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					                                     Topiramate Status Epilepticus (SE) Cases

CASE 1

39 year old man without significant past medical history was admitted with fever, headache and altered mental status.
During the admission he developed seizures/SE (no prior seizure history) and was found to have encephalitis of unknown
etiology (cultures negative). His first episode of SE lasted 10.5 hours (partial with secondary generalization) and was
controlled with lorazepam, fosphenytoin, valproate and pentobarb drip. He was maintained on pentobarb drip for over a
month, with propofol drip for several days, as clinicians were unable to wean pentobarb without the recurrence of spikes,
sharps or seizures. When pentobarb was weaned and discontinued for 1 day, he had a recurrence of SE for 20 hours and
was placed back on pentobarb. Two weeks later, still unable to wean the pentobarb, topamax was started. After the
initiation of topamax, pentobarb was successfully weaned without SE recurrence. He continued to improve and was
discharged to rehab on phenytoin 300mg Q8hours, phenobarb elixir 50 mg. Q 8 hours and topamax 400mg Q 8 hours.

SE day          AEDs                AED Dosage(s)      AED Levels (if available)                    Comments
  1                   LZP      2 mg. times 5           PHT 17.6 mg/l               Brief, intermittent seizures periodically
                      VAL      1000 mg. times 2        VAL 28 mg/l                 for several days treated with LZP, DZP,
                      VAL      1200 mg.                                            PHT, FOS - progressed to partial with
                      FOS      200 mg.                                             secondary generalized SE. Seizure
                      PTB      400 mg.                                             activity decreased to occasional facial
                   PTB drip    titrated to 80 mg./hr                               twitching on pentobarb.
   2                  VAL      1000 mg.                VAL 38.0 mg/l               Mouth twitching noted at times.
                      FOS      200 mg.                 PHT 13.5mg/l
                   PTB drip    max. 160 mg./hr         PTB 25.8 mg/l
   3                  PHT      175 mg.                 VAL 26.0 mg/l
                   PTB drip    max 180 mg./hr          PHT 13.1 mg/l
                                                       PTB 14.2 mg/l
   4                   PHT     175 mg. times 3         PHT 13.0 mg/l, free 1.6     Occasional facial twitching
                  PTB drip     max. 240 mg./hr         PTB 18.2 mg/l
   5                   PHT     500 mg.                                             Facial/mouth twitching at times.
                       PHT     175 mg.                                             Hypothermia initiated to 94-96 degrees
                       CBZ     200 mg.                                             Fahrenheit in an attempt to assist
                       CBZ     400 mg.                                             seizure control.
                  PTB drip     max. 240mg./hr
   6                   PHT     175 mg. times 3         PHT 11.7 mg/l               EEG still shows seizures. Temperature
                       CBZ     200 mg.                 CBZ 2.1 mg/l                maintained between 94-96 degrees
                  PTB drip     max. 240 mg./hr         PTB 23.2 mg/l               Fahrenheit.
               Propofol drip   max 50 mg./hr
   7                   PHT     175 mg. times 4
                       PHT     500 mg.                 PHT 8.4 mg/l free 1.1
                       PHT     200 mg.
                  PTB drip     max. 280 mg./hr
               Propofol drip   max. 130 mg/hr
   8              PTB drip     max. 280 mg./hr
                       PHT     175 mg. times 4         PHT 14.6 mg/l, free 1.7
               Propofol drip   max. 130 mg/hr
   9                   PHT     175 mg. times 4         PHT 15.0 mg/l, free 3.0     Propofol drip weaned, discontinued.
                  PTB drip     max. 256 mg./hr         PTB 34.5 mg/l
               Propofol drip   max. 85 mg/hr
   10                  PHT     175 mg. times 3                                     Facial twitching noted at times,
                  PTB drip     max. 280 mg./hr         PTB 31.1 mg/l               diminished with increased PTB
                     Topiramate Status Epilepticus (SE) Cases

11      PHT     175 mg. times 4        PHT 13.2 mg/l, free 3.2   Attempts to decrease PTB leads to
     PTB drip   max. 230mg./hr         PTB 31.5 mg/l             visible facial twitching.
12      PHT     175 mg. times 4        PHT 14.7 mg/l, free 2.2   Tolerating slow PTB weaning.
     PTB drip   max. 230 mg./hr
13      PHT     175 mg. times 3        PHT 16.5 mg/l, free 2.5   Order to make patient normothermic
     PTB drip   max. 120 mg./hr and                              and maintain. Wean PTB.
                 weaned,discontinued
14      PHT     175 mg. times 3        PHT 17.6 mg/l, free 2.1   Seizures/SE recurred 24 hours after
        DZP     5 mg. times 2                                    pentobarb drip discontinued
        LZP     2 mg.
        FOS     300 mg.
15      PHT     175 mg. times 4        PHT 24.0 mg/l, free 3.4   Facial twitches noted, EEG with
        LZP     1 mg.                                            intermittent seizures – restart PTB drip
          PB    120 mg. times 3
        PTB     400 mg.
     PTB drip   max. 240 mg./hr
16      PHT     175 mg. times 2        PHT 21.2 mg/l             Hypothermia protocol to enhance
        VAL     500 mg.                                          seizure control
          PB    120 mg. times 4        PB 6.6 mg/l
     PTB drip   max. 320 mg./hr
17      PHT     175 mg. times 4        PHT 22.6 mg/l, free 4.3
        FOS     200 mg. times 3
        VAL     500 mg. times 2
          PB    120 mg.                PB 12.5 mg/l
     PTB drip   max. 280 mg./hr
18      PHT     175 mg. times 3        PHT 17.3 mg/l
        FOS     200 mg.
        FOS     300 mg.
        VAL     500 mg. times 2
          PB    120 mg. times 3        PB 18.5 mg/l
     PTB drip   max. 280 mg./hr
19      PHT     175 mg. times 4        PHT 19.0 mg/l
        FOS     200 mg.
          PB    120 mg. times 3        PB 24.1 mg/l
     PTB drip   max. 280 mg./hr
20      PHT     175 mg. times 4        PHT 18.8 mg/l, free 2.8
          PB    120 mg. times 4        PB 22.8 mg/l
     PTB drip   max. 280 mg./hr
21      PHT     175 mg. times 4        PHT 21.0 mg/l, free 3.4
          PB    120 mg. times 5        PB 27.3 mg/l
     PTB drip   max. 280 mg./hr
22      PHT     175 mg. times 3        PHT 19.3 mg/l, free 3.1
          PB    120 mg. times 4        PB 36.5 mg/l
     PTB drip   max. 230 mg./hr        PTB 28.8 mg/l
23      PHT     175 mg. times 3        PHT 22.2 mg/l
          PB    120 mg. times 2        PB 41.5 mg/l
          PB    150 mg. times 6
     PTB drip   max. 180 mg./hr        PTB 22.2 mg/l
                     Topiramate Status Epilepticus (SE) Cases

24      PHT     175 mg. times 3       PHT 23.6 mg/l             Requiring increased PTB to maintain
          PB    150 mg. times 5       PB 50.5 mg/l              burst suppression
     PTB drip   180 mg.- 450 mg./hr
25      PHT     175 mg. times 2       PHT 18.1 mg/l, free 3.7
          PB    150 mg. times 3       PB 57.1 mg/l
     PTB drip   max. 450 mg./hr       PTB 31.8 mg/l
26        PB    150 mg. times 2       PB 65.4 mg/l
          PB    100 mg.               PHT 17.0 mg/l, free 3.1
     PTB drip   max. 450 mg./hr
27        PB    100 mg.               PB 73.4 mg/l
          PB    90 mg.                PHT 14.8 mg/l, free 2.9
     PTB drip   max. 450 mg./hr
28        PB    90 mg.                PB 54.0 mg/l
     PTB drip   max. 450 mg./hr       PHT 11.9 mg/l, free 3.2
29        PB    90 mg.                PB 52.5 mg/l
     PTB drip   max. 400 mg./hr       PHT 6.4 mg/l, free 1.1
30      FOS     300 mg.               PHT 4.4 mg/l, free 0.8
        TPM     100 mg. times 2
          PB    60 mg. times 2        PB 55.5 mg/l
     PTB drip   max. 400 mg./hr
31      TPM     300 mg.               PHT 4.3 mg/l, free 0.5
          PB    60 mg.                PB 56.5 mg/l
     PTB drip   max. 400 mg./hr
32      TPM     300 mg. times 2       PHT 5.0 mg/l, free 0.6
          PB    60 mg. times 2        PB 40.0 mg/l
     PTB drip   max. 320 mg./hr
33      TPM     300 mg. times 2       PHT 7.1 mg/l, free 0.8
          PB    60 mg. times 2        PB 37.7 mg/l
     PTB drip   max. 400 mg/hr
34      TPM     300 mg. times 2       PHT 9.3 mg/l, free 1.2
          PB    60 mg. times 3        PB 32.9 mg/l
     PTB drip   max. 400 mg./hr
35      TPM     200 mg. times 2       PHT 8.1 mg/l, free 1.2
          PB    90 mg. times 2        PB 34.3 mg/l
        PHT     300 mg. times 1
     PTB drip   max. 400 mg/hr
36        PB    120 mg. times 2       PB 32.9 mg/l
        PHT     300 mg. times 1       PHT free 1.2 mg/l
     PTB drip   max. 400 mg/hr
37      TPM     200 mg. times 1       TPM 7.7 mg/l
        TPM     300 mg. times 2
          PB    120 mg.               PB 34.7 mg/l
          PB    240 mg. times 2
        PHT     300 mg.               PHT free 1.1 mg/l
     PTB drip   max. 272 mg./hr
                     Topiramate Status Epilepticus (SE) Cases

38        PB    240 mg. times 2      PB 45.3 mg/l         Seizures/SE did not recur after
        TPM     400 mg. qid                               pentobarb discontinued on TPM 400
        PHT     300 mg.              PHT free 1.0 mg/l    mg. QID
     PTB drip   240 mg./hr, weaned
                and discontinued
                                     Topiramate Status Epilepticus (SE) Cases


CASE 2

55 year old woman with a history of right frontal craniotomy for meningioma resection several years prior to admission and
seizures prior to and after tumor resection (partial with secondary generalization, approximately 1 every 2 months), on
phenobarb 60 mg bid (allergic to phenytoin, “didn’t like” valproate). EMS was called for seizures. She reportedly had
several seizures that morning and upon arrival in the Emergency Department was awake but seemed distant, waxing and
waning between being oriented and confused, phenobarb level 13.4. She was admitted to the Epilepsy Monitoring Unit
where she was noted to have decreased responsiveness. Her EEG revealed numerous 60-second partial seizures of right
frontal origin with clinical correlate. She was given 2 mg. lorazepam, a loading dose of valproate and topamax to be started
25 mg. bid. She continued to have frequent seizures (average 14 per hour) and topamax was increased to 25 mg. Q 4
hours and lorazepam 2 mg Q 6 hours. The next day the seizures were less frequent on valproate 750 mg tid, phenobarb
120 mg bid and topamax 200 mg bid, with lorazepam weaning to 1 mg Q 6 hours then .5 mg Q 6 hours the following day.
She was transferred to the Neurology floor, drowsy, and after several days topamax was decreased to 100 mg. bid. Mental
status improved and she became more alert and conversant. She was discharged to home with her husband on phenobarb
30 mg. bid, topamax 100 mg. bid and medications for extensive sinusitis per CT.


  SE day              AEDs                   AED Dosage(s)            AED Levels (if available)           Comments
    1                          PB    60 mg. bid                       PB 13.4 on admission        On phenobarb 60 mg.
                              LZP    2 mg. times 3                                                bid at home prior to
                              VAL    500 mg., then 750 mg. tid        VAL 52                      admission
                              TPM    25 mg. times 3
     2                        LZP    2 mg. times 4                                                Seizures ceased 6 hours
                               PB    120 mg. bid                      PB 14.2                     after TPM dose
                              VAL    750 mg. tid                      VAL 73                      increased from 25 mg.
                              TPM    25 mg. times 2, then                                         bid to 200 mg. bid
                              TPM    200 mg. times 2
                                   Topiramate Status Epilepticus (SE) Cases


CASE 3

42 year old woman with a remote history of astrocytoma with resultant complex partial seizures was hospitalized with
respiratory failure secondary to pneumonia. Head CT showed right cerebral MCA-PCA watershed strokes. She developed
left-sided focal motor SE and was given lorazepam, valproate and midazolam with temporary seizure control. Two days
later, SE recurred and she was given lorazepam, phenytoin, valproate and fosphenytoin. Topamax was started at 100 mg
bid and increased to 150 mg bid with cessation of SE within 24 hours and she was discharged to rehab 2 weeks later.

  SE day            AEDs              AED Dosage(s)            AED Levels (if available)           Comments
    1                      LZP    2 mg. times 3
                           PHT    100 mg. times 3           Free PHT 2.8
                           VAL    1000 mg. times 2          VAL 85
                           VAL    650 mg.
                           VAL    500 mg. times 3
     2                     LZP    2 mg. times 4
                           PHT    100 mg. times 3           PHT 11.8
                           FOS    1000 mg.                  VAL 56
                           VAL    1000 mg. times 3
     3                     LZP    2 mg.                                                     Seizures ceased after
                           PHT    100 mg.                   Free PHT 3.1                    TPM added; TPM dose
                           VAL    1000 mg.                  VAL 70                          increased to 150 mg. bid
                           TPM    100 mg. bid                                               the next day.
                                     Topiramate Status Epilepticus (SE) Cases

CASE 4

46 year old woman with history of hypertension, and recent history of stroke and new onset right focal seizures 2 months
prior to admission, on phenytoin 400 mg QD. She arrived to the Emergency Department with seizures and received
lorazepam 2 mg times two, phenobarb 30 mg. IV, diazepam 5 mg. IV and fosphenytoin 750 mg. IV. She was unresponsive
and localized to painful stimulation. Her temperature reached 102.2 and she was started on Ampicillin, Acyclovir and
Rocephen. She had a left occipital hemorrhagic hypodensity on CT, and EEG with right temporal/occipital PLEDS and
intermittent seizures. Infectious Diseases consultant stated that presentation is consistent with hemorrhagic infarct,
especially with history of hypertension, but given fever and temporal focus of seizure activity, agree with work up of viral
encephalitis. EEG continued to show frequent right occipital focal seizures/SE, and topamax 200 mg. Q 6 hours was
started in addition to the pentobarb drip, phenytoin, phenobarb and valproate. She continued to have seizures, which
responded to lorazepam but would recur. Topamax was increased to 400 mg Q 6 hours (topamax level 20 after dose
escalation). EEG showed burst suppression and pentobarb was decreased and topamax decreased to 400 mg tid.
Infectious Diseases consultant states encephalitis of unknown etiology and recommends continuation of Acyclovir. EEG did
not show seizure activity and phenobarb and topamax were decreased (400 mg bid) and pentobarb was weaned. She
slowly improved over the next several weeks, becoming alert and oriented, pleasant and conversant and was discharged to
rehab.

  SE day             AEDs                 AED Dosage(s)                  AED Levels (if available)            Comments
    1                       DZP    5 mg. times 6
                            LZP    2 mg. times 2
                            LZP    8 mg.
                            FOS    750 mg., then 500 mg.           PHT 15.4 mg./l (after 750 mg. FOS)
                             PB    30 mg.                          PB = 0
     2                      LZP    2 mg. times 3
                            LZP    4 mg.
                            FOS    600 mg.
                            PHT    100 mg. bid                     PHT 16.6 mg/l
                             PB    60 mg.
                             PB    90 mg. times 2
     3                      FOS    500 mg. then 300 mg.
                            PHT    100 mg. bid                     PHT 21.8 mg/l
                             PB    90 mg. times 2, and             PB 18.4 mg/l
                             PB    120 mg. times 2
                            LZP    4 mg. times 2
                            TPM    100 mg. times 4, and
                            TPM    200 mg. QID
                            VAL    2400 mg.
                            PTB    100 mg.                         TPM 20 mg/l (the following day)
                            PTB    drip                            VAL 79 mg/l
                                     Topiramate Status Epilepticus (SE) Cases

CASE 5

59 year old woman was admitted after experiencing generalized tonic clonic seizures at a clinic where she had been taken
to evaluate odd behavior. She had been mildly confused, acting erratically and staring at times since the day before
admission. Past medical history includes stroke with resultant left sided weakness 6 months prior to admission,
osteoarthritis, gastroesophageal reflux disease, cervical and thoracic spondylosis, pulmonary fibrosis, coronary vascular
disease, numerous dental infections and panic attacks. There was no previous seizure history. Seizures consisting of right
arm tonic clonic progressing to generalized tonic clonic activity continued in the Emergency Department and she was given
10 mg. diazepam, repeated doses of lorazepam and 1 gram of fosphenytoin. Her temperature was 102.2 and she was
started on Ceftriaxone, Vancomycin, and Acyclovir. She was transferred to the Epilepsy Monitoring Unit and was observed
to have a staring spell during which EEG showed ictal activity. She was transferred to intensive care and loaded with
fosphenytoin. Right hemisphere seizures continued and she was given diazepam, loaded with valproate, intubated and put
on a pentobarb drip. SE was controlled and carbamazepine was started. Within 3 days partial nonconvulsive SE recurred
and topamax 400 mg. was given followed by 200 mg. Q 4 hours. She developed a rash and carbamazepine and phenytoin
were discontinued. EEG showed increased spikes on topamax, valproate and phenobarb, and PEDS the next day,
topamax increased to 400 mg. Q 6 hours (level 16 after several days at this dose). She was clinically stable with a diagnosis
of encephalitis of unknown etiology (2 lumbar punctures within normal limits, all cultures negative and MRI within normal
limits), with hyperammonemia and increased liver function tests, valproate was tapered. She was transferred to the
Neurology floor where she continued to improve, becoming more awake and alert. She was discharged to rehab.


  SE day             AEDs             AED Dosage(s)           AED Levels (if available)              Comments
                            VAL   2000 mg. times 2           CBZ 5.4                      She experienced seizures prior to
SE recurrent                VAL   750 mg. times 7            VAL 57                       SE – treated with LZP, CBZ and
  episode                    PB   120 mg. times 5            PB 37.4                      FOS – seizures continued and
                            TPM   400 mg.                    PHT free 2.2                 progressed to SE, which ceased
                            TPM   200 mg. times 2                                         after TPM was added.
                                     Topiramate Status Epilepticus (SE) Cases


CASE 6

72 year old woman with past medical history of left cerebral embolus with resultant right hemiparesis, complex partial
seizures (seizure free on carbamazepine), aortic valve replacement, atrial fibrillation, hypertension, and recurrent urinary
tract infections was admitted with confusion, difficulty walking and right lower lobe pneumonia. Head CT did not show acute
infarct or bleed. She was transferred to the Epilepsy Monitoring Unit where she continued to experience altered mentation
and EEG showed ictal sequences, which abated with diazepam but then returned. Topamax 100 mg. Q 8 hours was
initiated in an attempt to break SE without anesthesia. Within 48 hours SE was controlled.


SE day        AEDs             AED Dosage(s)               AED Levels (if available)                   Comments
  1              DZP    5 mg. times 2                                                   Admitted to Epilepsy Monitoring
                 CBZ    300 mg.                          CBZ 7.4 mg/l                   unit – try to break SE with topamax
                TPM     100 mg. times 2
   2             CBZ    300 mg. times 2                  CBZ 10.7 mg/l                  Increase TPM, will try to break SE
                TPM     100 mg. times 3                                                 without anesthesia
   3             CBZ    300 mg. times 2                  CBZ 10.1 mg/l                  SE ceased after TPM dose
                TPM     200 mg.                                                         increased
                TPM     100 mg. times 2

				
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