Cannabidiol for Status Epilepticus: A Case of Unrealistic Expectations
After a teenager spends 2 months in the ICU with refractory seizures, his family requests a trial of cannabidiol oil.
CASE REPORT
An 18-year-old man, who lives in New Zealand, presents with new-onset generalized
Three days after presentation, he is transferred to a regional hospital, where he receives care in the intensive care unit (ICU) and is anesthetized, intubated, and ventilated.
Laboratory and imaging results
Serum biochemistry results are normal. A full neurologic antibody screen of both CSF and serum is negative. Blood and CSF cultures show no growth.
Results of repeated brain MRI scans and lumbar puncture are normal. CT scans of the chest, abdomen, and pelvis are normal, as is a testicular ultrasound scan.
Diagnosis
The patient receives a presumptive diagnosis of cryptogenic new-onset refractory status epilepticus (NORSE), with a suspected
Treatment course
High-dose methylprednisolone is started, followed by intravenous (IV) immunoglobulin and five cycles of plasma exchange. Because of lack of response to these treatments, the patient also receives trials of prednisolone, cyclophosphamide, and rituximab-all to no effect.
To protect the brain, he is maintained on burst suppression, which is confirmed by continuous electroencephalographic monitoring. Repeated attempts to wake the patient confirm multifocal, bilateral sustained electrographic seizures. He undergoes several failed trials of AEDs, including pyridoxine, phenobarbitone, phenytoin, sodium valproate, lacosamide, and levetiracetam. A
For sedation, he receives midazolam throughout his ICU course. He also undergoes failed trials of concomitant propofol, diazepam, thiopentone, and ketamine.
After the patient spends 2 months in the ICU, his family requests a trial of
Over 2 weeks, the dose of Elixinol is increased to a maximum of 24 mg/kg. At that time, attempts are made to lighten the patient’s sedation, but the underlying electroencephalogram remains unchanged.
In consultation with the clinical team, the family agrees that further treatment is unlikely to succeed and opts for palliative care. CBD is continued at the family’s request. The patient dies after withdrawal of treatment, 88 days after presentation.
Next: the case discussion
Discussion
This is the
The use of
However, this may not be the case. A 2014
In 2018, the
“The results of these scientifically rigorous randomized clinical trials provide hope for the eventual development of a pharmaceutical formulation of purified CBD to treat epilepsy, but such a product is not currently available in the U.S. or FDA approved for patient use.”3
In this tragic case of a teenager with NORSE, CBD-while ultimately ineffective-may have addressed a need by the family to try everything, which in turn may have facilitated transition to palliative care.
The cause of NORSE remains unknown. Affected individuals are often young, with no history of epilepsy, and have a febrile prodrome. They may have initial CSF pleocytosis suggestive of an infective or autoimmune etiology. The outcome is often fatal, or results in severe neurological sequelae.4
Research offers little guidance on the treatment of refractory status epilepticus.
At the time of the guidelines, no data existed to guide intensity and duration of treatment. Also, the number of trials of electrographic seizure control before deeming therapy to be futile had not been defined.
Take-home points
• The case concerns a teenager with presumed new-onset refractory status epilepticus (NORSE) of unknown origin, which did not respond to multiple trials of antiepileptic drugs, immunotherapy, and cannabidiol
• Evidence suggests that cannabidiol may be moderately effective for treating refractory seizures in some genetic disorders, but it has more adverse effects than placebo
• NORSE is often fatal
References:
1. Rosemergy I, Adler J, Psirides A.
2. Koppel BS, Brust JC, Fife T, et al.
3. American Epilepsy Society.
4. Gall CR, Jumma O, Mohanraj R.
5. Brophy GM, Bell R, Claassen J, et al.
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