Refining Prognosis and Treatment in Post–Resuscitation Epilepsy Care

The 2025 American Epilepsy Society (AES) Annual Meeting, held December 5-9, in Atlanta, Georgia, provided clinicians with updated information on advances in the field of epilepsy. As part of the meeting, comprehensive annual course lectures summarized and highlighted the expanding knowledge base for clinicians who manage patients with epilepsy.

One annual course, titled “From Then to Now: The Evolving Spectrum of Epilepsy Care,” examined differing perspectives in surgical and nonsurgical management and focused on emerging and clinically relevant aspects of epilepsy care. Topics in the session addressed included multispecialty care, developments in diagnostics and treatment strategies, and the global impact of epilepsy.

The goal of the annual course was to provide attendees with an opportunity to review objective data, current clinical care recommendations, and treatment strategies relevant to multispecialty epilepsy care, with emphasis on neuropsychiatry, dementia, stroke, and neurocritical care. The course also addressed updates in epilepsy-related neuropsychological testing and genetics, approaches for MEG and SPECT evaluation, seizure monitoring devices, and alternative treatment strategies. Additional topics included management of new-onset refractory status epilepticus, epilepsy surgery, thalamic stimulation, and global issues in epilepsy care.

One of the attendees, Andrea Rossetti, MD, FAES, director of the EEG/Epilepsy Unit at the Department of Clinical Neurosciences at the Lausanne University Hospital in Switzerland, delivered a talk on post-resuscitation care for patients with epilepsy in the annual course. Prior to the symposium, Rossetti sat down with NeurologyLive^® for an exclusive interview to discuss his portion of the educational session.

In the interview, Rossetti provided his perspective on the presentation and offered clinical insights into post-resuscitation care. He highlighted the importance of accurate prognostication and advocated for routine EEG diagnosis testing over continuous EEG testing. Additionally, Rossetti expressed optimism about technological advances in the near future for the post-resuscitation field. He also praised the role of the AES Status Epilepticus Guidelines in supporting clinicians in patient care.

NeurologyLive: What are the key takeaways from your talk “Neurocritical Care: Controversies in Post-Anoxic Seizures”?

Dr. Rossetti: There are maybe 3 points that could be made. First of all, in patients that survive a cardiac arrest and that are comatose lying in the ICU, it seems that using continuous EEG is not necessarily related to a better outcome as compared to using repeated routine EEG.

Second, if these patients show epileptiform activity or seizures, they should be treated, but treatment should be directed especially towards those that can improve. The vast majority of patients that have seizures after cardiac arrest, unfortunately, don’t improve despite treatment. The whole art is to figure out who can improve, and that’s done by looking at the timing of the seizure appearance, the EEG background that’s associated with seizure appearance, and other modalities of prognostication, such as neuroimaging, clinical examination, biomarkers.

Finally, seizures in the ICU are mostly treated, at least in the US, with phenytoin, since it’s in the guidelines of status epilepticus treatment. However, in this specific cohort, it seems from available data that compounds that are more broad spectrum, such as levetiracetam, for example, zonisamide, topiramate, or even general anesthetics, are more indicated.

Why is focusing on the post-resuscitation portion of epilepsy care so important in the broader field of epilepsy?

It’s important because of several reasons. It’s a multidisciplinary enterprise, so you need epileptologists that are at ease with these patients that lie in the ICU, so not primarily in the neurology ward or the epilepsy monitoring unit. And you need a broad approach beyond epilepsy, namely neuroimaging, serum biomarkers, and it’s important that the epileptologist that has ties to the ICU is familiar with this approach.

How does continuing to evaluate post-resuscitation care help clinicians make informed decisions for patients and for themselves as clinicians?

You need evidence that’s robust in order to make good prognostications in a timely manner in these patients, both towards poor and good outcome. When we say robust prognostication, we are talking about specificity and sensitivity. For poor outcome prognosis, you need tools that are highly specific—you don’t want to make false pessimistic predictions that could have fatal issues at the end. Conversely, for good outcome, you need rather a high sensitivity in order to catch as many patients as possible that can potentially improve. Experience on the clinical data and the longitudinal follow-up are paramount.

Is technology being used to advance this facet of care? Is that becoming commonplace as we progress in this field?

According to the current guidelines, sophisticated technology is not at play. However, there has been growing interest towards quantitative EEG analysis to this extent, and even artificial intelligence analysis of EEG data and multimodal data.

That’s something that is going to be studied more and probably will develop in the future. Probably not in the near future, in the next few months or a couple of years, since one of the obstacles to generalized use of this approach is the fact that several groups still use their own algorithms. Of course, you need to have some, generalizability of this approach, but I’m quite confident that, let’s say, in 5 to 10 years, quantitative methods will be at play routinely.

In the next few years, where do you see this avenue of care progressing?

Refined prognostication. But prognostication is, in a way, a bit observational, contemplative. Another level is refined treatment. We need more standardized treatment and more trials on these patients. There has been one trial that was negative; a second trial is now being implemented. It’s an excellent move and we need more of those. Importantly, we need more attention to the long-term care of survivors in terms of psychosocial support, neuropsychological support, and all these elements will then interplay together.

Is there anything about your talk that you’d like to speak on that I might not have asked you directly?

Maybe the idea that, for the time being, more is not necessarily more. So, let’s say centers that are not extremely big or don’t have high resources—even in resource-limited settings—can still do a good job in applying the international guidelines, sticking to them, being used to applying them in a routine manner, and gaining experience.

They don’t have to automatically refer patients to bigger centers, to more experienced centers. Because if you keep referring patients, then you increase the knowledge gap between a few centers and the vast majority of medium-sized hospitals.

Transcript edited for clarity. Click here for more AES 2025 coverage.