Medications for epilepsy-like signals during coma do not aid in recovery

Ten to twenty percent of the patients admitted to the intensive care (ICU) after cardiac arrest and resuscitation shows signs of brain activity that appears like epilepsy. For a long time, it was unclear if anti-epileptic medication could help better recovery.

So, part of the patients received this medication and part of them didn't. Now, a largescale study done between 2014 and 2021, proofs that medication makes no sense: it doesn't help recovery, even makes a longer stay on the ICU necessary. The research was done by a group of eleven hospitals. The researchers, led by Professor Jeannette Hofmeijer of the University of Twente and Rijnstate Hospital in Arnhem, publish their findings in theNew England Journal of Medicine.

About 5000 patients in The Netherlands need a stay at the intensive care unit, after cardiac arrest and resuscitation. They are in a coma then. The cardiac arrest, by then, may have damaged the brain to such an extent that half of the patients will not recover from coma. The other half will also have permanent damage, for example of memory functions. Predicting if a patient will get awake and what his or her prospects will be, is a huge challenge. One of the instruments used for this is continuous evaluation of the brain signals using EEG (electroencephalography).

Although the outcome of the trial may be disappointing in terms of chances of recovery, it also takes away uncertainties from the family. The signals point at serious brain damage, that would lead to a much longer stay at the ICU."

Prof. Jeannette Hofmeijer

'Continuous epilepsy'

In ten to twenty percent of coma patients something unexpected happens. The EEG shows signs of epilepsy: not like an attack, but like continuous activity. It is known that this type of brain activity points to serious brain damage with bad prospects. For a long time, it was unclear if anti-epileptic medication would help improve the outcome. This resulted in one doctor prescribing the medication, while another didn't. From a large study in 11 medical centers in The Netherlands and Belgium, among 172 patients between 2014 and 2021, the conclusion is now that anti-epileptic medication does not give better recovery. The adverse effect is that patients need to stay longer at the ICU: for the patient an undesired situation, and it puts extra pressure on the health care system.

Apart from these continuous epileptic signals, a small group of patients show signs of a typical epileptic seizure: not continuous signals, but a short and heavy attack. Anti-epileptics could help in these situations, but this still needs further research. The results from the study that is now published, are essential for decision making at the ICU and can take away part of the uncertainties the family of the patient has to deal with.

The trial was called TELSTAR: Treatment of Electroencephalographic Status epilepticus After cardiopulmonary Resuscitation. The research was made possible by the Dutch Epilepsy Fund ('EpilepsieNL'). Jeannette Hofmeijer is Professor of Neurophysiology at the University of Twente and neurologist at Rijnstate Hospital in Arnhem.