title: Marked EEG worsening following Levetiracetam overdose: How a pharmacological issue can confound coma prognosis.
abstract: Levetiracetam is an anti-epileptic drug commonly used in intensive care when seizure is suspected as a possible cause of coma. We propose to question the cofounding effect of Levetiracetam during the prognostication process in a case of anoxic coma. We report the story of a young woman presenting a comatose state following a hypoxic cardiac arrest. After a first EEG presenting an intermediate EEG pattern, a seizure suspicion led to prescribe Levetiracetam. The EEG showed then the appearance of burst suppression, which was compatible with a very severe pattern of post-anoxic coma. This aggravation was in fact related to an overdose of Levetiracetam (the only medication introduced recently) and was reversible after Levetiracetam cessation. The increased plasmatic dosages of Levetiracetam confirming this overdose could have been favoured by a moderate reduction of renal clearance, previously underestimated because of a low body-weight. This EEG dynamic was unexpected under Levetiracetam and could sign a functional instability after anoxia. Burst suppression is classically observed with high doses of anaesthetics, but is not expected after a minor anti-epileptic drug. This report proposes that Levetiracetam tolerance might not be straightforward after brain lesions and engages us to avoid confounding factors during the awakening prognostication, which is mainly based on the severity of the EEG. Hence, prognosis should not be decided on an isolated parameter, especially if the dynamic is atypical after a new prescription, even for well-known drugs. For any suspicion, the drug's dosage and replacement should be managed before any premature care's withdrawal.
authors.affiliation: Hospices Civils de Lyon, Hopital de la Croix Rousse, Service de Reanimation Médicale, Lyon, France.
authors.forename: Baptiste
authors.initials: B
authors.lastname: Bouchier
authors.affiliation: Hospices Civils de Lyon, Hopital de la Croix Rousse, Service de Neurologie, Lyon, France, France; Université de Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France.
authors.forename: Geneviève
authors.initials: G
authors.lastname: Demarquay
authors.affiliation: Hospices Civils de Lyon, Hopital de la Croix Rousse, Service de Reanimation Médicale, Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France.
authors.forename: Claude
authors.initials: C
authors.lastname: Guérin
authors.affiliation: Université de Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France; Hospices Civils de Lyon, Hopital Pierre Wertheimer, Service des Explorations Fonctionnelles Neurologique, Bron, France.
authors.forename: Nathalie
authors.initials: N
authors.lastname: André-Obadia
authors.affiliation: Hospices Civils de Lyon, Hopital de la Croix Rousse, Service de Reanimation Médicale, Lyon, France; Université de Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France. Electronic address: gobert.flo@gmail.com.
authors.forename: Florent
authors.initials: F
authors.lastname: Gobert
mesh_terms: D000328:Adult; D000927:Anticonvulsants / Q000009:adverse effects*; D003128:Coma / Q000503:physiopathology*; D062787:Drug Overdose / Q000150:complications*; D004569:Electroencephalography / Q000187:drug effects*; D005260:Female; D006323:Heart Arrest / Q000503:physiopathology*; D006801:Humans; D000860:Hypoxia / Q000503:physiopathology*; D000077287:Levetiracetam; D010889:Piracetam / Q000009:adverse effects / Q000031:analogs & derivatives*
chemical_list: D000927:Anticonvulsants; D000077287:Levetiracetam; D010889:Piracetam
keywords: Awakening prognosis; Burst suppression; Levetiracetam; Overdose; Post anoxic coma