Abstracts

Rationale: Animal studies have shown very high glutamate levels in status epilepticus (SE). Vigabatrin (VGB) irreversibly inhibits ?-amino butyric acid-transaminase (GABA-T), increases GABA, and may indirectly lower glutamate levels. Theoretically, this effect could reduce excitatory states and help control SE. Our aims were to report the usefulness/efficacy of VGB in super-refractory status epilepticus (SRSE) as an adjunct to general anesthesia and other anti-seizure medications (ASM). Methods: After IRB approval, we reviewed charts of patients admitted to the Neuro ICU for management of SRSE between the years of 2014 and 2018 at Ochsner Clinic Foundation. This is a single center, retrospective analysis of cases of SRSE in which VGB was used as an adjunct treatment. Resolution of SRSE was defined when patients were successfully weaned off the anesthetic agents with no return epileptic activity on electroencephalogram (EEG). Results: We identified 70 patients diagnosed with SRSE treated with VGB.  Patient demographics were 37 females and 33 males. Ages ranged from 3 months to 89 years (mean 56.09 years). Etiologies included cerebrovascular accident (18), cerebral anoxia due to cardiac arrest (15), genetic/developmental (6), CNS / Non-CNS infection (6), autoimmune disease (4), toxic (3), ASM non-compliance (2), tumor (2), metabolic (1) and unknown (13).VGB was used as the last ASM in 56/70 (80%) patients. Clobazam, fycompa, valproic acid and perampanel were the final agents in 8, 4, 1 and 1, respectively. ASM used prior to the initiation of VGB were levetiracetum (70), lacosamide (69), clobazam (32), valproic acid (30), perampanel (12), topiramate (8), lamotrigine (3), phenytoin (2), oxcarbazepine (2), clonazepam (2), and midazolam (11). Propofol and ketamine were used alone in 22/70 and 4/70 patients, respectively. 44/70 received both propofol and ketamine infusions.The time from diagnosis of SE to VGB initiation ranged from 0.3 to 47.3 days (average 7.91 days, median 5.65 days). Maximal dose of VGB ranged from 200-4500 mg per day. SRSE resolved with the addition of VGB in 47/70 (67%) patients. In the 47 patients, 26 had SE suppression with general anesthetics, of which 20 had relapse when anesthetics were weaned and 6 had recurrence despite prior resolution with anesthetics. In 5/47 patients, clobazam and valproic acid was used as the last agent in 4 and 1 patient, respectively. 5/47 patients suffered in hospital mortality due to multisystem organ failure (2), and withdrawal of care (3).  Conclusions: Our results suggest that vigabatrin has beneficial role in the management of patients with super-refractory status epilepticus. Resolution of SE was achieved in 67% of patients on VGB. In 89%, status resolved when VGB was used as the last agent.  Funding: None