400 Section - A Stratified Approach To Weaning Antiseizure Medication In Patients With Prolonged Disorders Of Consciousness Following Severe Acquired Brain Injury

Seizures are common following severe acquired brain injury (ABI), yet antiseizure medications (ASMs) often cause side effects—particularly sedation—which can hinder assessment and recovery in patients with prolonged disorders of consciousness (PDOC). Many individuals exhibit non-epileptic movements that do not require pharmacological intervention, and when seizures occur, they are frequently mild and self-limiting. Rationalising ASM use is therefore essential to balance safety with the potential for neurological recovery. This study describes a stratified approach to ASM weaning based on individual seizure risk.

Design:

Data were collected for all patients admitted to a Level 1 Hyper-acute Rehabilitation Unit in London, UK, between March 2023 and June 2025 who were receiving ASMs. Patients were categorised according to their estimated risk of seizure recurrence (high, medium, low, or very low), and medication was weaned in line with this stratification.

Results:

Of 113 patients admitted in PDOC, 75 (66%) were receiving an ASM. Among these, 29 (39%) had no documented seizure history and were treated prophylactically. Of the remainder, 26% had experienced late seizures; 20 (43%) had major seizures (status epilepticus or tonic–clonic), and 19 (41%) had only focal or myoclonic episodes unlikely to necessitate treatment. Levetiracetam was prescribed in 96% of cases, with 21% receiving an additional ASM.

Overall, 65 of 72 (90%) patients on Levetiracetam were successfully weaned, with 7 (11%) experiencing a new tonic–clonic seizure (four low-risk, three medium-risk), none of these seizures were prolonged. Five of these patients were restarted on a less sedating ASM (Lacosamide). Among 51 VS/MCS-minus patients, 22% improved to MCS-plus, with none emerging into full consciousness.

Conclusion:

This stratified, individualised weaning protocol enabled the safe and rational reduction of unnecessary ASM use within a closely monitored rehabilitation setting, minimising sedative burden without significant seizure recurrence. Further comparison with historical cohorts will clarify any impact on awareness and recovery trajectories.