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Schematic representation of in-hospital treatment of patient with tonic SE. Clobazam, brivaracetam, cannabidiol, and fenfluramine were dosed via the G-tube. All other drugs were administered intravenously. Phenobarbital was added in an effort to wean off pentobarbital.
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Subsequent treatment is illustrated in Fig. 1.
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Panel A. EEG of tonic seizure on day of presentation showing brief 1-2 second burst of generalized 6-7 Hz activity, followed by several seconds of diffuse attenuation with superimposed fast activity and myogenic artifact that evolves into 2 Hz generalized rhythmic activity. Panel B. Breakthrough tonic seizures after 1 week of treatment for SRSE: gradual buildup of low voltage fast activity over 15-20 seconds, often followed by generalized slow wave and diffuse attenuation. Panel C. Interictal EEG one month into hospitalization showing generalized epileptiform discharges. In addition to multifocal epileptiform discharges, most frequent over the left temporal region. All EEGs displayed at 7 uV/mm, HFF 70 Hz, LFF 1 Hz.
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Video-EEG monitoring confirmed frequent seizures involving a buildup of fast activity evolving into generalized 5 Hz ictal rhythm, then 1 Hz spike-wave discharge, in addition to generalized spike-wave and polyspike-wave discharges and independent left and right temporal epileptiform discharges (Fig. 2A). Break-through tonic seizures persisted despite another week of aggressive treatment (Fig. 2B). An EEG after 1 month of treatment is shown in Fig. 2C.
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