Management of seizures in critically ill patients

Abstract

For many neurologists, seizures in critically ill patients represent a difficult problem. Etiology can be elusive because of the complexity of the environment, and treatment decisions can be compromised by the paucity of evidence-based guidelines. Emerging data support a higher than previously thought incidence of nonconvulsive epileptic activity in this patient population, which is another important consideration. Although a seizure in the intensive care unit should be treated aggressively, prophylactic antiepileptic drug administration is dependent on the specific etiology, time of onset, and ensuing complications. After ischemic stroke, prophylactic treatment is not generally recommended, and after intracerebral hemorrhage treatment is recommended only after a few weeks. After subarachnoid hemorrhage, prophylactic treatment beyond discharge is also not recommended. Although there is no reason to believe that late seizures after severe head trauma cannot be prevented with prophylactic treatment, such an approach may be useful during the first week after the injury. Physicians, however, have to individualize the treatment to the critical patient after stroke or trauma based on the presence of additional factors that increase the risk for seizures, including structural cortical injuries and medications used in critical illness with epileptogenic potential. A general therapeutic scheme for seizures in the intensive care unit and the role newer antiepileptic drugs can play are also presented in this review.

Post-traumatic epilepsy: current and emerging treatment options

“…Further, it has been shown that the use of cEEG leads to treatment changes in more than 50% of the monitored patients 104. These findings support the empiric use of AEDs and of the cEEG in the critical care setting 60,105–107. Finally, data from a recent randomized and blinded study support the notion that cEEG performed in the first 72 hours after TBI contributes to outcome prediction,26 with alpha variability being the most important predictive factor 108.…”

Intracerebral Hemorrhage Specific Intensity of Care Quality Metrics

“…Aggressive treatment of seizure in the ICU is recommended to reduce the risk of secondary neurological injury [97]. The first-line drug of choice is IV lorazepam in several guidelines because some studies have suggested that lorazepam may be associated with a reduced rate of seizure recurrence [98,99] followed by phenytoin or fosphenytoin as first-line and second-line therapies for status epilepticus [100].…”

Recommendations for the Management of Intracranial Haemorrhage – Part I: Spontaneous Intracerebral Haemorrhage

“…Furthermore non-convulsive seizure or status epilepticus has been detected in 28% of stuporous or comatose patients [110, 111]. …”