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Handbook of Palliative Medicine

Seizures

Seizures will be present in about 20% of patients with cerebral tumours, and may also complicate other terminal diseases, especially neurological conditions. Additionally there will be some patients with pre-existing seizures at the time of diagnosis, whose seizure threshold may be reduced by their illness.

Causes

  • Epilepsy, brain trauma, stroke, cerebral tumours
  • Medications which lower seizure threshold (e.g. tricyclics, tramadol)
  • Withdrawal of medication or drugs
  • Metabolic disturbances (e.g. hyponatraemia, uraemia)

Immediate treatment of seizing patient

  • First aid/BLS
  • Reassurance to patient and family
  • Check blood sugar
  • If no prior history, or previous seizures have not spontaneously resolved give benzodiazepine (SC, PR, buccal, IV depending on appropriate and available route)
  • If not terminating repeat STAT dose once more
  • Knowing appropriate escalation plan is important at this stage as if not for hospital admission SC treatment may be preferable
  • If not responding and not for admission to hospital a continuous subcutaneous infusion (CSCI) of midazolam, levetiracetam or phenobarbital may be considered

Prevention of further seizures

  • Use of and review of dexamethasone for cerebral tumours
  • First line anti-epileptic levetiracetam 250 mg-500 mg twice a day. This can be increased every 2 weeks to a maximum of 1.5 g twice a day
  • Second line choice is sodium valproate 150 mg- 200 mg twice a day, increased if needed every 3 days to a maximum of 1 g twice a day
  • If oral route is not available or reliable there are several options for CSCI via syringe driver
    • Levetiracetam - 1:1 dose conversion from oral over 24 hours. Less sedating than benzodiazepines
    • Midazolam - 20 mg - 60 mg required. Very sedating so while this may be appropriate in final days it may not be preferred longer term
    • Sodium valproate - 1:1 dose conversion from oral over 24 hours. Much less sedating than levetiracetam or midazolam
  • Phenobarbital may be considered by specialist for intractable seizures
  • Phenytoin is generally avoided due to pharmacokinetics and drug interactions causing difficulties in achieving therapeutic levels