Abstract Non-convulsive status epilepticus (NCSE) is difficult to diagnose due to its subtle clinical presentation. We present a rare case of severe refractory NSCE successfully treated with ventilatory support and EEG-guided burst suppression achieved through prolonged propofol and ketamine infusions, supplemented with high-dose corticosteroids and multiple antiepileptic agents. A 64-year-old female with a past medical history of partial complex epilepsy, nonadherent with lacosamide, was found unresponsive at home. She was intubated and started on a propofol infusion for suspected seizure activity. Laboratory, imaging, and toxicology studies were unremarkable. Her home lacosamide was restarted, and propofol was gradually weaned, allowing successful extubation within 72 hours. Continuous EEG at that time showed no ongoing seizures. Six hours later, she developed recurrent right facial twitching, repeated head turning, and vivid visual and auditory hallucinations. In addition to intravenous benzodiazepine therapy, to which she showed only partial improvement, additional antiepileptic drugs (AEDs) were induced sequentially in the following order: levetiracetam, phenytoin, and clobazam. Despite escalation to four AEDs at therapeutic doses within 24 hours, she continued to exhibit clinical and EEG evidence of seizures, consistent with refractory NCSE (RNCSE). She was reintubated and restarted on a propofol (100 mcg/kg/min) under continuous EEG monitoring. As is common with prolonged sedation, she required low-dose vasopressor support and close monitoring for propofol infusion syndrome. Burst suppression was achieved at 24 hours; however, seizures recurred during propofol weaning. Ketamine infusion (2-4 mg/kg/hr) and high-dose intravenous methylprednisolone (1 g/day for 5 days) were initiated for RNCSE. Sustained burst suppression was achieved after 48 hours, followed by gradual weaning of sedatives. The patient was successfully extubated on hospital day 14 and later discharged with no further seizure activity. This case highlights an uncommon manifestation of NCSE characterized by prominent hallucinations, which can obscure diagnosis and delay treatment. It also demonstrates a successful multimodal approach using propofol-ketamine combination therapy with corticosteroids after failure of standard antiepileptic regimens. Reports of such management are limited, but this case supports consideration of N-methyl-D-aspartate receptor antagonism and immunomodulation in refractory cases. Prompt recognition, continuous EEG monitoring, and coordinated critical care are essential to improving outcomes. This abstract is funded by: None
Radford et al. (Fri,) studied this question.