Transcranial magnetic stimulation for refractory focal status epilepticus in the intensive care unit

Abstract

Purpose: To examine the efficacy and safety profile of antiepileptic repetitive transcranial magnetic stimulation (rTMS) for refractory status epilepticus (RSE) in the intensive care unit (ICU) setting. In addition, hypothetical concerns about electrical interference of rTMS with ICU equipment have been previously raised.

Methods: We describe two cases of RSE treated with rTMS in the ICU.

Results: In one case, rTMS contributed to decreased seizure frequency; in the second case, rTMS transiently decreased seizure frequency. In both cases, rTMS was safe and did not interfere with the functioning of the ICU equipment.

Conclusion: rTMS is a potential therapy for RSE when conventional therapies have failed. Future studies should investigate the efficacy of various rTMS stimulation parameters, safety issues, and bioengineering considerations in the ICU setting.

Keywords: Epilepsia partialis continua; Intensive care unit; Refractory status epilepticus; Transcranial magnetic stimulation.

Copyright © 2013 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

Figures

Fig. 1

ICU course of Patient Number 1. On admission, the patient experienced between 40–50 seizures daily (blue line, daily seizure frequency). After the initiation of pentobarbital sedation on day 4, the patient's seizure frequency abated but did not completely discontinue. After developing ileus thought likely secondary to pentobarbital, there was an attempt to wean the pentobarbital on day 16 with resulting increased seizure frequency. His intravenous AEDS were further increased with modest improvement. On day 21, TMS was administered in the ICU over the seizure focus. The following day, the pentobarbital was successfully weaned with eventual cessation of seizures. The patient's EEG background (red line) and clinical status gradually improved.