Dexamethasone as Abortive Treatment for Refractory Seizures or Status Epilepticus in the Inpatient Setting

Abstract

Refractory seizures or status epilepticus (RS/SE) continues to be a challenge in the inpatient setting. Failure to abort a seizure with antiepileptic drugs (AEDs) may lead to intubation and treatment with general anesthesia exposing patients to complications, extending hospitalization, and increasing the cost of care. Studies have shown a key role of inflammatory mediators in seizure generation and termination. We describe 4 patients with RS/SE that was aborted when dexamethasone was added to conventional AEDs: a 61-year-old female with temporal lobe epilepsy who presented with delirium, nonconvulsive status epilepticus, and oculomyoclonic status; a 56-year-old female with history of traumatic left frontal lobe hemorrhage who developed right face and hand epilepsia partialis continua followed by refractory focal clonic seizures; a 51-year-old male with history of traumatic intracranial hemorrhage who exhibited left-sided epilepsia partialis continua; and a 75-year-old female with history of breast cancer who manifested nonconvulsive status epilepticus and refractory focal clonic seizures. All patients continued experiencing RS/SE despite first- and second-line therapy, and one patient continued to experience RS/SE despite third-line therapy. Failure to abort RS/SE with conventional therapy motivated us to administer intravenous dexamethasone. A 10-mg load was given (except in one patient) followed by 4.0- 5.2 mg q6h. All clinical and electrographic seizures stopped 3-4 days after starting dexamethasone. When dexamethasone was discontinued 1-3 days after seizures stopped, all patients remained seizure-free on 2-3 AEDs. The cessation of RS/SE when dexamethasone was added to conventional antiseizure therapy suggests that inflammatory processes are involved in the pathogenesis of RS/SE.

Keywords: anti-inflammatory; antiepileptic drugs; dexamethasone; inflammation; refractory seizures; status epilepticus; steroid.

Figure 1.

EEG of Patient 1. Top: generalized 2 to 3 Hz semirhythmic delta activity superimposed on rhythmic theta and alpha activity with patient delirious and perseverating consistent with NCSE and with patient blinking every second on average (see eye blink artifacts) consistent with oculoclonic status. Bottom: electrographic (and clinical as seen on video) resolution of status epilepticus 3 days after dexamethasone was added to conventional inpatient antiepileptic therapy. Display parameters: longitudinal bipolar montage (from top to bottom: left-mid-right-ECG), digital filter bandpass of 1 to 70 Hz, and 60-Hz notch filter turned on; voltage-time scale is included in the tracing.

Figure 2.

EEG of Patient 2. Top: lateralized periodic discharges (sharp delta waves) over the left hemisphere time-locked to the myoclonic jerks of the right hand and face (surface EMG recorded over right face) consistent with epilepsia partialis continua. Note fluctuation of discharge rate from 1.5 to 2/s to 0.5 to 1/s. Bottom: electrographic resolution of periodic discharges 3 days after dexamethasone was added to conventional antiepileptic therapy coinciding with complete control of clinical seizures. Display parameters: longitudinal bipolar montage (from top to bottom: left-mid-right-EMG/ECG), digital filter bandpass of 1 to 70 Hz, and 60-Hz notch filter turned on; voltage-time scale is included in the tracing.

Figure 3.

EEG of Patient 3. Top: 0.5 to 1/s lateralized periodic discharges (sharp/delta waves) with maximum voltage over the right frontocentral superimposed on irregular slow waves and time-locked to the myoclonic jerks of the left face, arm, and leg consistent with epilepsia partialis continua. Bottom: electrographic (and clinical as seen on video) resolution of epilepsia partialis continua 3 days after dexamethasone was added to conventional antiepileptic regimen. Display parameters: longitudinal bipolar montage (from top to bottom: left-mid-right-ECG), digital filter bandpass of 1 to70 Hz, and 60-Hz notch filter turned on; voltage-time scale is included in the tracing.

Figure 4.

EEG of Patient 4. Top: 1 to 2/s lateralized (left > right) periodic discharges with sharp morphology and superimposed on semirhythmic delta activity recorded while the patient was stuporous with intermittent episodes of right lower extremity jerking findings that are consistent with NCSE without coma with impaired consciousness and focal clonic seizure. Bottom: Persistence of left frontocentral 0.3 to 0.5/s periodic discharges approximately 5 days after dexamethasone was added and the patient was already seizure-free. Display parameters: longitudinal bipolar montage (from top to bottom: left-mid-right-ECG), digital filter bandpass of 1 to 70 Hz, and 60-Hz notch filter turned on; voltage-time scale is included in the tracing.