Abstract Introduction Propofol is widely used for procedural sedation due to its rapid onset and short duration of action. While generally considered safe, seizure-like phenomena (SLP) have been reported during anesthesia induction and emergence phases. Patients with a history of epilepsy may be at increased risk, even if seizure-free for years. Prior episodes of seizure following propofol exposure may heighten susceptibility. Case Presentation A 50-year-old woman with a remote history of epilepsy, not on anti-epileptic drugs (AEDs) for the past seven years, underwent upper endoscopy and colonoscopy under propofol sedation. Fourteen years prior, she had developed seizure-like activity following a breast biopsy where she received propofol anesthesia. During the procedures, propofol was administered intravenously without complication. Shortly after sedation was discontinued, the patient experienced two brief, generalized, tonic-clonic seizures approximately 10 minutes apart. Seizure activity aborted with the administration of intravenous (IV) midazalom. Fingerstick glucose was 94 mg/dL. After the second seizure, the patient received 4.5 g IV levetiracetam and an additional 4 mg midazolam. No further seizures occurred, and mental status returned to baseline. EEG demonstrated no epileptiform activity. Brain imaging revealed no acute infarct, hemorrhage, or mass. Labs demonstrated an elevated lactate consistent with postictal physiology. The patient was discharged on Keppra 750 mg twice daily with outpatient Neurology follow-up. Conclusion This case highlights seizure provocation during emergence from propofol sedation in a patient with remote epilepsy who had been seizure-free for seven years. Walder et al (Neurology, 2002) reviewed eighty-one cases of SLP linked to sedation with propofol, with most events occurring during induction or emergence and 25% of events occurring post-emergence. These induction and emergence phases of sedative administration involve rapid changes in consciousness and fluctuating propofol concentrations, which may increase cortical excitability and lower seizure threshold. In contrast, the sedation maintenance phase features steady drug levels and reduced muscle tone, reducing seizure risk and masking motor activity. Clinical guidance emphasizes the importance of individualized anesthetic planning in patients with epilepsy, including the consideration of preemptive AED coverage and careful anesthetic selection (Kofke 2010). Given this patient’s history and recurrence of seizures in procedural contexts, prophylactic AED therapy should be considered for future anesthetic exposures. Patients with epilepsy may be vulnerable to seizures during emergence from propofol sedation. Preemptive AED therapy and individualized anesthetic planning should be considered to reduce recurrence risk. This abstract is funded by: None
Deb et al. (Fri,) studied this question.