(841) Electroconvulsive Therapy in New-Onset Refractory Status Epilepticus (NORSE) in a Pediatric Patient

Introduction: NORSE refers to new onset refractory status epilepticus in patients without known epilepsy or seizure etiology. When patients fail conventional therapy, alternative methods are pursued. Electroconvulsive therapy (ECT) has been occasionally used, but rarely in children. We report a previously healthy 8-year-old female with NORSE whose epileptic burden improved with aggressive therapies including ECT.

Description: Our patient presented with a week of headaches and fever before developing multiple focal seizures that rapidly evolved into RSE. Extensive infectious, autoimmune, metabolic, neoplastic, and genetic work up was unrevealing. Sequential brain MRIs remained normal. Aggressive anti-seizure medications (ASMs), pentobarbital coma, high dose propofol and ketamine infusions, pulse-dose steroids, IVIg, ketogenic diet, cannabidiol, and rituximab were initiated during her first 12 hospital days.

Despite these measures, EEG remained highly epileptic prior to ECT initiation on day 12. ECT was performed daily for 7 days with two stimulations per session using a Thymatron device with bitemporal electrode placement.

ECT achieved seizures in all treatments with median post-ictal suppression of 70.5% , indicating robust seizure quality. All ASM infusions were weaned one day post-ECT completion, and the patient was extubated shortly thereafter. About one week after extubation, a vagal nerve stimulator was placed (hospital day 29), after which point she has remained essentially seizure-free.

Discussion: Our 8-year-old with NORSE responded well to a 7-day course of ECT. Multiple ASMs and infusions failed to improve overall epileptic burden. Efficacy of ECT is evidenced by a high post-ictal suppression but is limited by close succession of other treatments including rituximab, cannabidiol, and ketosis.