AAN 2025 | The management of patients who present with an acute symptomatic seizure

It is important to recognize acute symptomatic seizures, not only the clinical ones, but also the electrographic ones. I want to remind that, you know, Beghi and colleagues when they describe acute symptomatic seizures in his article, in his own manuscript, it states that it’s clinical acute symptomatic seizure. But it was about almost like 15 years ago about these publications, and we have to remember that over the last two decades, the use of continuous EEG has increased tremendously, especially in high-income countries. And nowadays, it’s a standard of care. We know that we have to put patients with certain conditions on continuous EEG because we know that seizures are a common complication of critically ill patients. And with that, I want to think about or make the audience think about acute symptomatic seizure also being electrographical and not only clinical, a definition that we’re now evolving in the societies. So, in terms of the management, the importance of this is that clinical as electrographic seizures in the critically ill patient, aka acute symptomatic seizures, have been associated with mortality and worse outcomes in patients because the patients, mainly the patients that have a primary brain injury, if they have a secondary complication of the seizures, will put those unaided brains in a metabolic crisis, but it will decrease the brain reserve for rehabilitation and recovery in the acute and subacute phase. So, the importance of these managers, I want to highlight it in order to prevent more metabolic crisis and secondary brain injury in these patients, mainly in the ones that had primary brain injury. The algorithms of treatment for acute symptomatic seizures are not well established. Nowadays, we follow the algorithm of treatment for convulsive status epilepticus, which is the first line, the use of benzodiazepine. The second line is the use of non-benzodiazepine medications, and then we continue to escalate care as the seizures are refractory. We don’t know if escalation of care to anesthesia for acute symptomatic seizures is the best next step, but nowadays, given the information and everything that we do, we follow the convulsive status epilepticus guidelines. Something that I also want to highlight for the audience is that when we talk about treatment for acute symptomatic seizure, we have to be very careful into dividing what is called primary prophylaxis for acute symptomatic seizure and secondary prophylaxis for acute secondary seizure. Primary prophylaxis is for the prevention of the occurrence of acute symptomatic seizures. And lots of studies have been done, especially in traumatic brain injury populations. We also have a study published two years ago, the PEACH trial, that was trying to prevent acute symptomatic seizures in intracerebral hemorrhage. For primary prophylaxis, we have no data to suggest that we have to start patients on medications to prevent acute symptomatic seizure except for traumatic brain injury patients with fosphenytoin, phenytoin, or levetiracetam. Now, for secondary prophylaxis is the treatment that we give when the acute symptomatic seizure has occurred. And those are the ones I was referring to, the metabolic crisis is happening. And then the treatment that we follow are the algorithms for convulsive status epilepticus.

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