1/ Seizures are scary. But what about seizures that continue to occur even after you’ve used your first, second, and third line agents? Let’s talk about super refractory status epilepticus #Neurotwitter #Meded #Medtwitter #tweetorial
2/ We have a 50 yo M with hx of HTN, DM, and testicular ca in remission who was admitted for witnessed seizures @MUSCNeuroICU
3/ The patient was placed on EEG and found to have the following: 
4/ He was started on levetiracetam, lacosamide, phenytoin, and valproate with any success. Given the # and duration of seizures he was ultimately intubated and started on propofol but continued to have up to 10-12 sz/hr
4/ Drips escalated to include propofol, ketamine, versed, and pentobarbital. With the addition of pentobarb, his EEG finally quieted down and finally the seizures stopped
5/ Let’s review his ASM regimen/history: levitiracetam, valproate, lacosamide, clobazam, topiramate, phenytoin, propofol gttt, ketamine gtt, versed gtt, pentobarb gtt
6/ Workup included an MRI which showed:
7/ LP was unremarkable (including negative paraneoplastic autoantibody panel and autoimmune epilepsy panel). CT CAP to rule out other malignancy was negative. Serum labs were largely unremarkable
8/ While his EEG was quiet for 4 days (and at this time he was off all drips, including pentobarb), his EEG started to pick up again. Therefore, ketamine and versed were re-initiated; despite this, she continued to have 7-8 sz/h
9/ She was treated with 5 days of IV Solumedrol and 5 rounds of PLEX in the interim
10/ So what is super refractory status epilepticus??
Status epilepticus which has continued despite treatment with anesthetic for >24h
Status epilepticus which has continued despite treatment with anesthetic for >24h
11/ What do you think the etiology of his SRSE is?
12/ He ended up getting a dose of cyclophosphamide while he continued to seizure at 4-5 sz/h. Question:: what would be your immunosuppressive medication of choice in this situation?
13/ Unfortunately, this patient ended up developing complications such as UTI and PNA and furthermore, his seizures returned with the same vengeance. Family opted to focus on patient’s comfort
14/ Food for thought: is ketogenic diet practical in this setting? Shoutout @NeyensRon for the article reference: pubmed.ncbi.nlm.nih.gov/33671485/
15/ SRSE continues to be on e of the most intellectually stimulating and challenging entity to treat in the neuro-ICU
16/ Would love to hear everyone's input on how they manage SRSE at their institutions! @caseyalbin @DeniseFChen @drhibahaider @bensalem_owen @NeurocriticalE @MonicaDhakar @aartisarwal @rohitmarawar @TheNotoriousEEG @annamayabank
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