion of interventions, all patients underwent head CT which showed no intracranial hemorrhage (or no worsening hemorrhage). The Cangrelor infusion was then terminated and all patients immediately received oral/enteral antiplatelet load. No immediate/early postoperative complications were noted and follow-up (24-96 hours) angiographic or noninvasive imaging confirmed patency of all the implanted devices. Conclusion: Intravenous Cangrelor could serve as a safe and convenient alternative to traditional antiplatelets or glycoprotein inhibitors in emergent neuroendovascular stenting
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