Indian
20 J. Anaesth. 2006; 50 (1) : 20 - 26 INDIAN JOURNAL OF ANAESTHESIA, FEBRUARY 2006
ANAESTHESIOLOGIST’S ROLE IN THE MANAGEMENT
OF AN EPILEPTIC PATIENT
Downloaded from http://journals.lww.com/ijaweb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1
Dr. Hemant Bhagat1 Dr. Hari H. Dash2
AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/20/2023
SUMMARY
Epilepsy surgery is slowly becoming popular in India. Management of epileptic patients in the intensive care unit and in the perioperative
period demands thorough knowledge and understanding of the varied aspects of anaesthesia. This article highlights the management
of status epilepticus and the perioperative management of an epileptic patient.
Keywords : Status epilepticus, Epilepsy surgery, Anaesthetic management.
Introduction
Epilepsy is as old as mankind. It was first described
about 3000 years ago in Akkadian (oldest written language)
in Mesopotamia (Iraq). The seizure was attributed to the
God of moon. At the turn of 17th century, William Gilbert
had introduced the magnetic and electric phenomenon
responsible for epilepsy and discarded the mystical and
supernatural theory to a scientific approach.1
The word epilepsy is derived from Greek verb
‘epilamvanein’ (“to be seized” or “to be attacked”).
Epilepsy is a group of electrical disturbances of brain function
where the usual periods of normal EEG activity and
behaviour are disrupted by episodes of gross electrical
disturbances.2 A seizure or convulsion is a finite event; it
has a beginning and an end. Epilepsy on the other hand is
a chronic disorder characterized by recurrent seizures.3
Epilepsy is one of the common neurological
disorders, second only to stroke.3 In developed countries
the age adjusted incidence is 24-53 per 1,00,000 person
years, with higher incidence in males and in lower
socioeconomic class. The age adjusted prevalence is 4-8
per 1000 population.4 Though there are no incidence
studies in India, the overall prevalence rate of epilepsy is
5.59 per 1000 population, with no statistical difference
between men and women or urban and rural population.5
Role of an anaesthesiologist
An anaesthesiologist may encounter an epileptic
patient in three clinical settings :
1. M.D., Sr. Resident
2. M.D., Prof. and Head
Department of Neuroanaesthesiology
AIIMS, New Delhi -110029.
Correspond to :
Dr. H. H. Dash
E-mail : drhh_dash@yahoo.com
(Accepted for publication on 29-11-2005)
20
REVIEW ARTICLE
1. In an intensive care unit for the management of status
epilepticus.
2. Perioperative management for epilepsy surgery.
3. Perioperative management for non epilepsy surgery.
Though the basic principles of management essentially
remains the same in all the three clinical situations , this
review shall focus on the management of status epilepticus
and epilepsy surgery.
Status epilepticus
The operational definition is two or more seizures
without full recovery of consciousness between seizures or
recurrent epileptic seizures for more than 30 minutes.6
The overall mortality rate among adults with status
epilepticus is approximately 20%.7 Status epilepticus should
be stopped quickly, ideally within 30 minutes from the start
of episode. Status epilepticus causes profound physiological
changes that may result in severe systemic complications
and may also damage or even kill cerebral neurons.8
Management of status epilepticus
The management protocol of status epilepticus has
been outlined in table - 1.7,9,10 Fosphenytoin, a new drug
has gained popularity in the management of seizures. It is
a water soluble prodrug of phenytoin which is converted to
phenytoin (t1/215 minutes) by non-specific phosphatases.
Doses of fosphenytoin are expressed as phenytoin equivalents
(PE), which are amounts of phenytoin released from the
prodrug. Since it is not formulated with propylene glycol,
it can be administered at phenytoin equivalent rates of
upto 150 mg per minute. Though the onset of effect,
hypotension and adverse cardiac effects are similar with
both phenytoin and fosphenytoin loading, infusion site
reactions (phlebitis and soft tissue damage) are less common
with fosphenytoin.7
For refractory status epilepticus, use midazolam as
a slow intravenous bolus injection in a dose of 0.2 mgkg-1
 BHAGAT, DASH : ANAESTHESIA FOR EPILEPTIC PATIENTS 21

followed by 0.75 – 10 gkg-1hr-1 or propofol in a dose of around 30% of the epileptic patients may require surgery,
1-2 mgkg-1 followed by 2-10 mgkg-1hr-1. Thiopentone sodium while in India the potential surgical patients amount to
administered in a dose of 10-15 mgkg-1 slowly over a period 10,000 to 20,000 per year.11 Patients with refractory epilepsy
Downloaded from http://journals.lww.com/ijaweb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1

of one hour followed by a dose of 0.5–1 mgkg-1hr-1 is highly often undergo surgery to resect an epileptogenic focus or to
effective, but cardiovascular toxicity is occasionally life interrupt a seizure pathway. These procedures include;
threatening and post-infusion weakness may delay weaning
AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/20/2023

i) Temporal lobectomy
from ventilatory support.
ii) Amygdalohippocampectomy
Table - 1 : Management protocol for status iii) Extratemporal cortical excision
epilepticus.
iv) Hemispherectomy
MINUTES MANAGEMENT
v) Corpus callosotomy
0 1. Assess and control airway.
2. Monitor vital signs (including temperature) establish ECG Other surgical procedures
and spO2 recording.
3. Draw venous blood for biochemical analysis (including RBS). Vagal stimulation and electrical stimulation of the
4. Draw arterial blood for ABG analysis. centromedian thalamic nucleus are also used to treat intractable
5. Work up to define cause. epilepsy. However the results are not very encouraging.
5. Manage other medical problems.

5 1. Start IV infusion (normal saline).

Anaesthetic considerations
2. If hypoglycemic or if blood glucose measurement is not When surgery is contemplated the role of an
available, give glucose-
anaesthesiologist is paramount. In our center, the neurologist,
Adults : 100mg thiamine IV followed by 50ml of 50%
glucose. Children: 2 mlkg-1 of 25% glucose.
neurosurgeon, neuroradiologist and neuroanaesthesiologist
comprise the epilepsy surgery core group, which identifies
10 1. Benzodiazepines -
Lorazepam : 0.1 mgkg-1 (max rate 2 mgkg-1 upto 4 mg and discusses the problems of each patient regularly. The
total dose). role of neuroanaesthesiologist during anaesthetic management
Diazepam : 0.2 mgkg-1 (max rate 5 mgkg-1 upto 20 mg of patients for epilepsy surgery are multidimensional.12 They
total dose).
are:
20 Seizure persists -
Phenytoin: 20 mgkg-1 (max: adults@50ml/min; 1. Appropriate anaesthetic technique for epileptic patients.
children@1 mgkg-1min-1).
Fosphenytoin: 20 mgkg-1 PE (@ 150 mgmin-1). 2. To provide sedation and monitored anaesthetic care
Monitor ECG / BP during infusion. during awake craniotomy.
40 Seizure persists - 3. To induce intraoperative seizures for intraoperative
Additional phenytoin (5-10 mgkg-1) or fosphenytoin
(5-10 mgkg-1 PE).
electrocorticography.
60 Seizure persists - 4. Maintenance of intracranial haemodynamics.
Phenobarbital 20 mgkg-1 (max @ 60 mgmin-1).
Expect respiratory depression / apnea, assist ventilation
5. To provide brain protection so as to achieve good
neurological recovery.
If seizure 1. Anaesthesia with thiopentone sodium, midazolam or propofol.
continues 2. Consider intubation and ventilation. 6. Provide rapid recovery for postoperative neurological
3. Place arterial and central venous catheter, if indicated. assessment.
4. Use iv fluids and vasopressor for treating hypotension.
7. Management of refractory status epilepticus.
5. Continue maintenance dose of phenytoin and phenobarbital.
6. Taper infusion at 12 hours to observe further seizure
activity. If seizures recur, reinstate infusion in intervals of
Preoperative investigations
atleast 12 hours. The services of anaesthesiologist are often required
RBS: Random blood sugar; ABG: Arterial blood gas; PE: Phenytoin equivalent. to perform different investigative procedures in an epileptic
patient.
Anaesthesia for epilepsy surgery
i) Radiological procedures : MRI and positron emission
Surgical procedures
tomography (PET) scans are carried out in patients
Although medications are the mainstay of management
with seizures to identify the surgical lesion. Intravenous
in an epileptic patient, it may occasionally be ineffective
sedation is recommended during these procedures.
or their side effects unacceptable. In such situations, surgical
management is looked upon as an alternative, especially ii) Intracranial electroencephalograph (EEG) electrode
when epileptic focus can be localised. In advanced countries insertion : Intracranial EEG electrodes are used to
 22
maximize sensitivity and specificity in electrographic
localization of a seizure focus. Stereotactic electrode
insertion can be done under local anaesthesia, while
Downloaded from http://journals.lww.com/ijaweb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1
epidural electrodes or grids are placed under general
anaesthesia.
AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/20/2023
iii) Thiopentone test : This test is performed to provide
data regarding the EEG localization of seizure focus.
This technique is used to produce a gradual increase
in blood levels of thiopentone, thereby producing
electroencephalographic beta activity. Such beta
activity will occur in normally functioning neural tissue,
whereas the seizure foci will show an abnormal response.
iv) Wada test : It is carried out to ascertain the dominant
cerebral hemisphere. A small dose of amobarbital
(amytal sodium) is injected into the carotid artery to
lateralize the cerebral speech dominance. Alternatively
methohexital (3 to 5 mg ) can be injected after 1 mg
test dose.
Preanaesthetic evaluation
Surgery for epilepsy is usually major and time
consuming due to intraoperative electrocorticography.
Therefore, it is imperative on the part of the anaesthesiologist
to undertake meticulous and detailed preoperative evaluation
of these patients. The preoperative concerns are :
1. General fitness of the patient : Epilepsy surgery is
elective and the patient needs to be in good health.
2. Concomitant medical problems : These patients may
have associated medical illnesses which needs to be
evaluated as the patients are optimized prior to surgery.
3. The genetic syndromes : associated with seizure
disorders may have anaesthetic implications.
i) Autosomal dominant disorders
(a) Huntington’s chorea : Patients may have abnormal
response to thiopentone.
(b) Tuberous sclerosis : There may be associated cardiac
arrhythmias, cardiac tumors, renal and pulmonary
dysfunction.
(c) Neurofibromatosis (Von Recklinhausen’s disease):
Patients may have compromised airway, fibrosing
alveolitis, atlanto-axial instability and prolonged
neuromuscular blockade.
ii) Autosomal recessive disorder : Airway
compromise is frequently observed in patients with
hemihypertrophy.
iii) X - linked disorder : Patients of Lesch Nyhan
disorder may have associated urate nephropathy and
aspiration pneumonitis.
INDIAN JOURNAL OF ANAESTHESIA, FEBRUARY 2006
4. Drug interaction : Anaesthesiologist must have
knowledge pertaining to interaction of anaesthetic drugs
with anticonvulsants.
5. Gingival hypertrophy : Fibrous hyperplasia and bleeding
tendency of the gums associated with chronic phenytoin
therapy may pose as a troublesome airway.
6. Anaemia : Pallor if present, should also be thought in
terms of megaloblastic anaemia.
7. Preoperative counselling : There are a lot of
psychosocial concerns associated with an epileptic
patient. The personality development is often poor
with low self esteem. The anaesthesiologist needs to
provide a good preoperative psychological support and
should discuss the perioperative aspects of the surgery.
Premedication
i) Benzodiazepine is an ideal premedicant because
of its anticonvulsant properties. However, in patients
undergoing thiopentone test, awake craniotomy or
electrocorticography, the premedication is restricted
to an antacid and an antiemetic.
ii) Since the patient’s head and neck are inaccessible
during surgery, it is appropriate to premedicate the
patients with atropine or glycopyrrolate.
iii) Morning dose of anticonvulsants are continued.
Monitoring
Continuous monitoring of ECG (HR), NIBP, SpO2,
EtCO2, temperature and urine output are essential. In children
the blood volume is smaller than adults, while the size of
surgical incision is relatively large. The blood loss may be
more significant than the adults. Hence central venous
pressure monitoring is useful in paediatric patients.13
Anaesthetic management
Although modern anaesthesia has multiple benefits
and is fairly safe, it is important to realize that anaesthetic
complications may either result in major catastrophe like
permanent brain damage or death or leave minor neurological
sequelae like headache, backache or peripheral nerve injury.14
The same holds true for epilepsy surgery also. The optimal
anaesthetic agents for epilepsy surgery are yet to be
ascertained. Although there are few good outcome trials,
the animal studies and surrogate outcome studies are often
obtuse or contradictory.15 Nevertheless, the goals of
anaesthetic management are :
1. To maintain haemodynamic stability.
2. Avoidance of any increase in ICP.
3. Minimal impact on electrocorticographic monitoring.
 BHAGAT, DASH : ANAESTHESIA FOR EPILEPTIC PATIENTS 23

4. Provide brain protection. auditory, visual and tactile stimulations. There are EEG
evidence of seizure activity with sevoflurane.22 Convulsions
5. To avoid any secondary systemic insults.
have been reported following use of sevoflurane in a neonate,
Downloaded from http://journals.lww.com/ijaweb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1

6. Rapid and smooth emergence. young children and parturients.23,24,25 Suppression of

refractory status epilepticus and EEG has been reported
To achieve all these above goals, the anaesthesiologist
both with isoflurane and desflurane.26,27
AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/20/2023

must have detailed and thorough knowledge of various

anaesthetic agents particularly their pro and anti convulsant
properties. Table - 2 : Effects of intravenous anaesthetics on
seizure activity in epileptics.
Proconvulsant and anticonvulsant effects of
Agents Seizure documentation
anaesthetics
There are various anaesthetics which can exhibit Clinical EEG study

both proconvulsant and anti convulsant properties with Thiopental - -

different doses and under different physiologic conditions.
Methohexital + +
Consequently, the anaesthetic management in epileptic
patients must be planned accordingly. Etomidate + +

Intravenous anaesthetics : Thiopentone and Benzodiazepines + +

benzodiazepines have anticonvulsant properties. However
Ketamine + +
benzodiazepines can induce brief periods of EEG and clinical
seizure activity in patients with Lennox-Gastaut syndrome, Propofol - +
a form of secondary generalized epilepsy.16 Methohexitone (+) presence of seizure ; (-) absence of seizure
on the other hand produces seizure activity during its
administration by intravenous, intramuscular as well as
rectal route (Table - 2).16 Ketamine, however activates Table - 3 : Effects of inhalational agents on seizure
epileptogenic foci in epileptic patients. Clinical reports of activity in epileptics.
seizure following parenteral administration of ketamine
have been documented in both epileptic and non-epileptic Agents Seizure documentation

patients. Etomidate possesses both pro and anticonvulsant Clinical EEG study
properties. Higher dose suppresses and low dose etomidate
N2O - -
induces involuntary motor activity. Therefore, the dose and
the rate of etomidate administration determines which of Halothane - -
the contrasting effects on the seizure threshold will occur
Enflurane + +
in a particular setting. Intravenous droperidol when given
along with fentanyl as a component of neurolept anaesthesia Isoflurane - -
was not observed to produce epileptiform activity on EEG.17 Sevoflurane + +
The role of propofol in epileptiform surgery is somewhat
controversial. Although the clinical reports suggest that it Desflurane - -

has anticonvulsant properties, abnormal EEG activity
have been documented following administration of propofol
in epileptic patients.16
Inhalational anaesthetics: Nitrous oxide (N2O)
has extremely low epileptogenic potential, and is considered
to be safe in epileptic patients. However, it has no
anticonvulsant properties.16 Halothane and isoflurane do not
provoke seizure activity in anaesthetized patients. However,
reports of convulsions have been documented following
use with N2O.18,19 Enflurane, however produces both EEG
changes20 and abnormal motor activities21 (Table - 3). Seizure
manifestations are evident at minimal alveolar concentrations
of 1 to 2, which are accentuated by hyperventilation,
(+) presence of seizure ; (-) absence of seizure
Opioid anaesthetics : Though there are clinical
reports of seizures with the use of morphine, but no
epileptiform activity has been reported during and following
the use of morphine. Meperidine’s neurotoxicity is well
known in inducing seizures and is attributable to its
metabolite normeperidine.
Fentanyl and its analogues : Clinical reports of
convulsions with the use of fentanyl and its congeners have
been published. But, the EEG findings were not corroborated.
Recently, it has been documented that fentanyl, alfentanil
and remifentanil activates epileptiform activity in patients
with temporal lobe epilepsy.28,29
 24 INDIAN JOURNAL OF ANAESTHESIA, FEBRUARY 2006

Muscle relaxants : None of the muscle relaxants is the choice for intraoperative ECoG monitoring and seizure
including atracurium used in clinical anaesthesia have been foci removal during awake craniotomy.33
reported to cause either EEG or clinical seizure activity.
Downloaded from http://journals.lww.com/ijaweb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1

If general anaesthesia is preferred, the maintenance

However, the long term infusion of atracurium in ICU
of anaesthesia should consist of N2O and a narcotic with
setting needs to be investigated.
or without lower concentration of isoflurane. For foci
AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/20/2023

Anticholinesterases : Clinical seizure or EEG identification enflurane may be very useful. Although
activity have yet to be reported following the use of sevoflurane has greater neuro-excitatory properties than
cholinesterase inhibitors during clinical anaesthesia. isoflurane, the widespread irritative response to sevoflurane
administration is not helpful in localizing the epileptogenic
Local anaesthetics : They possess both
area34. Amongst the newer synthetic opioids, alfentanil
proconvulsant and anticonvulsant properties due to their
and fentanyl are used intraoperatively to localize seizure
membrane stabilizing effects. At subtoxic doses, local
focus. But, alfentanil appears to be a better choice for
anaesthetics can act as anticonvulsants, sedatives and
intraoperative ECoG monitoring.29 Remifentanil can also
analgesics, while at higher concentration, resistant
be used during awake epilepsy surgery as its sedation
excitatory pathways can cause frank convulsions.
does not adversely affect intraoperative interictal spike
Drug interactions activity.35 When unmasking of epileptogenic foci is planned
during N2O - narcotic anaesthesia, a common reasonable
A matter of concern in anaesthetic practice during
approach is to use methohexital intraoperatively in 10-25
epilepsy surgery is the interaction between the antiepileptic
mg increments, along with hyperventilation.
drugs and anaesthetic agents. It has been demonstrated that
patients treated chronically with various anticonvulsants Fluid management
are resistant to non-depolarizing muscle relaxants and to
The target for fluid management during epilepsy
usual clinical dose of opioids. A comparatively higher doses
surgery is to maintain normovolemia. Normal saline is
of fentanyl were required in epileptic patients receiving
regarded as fluid of choice because of slightly high
anti-epileptic drugs.30 Among the non-depolarizing muscle
osmolality. Rarely, epilepsy surgery can be associated with
relaxants, only atracurium has been shown to have same
large blood loss. Though the adult patients may tolerate a
effect whether or not the patients were on chronic
low haematocrit, but in children avoiding blood transfusion
phenytoin therapy.31 Vecuronium when used during concurrent
may become hazardous particularly in anaemic or
phenytoin therapy has both a decreased effect and a shorter
hypovolemic child.
duration of action. The mechanism of this resistance to
opioids and neuromuscular agents is possibly due to hepatic Emergence
enzyme induction by antiepileptics which tends to increase
Early awakening is a priority in epileptic patients
clearance and decrease the half life of opioids and non-
as most of the surgeries are non-emergent procedures
depolarizers.
and the patients have a good preoperative conscious
Management of ICP level and neurological status. Moreover, early awakening
allows a rapid and complete neurological examination.
Intracranial hypertension is rarely a problem in
Suitable pharmacological agents (i.e, lignocaine, esmolol
epilepsy surgery. However, maintenance of ICP at a lower
or labetolol) should be administered so as to blunt the
level aids in surgery. Thiopentone and propofol produces
hypertensive response to extubation and emergence.
the most consistent reduction in cerebral blood volume and
Paediatric epileptic patients may remain drowsy after corpus
ICP. Isoflurane and sevoflurane have similar effects when
callosotomy and hemispherectomy. To overcome this
used in sub MAC concentrations and in the background of
problem anaesthetic management needs to be tailored
opioids and hyperventilation. Increased ICP can result from
accordingly.
poor positioning and venous obstruction, light plane of
anaesthesia, inadequate analgesia and hypercarbia. Postoperative care
Intraoperative electrocorticography (ECoG) Post craniotomy patients need to have adequate pain
relief. Codeine can be a suitable choice in children as it
A normal functioning brain is ideal for ECoG. But,
has less respiratory depression and sedation. Nausea and
the major constraint during anaesthesia is the depressant
vomiting may be a problem in the postoperative period.
effects of anaesthetics on the normal EEG. The only valid
Effective control of postoperative sickness can be achieved
reason for awake craniotomy is to fascilitate ECoG.32
with metoclopramide or ondansetron.36
Neurolept anaesthesia (fentanyl and droperidol) technique
 BHAGAT, DASH : ANAESTHESIA FOR EPILEPTIC PATIENTS
Blood levels of an antiepileptic drug can significantly
be affected by anaesthetics and the changes in body
physiology resulting from surgery. The blood levels of
Downloaded from http://journals.lww.com/ijaweb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1
carbamazepine and phenytoin increases substantially after
anaesthesia and surgery. Increasing levels of antiepileptic
drugs may cause clinical toxicity, which may mimic an
AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/20/2023
intracranial complications. Conversely, if the antiepileptic
drug levels decrease unexpectedly, seizure can be
precipitated. Thus the blood levels of anti-epileptic drugs
should be obtained preoperatively and closely monitored in
the postoperative period.
Awake craniotomy
The terminology means, craniotomy carried out
under local anaesthesia and conscious sedation. Awake
craniotomy is performed in those epileptic patients where
the epileptic foci lies close to eloquent areas of the brain
(i.e. motor areas, speech or to temporal structures critical
to short term memory). Majority of these patients have
temporal lobe epilepsy.
Neuroleptanaesthesia was developed to maintain
normal cerebral cognitive function while eliminating the
perception of nociceptive stimuli. Combination of fentanyl
and droperidol was traditionally being used with advantages
like excellent cardiovascular stability and rapid postoperative
recovery. However, unconsciousness, postoperative
extrapyramidal excitation, restlessness and confusion were
among the major side effects associated with its use.
Recently however, with the advent of newer
anaesthetic agents, neurolept anaesthesia has evolved into
“conscious sedation”.33 Propofol is being used successfully
and predictably to provide sedation and hypnosis. The
introduction of newer opioids, alfentanil and remifentanil
have contributed to improve intraoperative analgesia
while offering better control of postoperative recovery and
discharge time. The success in winning patient’s cooperation
maximizes with an excellent field block. This can be
achieved by infiltrating local anaesthetics into the scalp in
a circular fashion, along with supratrochlear, supraorbital,
auriculotemporal, lesser and greater occipital nerve blocks.
The anaesthesiologist must provide adequate preoperative
psychological advice,37 which builds in a feeling of confidence
and minimizes the discomfort to the patient.
Conclusion
Achieving the various goals of anaesthesia for
epileptic patients is a challenge. Safe anaesthesia requires
a high degree of preparation, vigilance and attention to
detail. The choice of anaesthetic agent is of lesser
importance. Remifentanil with isoflurane is perhaps the
25
best choice for surgery. For awake craniotomy, propofol
with fentanyl is the preferred technique. During electro-
corticography low concentration of isoflurane or propofol
with fentanyl is ideal. Management of refractory status
epilepticus needs to be tailored according to the neurological
and haemodynamic status of the patient.
References
1. Goldensohn ES. Historical perspectives. In: Engel J, Jr, Pedley
TA, editors: Epilepsy: A comprehensive textbook.
Philadelphia: Lippincott-Raven 1997: 15-16.
2. Jefferys JCR. The pathophysiology of epilepsies. In: Laidlaw
J, Richens A, Chadwick D, editors : A textbook of epilepsy.
New York: Churchill Livingstone 1993: 241.
3. Porter RJ. Classification of epileptic seizures and epileptic
syndromes. In: Laidlaw J, Richens A, Chadwick D, editors:
A textbook of epilepsy. New York: Churchill Livingstone,
1993: 1.
4. Hauser WA. Incidence and prevalence. In: Engel Jr J, Pedley
TA, editors : Epilepsy: A comprehensive textbook.
Philadelphia: Lippincott- Raven 1997: 47-57.
5. Bharucha NE. Epidemiology of epilepsy in India. Epilepsia
2003; 44(S1): 9-11.
6. Treiman DM. Status epilepticus. In: Laidlaw J, Richens A,
Chadwick D, editors : A textbook of epilepsy. New York,
Churchill Livingstone 1993: 205.
7. Lowenstein DH, Alldredge BK. Status epilepticus. N Eng J
Med 1998; 338(14): 970-76.
8. Treiman DM. Treatment of status epilepticus. In: Engel Jr J,
Pedley TA editors : Epilepsy: A comprehensive textbook.
Philadelphia: Lippincott- Raven 1997: 1317-23.
9. Treiman DM. Current treatment strategies in selected
situations in epilepsy. Epilepsia 1993; 34(S5): S17-23.
10. Treatment of convulsive status epilepticus: recommendations
of the epilepsy foundation of America’s working group on
status epilepticus. JAMA 1993; 270: 854-59.
11. Radhakrishnan K. Epilepsy care in developing countries:
diagnostic evaluation and treatment. In: Radhakrishnan K,
editor; Reviews in Indian Neurology 2003: 167-94.
12. Dash HH, Bhagat H. Anaesthesia for epilepsy surgery. In:
Grover VK, Mathew PJ, editors: 6th Annual Conference of
Indian Society of Neuroanaesthesiology and Critical Care,
Chandigarh: Conference lectures 2005: 56-64.
13. Chaturvedi A, Bithal PK, Dash HH et al. Catheter
malplacement during central venous cannuation through arm
veins in pediatric patients. J Neurosurg Anesthesiol 2003; 15:
170-75.
14. Sandhu K, Dash HH. Anaesthesia related neurological
complications. Indian J Anaesth 2004; 48(6): 439-45.
15. Davidson AJ. Anaesthesia for paediatric epilepsy surgery. J
Clin Neuroscience 2004; 11(3): 280-82.
 26 INDIAN JOURNAL OF ANAESTHESIA, FEBRUARY 2006

16. Modica PA, Tempelhoff R, White PF. Pro-and anti-convulsant 28. Manninen PH, Burke SJ, Wennberg R et al. Intraoperative
effects of anesthetics (Part 1-2). Anesth Analg 1990; 70: localization of an epileptogenic focus with alfentanil and
303-315, 433-44. fentanyl. Anesth Analg 1999; 88: 1101-06.
Downloaded from http://journals.lww.com/ijaweb by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1

17. Opitz A, Marschall R, Degan R et al. General anaesthesia in 29. Mc Guire G, El-Beheiry, Maninen P et al. Activation of
patients with epilepsy and status epilepticus. Adv Neurol electrocortico graphic activity with remifentanil and alfentanil
1983; 34: 531-33. during neurosurgical excision of epileptogenic focus. Br J
AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 03/20/2023

18. Smith PA, Mc Donald TR, Jones CS. Convulsions associated
with halothane anaesthesia. Anaesthesia 1966; 21: 229-33.
19. Hymes JA. Seizure activity during isoflurane anesthesia.
Anesth Analg 1985; 64: 367-68.
20. Lebowitz MH, Blitt CD, Dillon JB. Enflurane - induced
central nervous system excitation and its relation to carbon
dioxide tension. Anesth Analg 1972; 51: 355-63.
21. Burchiel KJ, Stockard JJ, Myers RR et al. Metabolic and
electrophysiologic mechanisms in the initiation and termination
of enflurane - induced seizures in man and cats.
Electroencephalogr Clin Neurophysiol 1975; 38: 555.
22. Ian JW, Richard GH, Mathew RC et al. Electroencephalic
evidence of seizure activity under deep sevoflurane anesthesia
in a non-epileptic patient. Anesthesiology 1997; 87: 1579-82.
23. Hsieh SW, Lan KM, Luk HN, Jawan B. Postoperative seizures
after sevoflurane anaesthesia in a neonate. Acta Anaesthesiol
Scand 2004; 48: 663.
24. Akeson J, Didriksson I. Convulsions on anaesthetic induction
with sevoflurane in young children. Acta Anaesthesiol Scand
2004; 48: 405-07.
25. Kuczkowski KM. Sevoflurane and seizures: deja vu. Acta
Anaesthesiol Scand 2004; 48: 1216.
26. Mirsattari SM, Sharpe MD, Young GB. Treatment of
refractory status epilepticus with inhalational anaesthetic
agents isoflurane and desflurane. Arch Neurol 2004; 61:
1254-59.
27. Sharpe MD,Young GB, Mirsattari SM, Harris C. Prolonged
desflurane administration for refractory status epilepticus.
Anesthesilogy 2002; 97: 261-64.
Anaesth 2003; 5: 651-55.
30. Tempelhoff R, Modica PA, Spitznagel Jr EL. Anticonvulsant
therapy increases fentanyl requirements during anaesthesia
for craniotomy. Can J Anesth 1990; 37(3): 327-32.
31. Ornstein E, Matteo RS, Schwartz AE et al. The effect of
phenytoin on the magnitude and duration of neuromuscular
block following atracurium or vecuronium. Anesthesiology
1987; 67(2): 191-96.
32. Kofke WA, Tempelhoff R, Dasheiff RM. Anaesthesia for
epileptic patients and for epilepsy surgery. In: Cottrell JE,
Smith DS, editors: Anesthesia and Neurosurgery, 4th ed.
St.Louis: Mosby 2001: 473-95.
33. Bissonnete B, Swan H, Ravussin P et al. Neuroleptanesthesia
: current status. Can J Anesth 1999; 46(2): 154-68.
34. Hisada K, Morioka T, Fukui K et al. Effects of sevoflurane
and isoflurane on electrocorticographic activities in patients
with temporal lobe epilepsy. J Neurosurg Anesthesiol 2001;
13(4): 333-37.
35. Herrick IA, Craen RA, Blume WT et al. Sedative doses of
remifentanil have minimal effect on ECoG strike activity
during awake epilepsy surgery. J Neurosurg Anesthesiol 2002;
14(1): 55-58.
36. Kathirvel S, Dash HH, Bhatia A et al. Effect of prophylactic
ondansetron on postoperative nausea and vomiting after
elective craniotomy. J Neurosurg Anesthesiol 2001; 13(3):
207-12.
37. Klimek M, Verbrugge SJC, Raubos S et al. Awake craniotomy
for glioblastoma in a 9-year old child. Anaesthesia 2004; 59:
607-09.

Back issues Order from Indian Journal of Anaesthesia

- Available
Year 2001 2002 2003 2004 2005 2006
X - not available
Vol. 45 46 47 48 49 50

Feb. X

April




Each Copy Rs.300/-

All six issues of the year
June




Rs. 1500/- inclusive of postage.
The payment by crossed DD
Aug.





favouring ‘Editor IJA’ payable
Oct.




at Belgaum (Karnataka).
Dec.