Clinical Reasoning: Ketogenic diet in adult super-refractory status epilepticus

We present a case of super-refractory status epilepticus (SRSE) in a previously healthy 38-year-old right-handed man who initially presented at an outside hospital after a car accident. He was the driver, and had a witnessed convulsive event at the scene. A week previously, he had presented to the outside hospital with fever (102oF), flu-like symptoms, and low back pain, and was discharged home on hydrocodone/acetaminophen. Upon presentation after the car accident, the patient was febrile and displayed fluctuating mental status without meningeal signs. There were no focal deficits on neurologic examination. Preliminary diagnostic studies included lumbar puncture (LP), which showed an elevated opening pressure of 35 cm H2O, and pleocytosis, with 42 leukocytes/mL (54% lymphocytes). MRI of the brain with and without contrast showed hyperintense fluid-attenuated inversion recovery (FLAIR) signal and restricted diffusion in the left hippocampus. There were no imaging findings to support traumatic brain injury. Acyclovir treatment was started. An IV loading dosage of phenytoin was administered immediately after his presentation in the outside hospital. Serial EEGs thereafter showed evidence of electrographic seizures arising from the right frontotemporal region, which continued despite IV loads of phenobarbital and levetiracetam. It was unclear if benzodiazepine was tried initially. The patient was transferred to our hospital for management of refractory status epilepticus (RSE). Continuous EEG monitoring upon transfer was consistent with partial status epilepticus with seizures originating from the right frontotemporal region (figure).