Intravenous initiation and maintenance of ketogenic diet: Proof of concept in super-refractory status epilepticus

Strzelczyk, Adam; Reif, Philipp S.; Bauer, Sebastian; Belke, Marcus; Oertel, Wolfgang H.; Knake, Susanne; Rosenow, Felix

doi:10.1016/j.seizure.2013.03.007

Cited by 62 publications

(77 citation statements)

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“…The use of KD to control SRSE has been previously reported in case reports and small case series. [6][7][8][9][10][11] One case in the present series was previously reported in the literature. 7 Wusthoff et al 10 reported the largest number of adult patients (2) treated with KD for RSE to date.…”

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confidence: 81%

“…5 Despite their established success in children with refractory epilepsy, only a few case series from single centers describe the use of KD and MAD in adults with refractory SE (RSE) and SRSE. [6][7][8][9][10][11] Given the severity of illness in patients with SRSE, there is a critical need for new therapies to halt ongoing seizure activity. We investigated KD as a treatment for critically ill adults with SRSE treated in intensive care units (ICUs).…”

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confidence: 99%

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Ketogenic diet for adults in super-refractory status epilepticus

et al. 2014

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Objective: To describe a case series of adult patients in the intensive care unit in super-refractory status epilepticus (SRSE; refractory status lasting 24 hours or more despite appropriate anesthetic treatment) who received treatment with the ketogenic diet (KD). Methods:We performed a retrospective case review at 4 medical centers of adult patients with SRSE treated with the KD. Data collected included demographic features, clinical presentation, diagnosis, EEG data, anticonvulsant treatment, and timing and duration of the KD. Primary outcome measures were resolution of status epilepticus (SE) after initiation of KD and ability to wean from anesthetic agents.Results: Ten adult patients at 4 medical centers were started on the KD for SRSE. The median age was 33 years (interquartile range [IQR] 21), 4 patients (40%) were male, and 7 (70%) had encephalitis. The median duration of SE before initiation of KD was 21.5 days (IQR 28) and the median number of antiepileptic medications used before initiation of KD was 7 (IQR 7). Ninety percent of patients achieved ketosis, and SE ceased in all patients achieving ketosis in a median of 3 days (IQR 8). Three patients had minor complications of the KD including transient acidosis and hypertriglyceridemia and 2 patients ultimately died of causes unrelated to the KD. Conclusion:We describe treatment of critically ill adult patients with SRSE with the KD, with 90% of patients achieving resolution of SE. Prospective trials are warranted to examine the efficacy of the KD in adults with refractory SE. Classification of evidence:This study provides Class IV evidence that for intensive care unit patients with refractory SE, a KD leads to resolution of the SE. Neurology ® 2014;82:665-670 GLOSSARY AED 5 antiepileptic drug; GCS 5 Glasgow Coma Scale; ICU 5 intensive care unit; IQR 5 interquartile range; KD 5 ketogenic diet; LOS 5 length of stay; MAD 5 modified Atkins diet; RSE 5 refractory status epilepticus; SE 5 status epilepticus; SRSE 5 super-refractory status epilepticus.Super-refractory status epilepticus (SRSE) is defined as status epilepticus (SE) that continues for at least 24 hours after initiation of general anesthetic medications, including cases in which the SE recurs with reduction or withdrawal of anesthesia.1 SRSE holds a high risk of morbidity and mortality and has been associated with conditions such as encephalitis, anoxic brain injury, and intracranial hemorrhage. The ketogenic diet (KD) and modified Atkins diet (MAD) are high fat, low carbohydrate, adequate protein diets designed to mimic the fasting state that have been proven as effective dietary therapies for some children with epilepsy. 3,4 Small open-label studies suggest efficacy in adults as well. 5 Despite their established success in children with refractory epilepsy, only a few case series from single centers describe the use of KD and MAD in adults with refractory SE (RSE) and SRSE. [6][7][8][9][10][11] Given the severity of illness in patients with SRSE, there is a critical need

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Ketogenic diet for adults in super-refractory status epilepticus

et al. 2014

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“…The ketogenic diet is now considered a safe and effective optional therapy not only for children but also for adults with intractable epilepsy (Stafstrom and Rho, 2004;Freeman et al, 2006Freeman et al, , 2009Kossoff et al, 2008;Caraballo and Vining, 2013;Neal et al, 2008Neal et al, , 2009Caraballo et al, 2011). Interest in the diet has been increasing including for the emergency treatment of status epilepticus (SE) (Freeman et al, 2009;Neal et al, 2008Neal et al, , 2009Caraballo et al, 2011;Bodenant et al, 2008;Wusthoff et al, 2010;Nabbout et al, 2010;Nam et al, 2011;Cervenka et al, 2011;Vaccarezza et al, 2012;Strzelczyk et al, 2013).…”

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confidence: 99%

Ketogenic diet in pediatric patients with refractory focal status epilepticus

et al. 2014

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“…The use of the KD to control status epilepticus in adults has been reported in several case reports and one case series, with a total of 13 patients (12 treated with an enteral diet, one treated with a parenteral KD) [15,35,37]. Patients were generally in status for a number of days prior to the initiation of the ketogenic diet as a rescue therapy.…”

Section: Discussionmentioning

confidence: 99%

“…In this patient there was complete resolution of seizures within one month with no significant adverse effects reported, and the patient was discharged home with normal neurological function. Strzelczyk et al investigated the effects of an intravenous and enteral ketogenic diet in an adult patient with SRSE [35]. Commencement of the KD was associated with a resolution of status epilepticus, however there was ongoing myoclonus and the patient still had generalised tonic-clonic seizures every 3-4 days.…”

Section: Status Epilepticusmentioning

confidence: 99%