Super-Refractory Status Epilepticus (SRSE) Secondary to Neurosyphilis Complicated by a Prolonged Drug-Induced Cardiac Arrest Successfully Bridged With Extracorporeal Membrane Oxygenation (ECMO) and Impella®: A Case Report.

Abstract

Neurosyphilis is a rare but readily treatable cause of status epilepticus (SE). Nevertheless, SE has a substantial morbidity and mortality if treatment is refractory and/or life-threatening complications occur. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has previously been successfully employed following life- threatening arrhythmias with refractory circulatory failure due to antiseizure medications (ASM) in the context of SE. Here we describe the combined use of VA-ECMO along with an Impella CP® micro-axial pump to provide full circulatory support and left ventricular unloading in a patient with a presumed drug-induced, refractory cardiac arrest amidst treatment for super-refractory status epilepticus (SRSE). This patient presented with a recurrent episode of convulsive SE with subsequent treatment-refractory nonconvulsive seizure activity on incremental ASM therapy. Investigations consistent with neurosyphilis prompted the initiation of antimicrobial therapy. ASM adjustments were made in view of suspected lacoseamide-induced arrhythmias, but subsequently a treatment-refractory cardiac arrest occurred with ensuing pulseless electrical activity and asystole. Mechanical life support followed by VA-ECMO was promptly initiated and an Impella CP® device was then placed given a non-ejecting heart. Subsequently, hemodynamic stabilization and seizure control were readily achieved and full cardiac recovery occurred after seven days. VA-ECMO plus Impella® provided effective circulatory support under which seizure control could be achieved and cardiac function recovered. Increased pro-arrhythmic risks due to possible synergistic inhibition of cardiac ionic channels need to be anticipated when multiple ASM and anesthetic agents are introduced during SE treatment. Neurosyphilis needs to always be considered as a rare cause of SE.