A 29-year-old, 26 weeks pregnant patient presented with a past medical history of hypertension, traumatic brain injury (TBI), synthetic marijuana abuse, and generalized seizure disorder (diagnosed after TBI in 2014 and has not been compliant with taking her AEDs). She developed seizure activity while driving, leading to a motor vehicle accident. On arrival to the emergency department, she continued to experience generalized tonic-clonic seizures. Repeat doses of intravenous (IV) lorazepam were required to physically suppress the convulsions. IV magnesium was given as it was unknown at this point whether eclampsia was playing a role in her condition. Emergency medical services (EMS) reported that the patient had large amounts of synthetic marijuana in her possession at the scene.
On physical examination, she was somnolent with a Glasgow Coma Scale score of 6. Vital signs were stable. She was noted to have a gestational uterus and a concave right cranial defect secondary to her prior TBI. She was intubated for airway protection due to declining neurological status and was taken to the medical intensive care unit.
Initial electroencephalography (EEG) showed periodic lateralized discharges in the right hemisphere. Head imaging were negative for acute findings. Laboratory results showed an elevated white blood count of 23.6 x 103/microL and a high random urine protein/creatinine ratio of 0.6. Cerebrospinal fluid analysis, blood and urine cultures, and liver function tests, among others, all of which were unremarkable.
She was started on IV levetiracetam and midazolam, but her seizure activity persisted. Midazolam was discontinued. Propofol 55 mcg/kg/min, fosphenytoin 100 mg IV three times per day, lacosamide 400 mg IV twice per day, ketamine 2 mg/kg/h, and pentobarbital 2 mg/kg/h were added to the regimen, given the persistent abnormal EEG findings. An EEG burst suppression pattern (seizure control) was finally achieved for the first time after 25 h of pharmacologic therapy at maximal doses. Propofol was eventually discontinued.
Weaning of pentobarbital was attempted after several days of non-epileptic EEG pattern, but bilateral cerebral hemisphere seizure activity quickly recurred, forcing continued use of pentobarbital at maximum doses. However, no improvement in the EEG tracing was obtained after increasing this medication and EEG seizure activity continued. Furthermore, fetal distress was noted on hospital day 6 requiring an emergent bedside cesarean section. After delivery, valproic acid and pyridoxine were added, and burst suppression pattern was again achieved on hospital day 10. The patient's neurological status slowly improved, allowing for liberation from mechanical ventilation. Finally, after 14 days of hospitalization, a normal EEG pattern was obtained, and the patient was transferred out of the intensive care unit. The patient's baby had a prolonged hospitalization, but was eventually discharged home.