Abstracts

Rationale: Status epilepticus is (SE) a life-threatening complication of chronic epilepsy and still associated with substantial mortality. New effective treatments are therefore required. Brivaracetam is a new anti-epileptic drug with a higher affinity to SV2A than levetiracetam, and was recently approved for add-on therapy for partial onset seizures with and without generalisation. It has a more rapid onset of activity and may therefore be suitable for treatment of seizure clusters and SE. Methods: We here report on a 58 year old caucasian male, patient with recurrent, refractory non-convulsive SE that was successfully treated with brivaracetam. The patient was suffering from a glioblastoma multiforme in the left parietal lobe that was diagnosed and operated in december 2014, treated with radiotherapy (60 Gy) and with concomitant and maintenance chemotherapy with temozolomide. After initial stabilization, the tumor recurred in May 2015 with a first epileptic seizure (tonic-clonic) and epileptic treatment with levetiracetam and oncologic treatment with bevacizumab and irinotectan was started. A total of 12 cycles were given and the tumor was radiologically stable since and the patient remained seizure-free. In March 2016, the patient was admitted to the Department of Neurology, Odense University Hospital, with a series of tonic-clonic seizures refractory to diazepam i.v. and levetiracetam i.v. but with prompt response to i.v. fosfenytoin. The patient remained again seizure-free afterwards under a combined therapy with levetiracetam 3000 mg daily and fenytoin 200 mg daily. Results: In May 2016, the patient presented with a generalized tonic-clonic seizure that further developed into a subtle, EEG-verified status epilepticus. Clinically, the patient was near comatose. The EEG-verified focus of the seizures was in the right temporal lobe that was previously not affected by the glioblastoma. Conversely, MRI was without evidence of visible tumor manifestations in the right neither temporal lobe and tumor growth in the left parietal lobe. Treatment with diazepam 10 mg i.v. was without effect, loading with levetiracetam remained ineffective. The patient developed seizures despite serum fenytoin of 109 M/l. Due to the incurable malignancy, we tried to avoid narcosis with midazolam/propofol or treatment with phenobarbiturate. The patient was then loaded with lacosamide 400 mg and improved slightly. He was more awake and confuse and still had countless, EEG-verified complex-partial seizures without reacquisition of consciousness. We therefore stopped treatment with 3000 mg levetiracetam and started treatment with brivaracetam 200 mg daily. After start of brivaracetam, the patient had only one observed complex-partial seizure and became seizure-free in the following days. He became fully awake and regained consciousness. The SE was stopped. Conclusions: This is the first case report on a successful treatment of a patient with refractory non-convulsive status epileptics with brivaracetam. The prompt effect of briviracetam in this difficult-to-treat patient suggests that briviracetam may be effective in refractory SE and that further studies are warranted. Funding: CB received honorarium from UCB and was member of advisory board for UCB. MB who was the responsible consultant for the patient has no conflicts of interest.