Transcranial magnetic stimulation in the treatment of refractory and superrefractory status epilepticus

Abstract

Background. Pharmacological treatment of Refractory status epilepticus (RSE) and Super-refractory status epilepticus (SRSE) remains a challenge, while transcranial magnetic stimulation (TMS) is one of non-pharmacological options considered to attempt. Objective of the study. We present two intriguing cases of RSE and SRSE successfully managed by pharmacological approach and TMS. Material and methods. All data were collected from medical database. Patients underwent all pharmacological stages of the treatment of RSE/ SRSE and TMS. Results. A 73-year-old female suspected of ischemic stroke with aphasia and right hemiplegia and a 63-year-old female with generalized tonicclonic seizures evolved to unconscious state, were admitted to ICU. In both cases lab tests, cerebrospinal fluid, brain computed tomographies as well as magnetic resonance imaging were unremarkable. In the first case video-electroencephalography (EEG) monitoring showed pathological patterns and protocoled pharmacological treatment failed. At the third stage, repetitive TMS was associated to continuous midazolam. In the second case, fluctuating lateralized rhythmic delta activity on EEG was not resolved despite phenytoin, phenobarbital, propofol and ketamine administration. Under TMS sessions, diffuse delta slowing and background reactivity were observed. Following days after withdrawal of anesthetic and TMS modulation, clinical status and patients’ EEG improved. Conclusions. Synergistic effects of pharmacological and TMS modulation probably suppressed seizure activity and helped us to acquire favorable outcomes in management of RSE and SRSE.