[Dysphagia] Keppra

[eripley at yahoo.com (Irene Campbell-Taylor)]

Keppra has been around for only a short time so we don't know what the long term effects will be. When ataxia occurs as a side effect it is always "severe". In a man who already has compromised cerebellar function, I would guess it would be very severe. Most of the anticonvulsants, including the new ones, can be toxic to the cerebellum at even therapeutic levels. Only long term use of Dilantin has shown atrophy of the cerebellum but there is no information on damage to the cerebellum with the other anticonvulsants. Perhaps another form of seizure control should be considered.
Irene.

acellucc@bidmc.harvard.edu wrote:
I'm posting a question for a colleague of mine, re: 33 yo male who had redo
AVR 3/04 with significant postop complication which included bilateral
frontal, bilateral cerebellar, left thalamic, & right occipital-parietal
lobe infarcts and several seizures. He was referred for 'speech eval'.
Apparently, the pt had 'some dysarthria', per the pt's wife, mildly slurred
speech (we don't have much more than that), however this had been improving
-and actually my colleague did hear a voice recording of the pt from 5/04
where his rate was 'near normal, minimal slurring of /dz/ sounds, prosody
was near normal, and voice was not nasal. 
In any event, now, he is clearly ataxic. 
However, after the events in March, some time around 6/9/04 to be exact -
while golfing, the pt reportedly developed worsening ataxia - speech only
(no other gross motor ataxia) and dysphagia (which has completely resolved
at this point), repeat MRI did not reveal any new infarcts. Additionally,
the pt was somewhat 'out of it' while on the course. 
Additionally, the pt had started on Keppra during the initial
hospitalization in March after being on Dilantin for only a short while, his
max dose was 2000mg qd, and he is now being weaned off the Keppra. So, the
Keppra had been started by the end of March. 

QUESTIONS: 
Aside from the infarcts and their influence on his speech (which by report
was improving, mind you before the 'onset in June', what role could the
Keppra be playing here? I know it does list ataxia as a side effect.
However, if this is playing a part, can there be any expected improvement
once it's d/c'd, or is it a situation like tardive dyskinesia, where it may
be permanent unless caught early on. 

Also, my colleague and I were postulating if there may have been another
seizure, not sure that there was a repeat EEG to confirm/deny this notion,
but if this was the case, why would the dysphagia have resolved and not the
ataxia?

So, while not being sure why or how this came on so suddenly, we're unsure
as for what to expect for any recovery for this guy. 

There are some 'social' issues with the pt's spouse, and so prior to their
return (they've only been seen for an eval at this point) my colleague is
trying to construct her approach to education and potential acceptance
issues for the spouse. While knowing the cause is apparently a HIGH priority
for her, my colleague is hoping to shift their focus somewhat to dealing
with the current functional impact this has on his life, since he pretty
much sounds drunk whenever he speaks. 

Alexandria Cellucci, MS CCC-SLP 
Speech Language Pathologist

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Dr I Campbell-Taylor
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