Is rapid withdrawal of anti-epileptic drug therapy during video EEG monitoring safe and efficacious?

Purpose: Video electroencephalographic monitoring (VEM) is used to record ictal and interictal epileptiform activity and to ascertain the level of concordance between the two. Often, taper or discontinuation of anti-epileptic (AED) therapy is needed to facilitate seizure occurrence. The safety of this practice is unclear and long-term sequelae have yet to be elucidated.

Methods: This is a prospective study of 158 patients subjected to combined sleep-deprived VEM with rapid AED withdrawal, for evaluation of seizure-like episodes over 24 months under the care of an epileptologist with direct nursing observation and EEG technician support in our telemetry unit. In most cases, AEDs were discontinued within 24h of admission. We assessed the diagnostic yield and safety of VEM as well as epilepsy surgery outcomes.

Results: VEM answered the study question in 90.5% of cases but failed to record ictal events in 9.5%. This diagnostic yield was achieved over a mean VEM duration of 4.53±1.44 days, with no benefit of longer monitoring. These findings improved quality of life by optimizing medical and surgical therapeutic planning, leading to improved seizure control. Overall, 32.9% of the cohort received epilepsy surgery. The complication rate was 5.06%, characterized largely by musculoskeletal pain secondary to clinical seizure activity, with no mortality observed. In the first month following VEM 2.5% of patients received emergency-room admission for seizure clustering.

Conclusions: VEM with combined sleep deprivation and protocolized rapid AED withdrawal is a safe and effective investigative technique with no adverse long-term sequelae. It is a reliable strategy for therapeutic planning and can be used to determine candidacy for surgical treatment.