Objective To evaluate the efficacy and tolerability of antiepileptic drugs (AEDs) in elderly individuals with epilepsy. Methods We searched four electronic databases as well as bibliographies and conference abstracts. Published and unpublished, randomized, or quasirandomized trials reporting the use of AEDs in people aged at least 60 years with epilepsy were eligible for inclusion. Two authors independently carried out each stage of the review. Meta‐analyses were performed using random‐effects models. Results Three thousand four hundred seventeen titles and abstracts were reviewed. Eighteen studies evaluating 12 AEDs met all eligibility criteria. Ten studies, comprising 1999 subjects, were suitable for meta‐analysis. Among the elderly with epilepsy, lamotrigine (LTG) is better tolerated relative to carbamazepine (pooled weighted risk ratio [RR] of experiencing withdrawal due to adverse events = 1.83, 95% confidence interval [CI] = 1.23‐2.43). There is a higher probability, although with a 95% CI of borderline importance, of seizure freedom when comparing levetiracetam to LTG (RR = 0.83, 95% CI = 0.68‐0.97). Single studies provide evidence for the efficacy and/or tolerability of other AEDs in the elderly, including brivaracetam, gabapentin, lacosamide, perampanel, and topiramate. The risk of bias of the included studies was frequently low or unclear, although there was on occasion a high risk of bias (especially with regard to selective reporting). Significance There is some evidence for AED use in the elderly with epilepsy. More evidence is required, comparing newer AEDs to prior generations as well as examining the effects of determinants such as frailty, to guide clinicians when treating this rapidly growing patient population.

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Hyperammonemic encephalopathy (HE) is a metabolic condition precipitated by elevated blood ammonia, which may be idiopathic or secondary to increased production (e.g., infection with urease-positive bacteria) or decreased elimination of ammonia (e.g., liver failure), or drug-induced (e.g., valproic acid). c Chemotherapy-associated HE is a rare but highly fatal condition requiring rapid identification and neurocritical care. Oyster c Although uncommon in the adult population, hyperammonemia can be triggered by a metabolic stressor in the context of a previously undiagnosed urea cycle disorder, particularly heterozygous ornithine transcarbamylase deficiency. A 55-year-old, right-handed, functionally independent woman was brought to the emergency department by her sister, who found her acutely disoriented and agitated. The patient's medical history was significant for major depression and dyslipidemia. One year prior to presentation, the patient completed a full course of chemotherapy (bendamustine and rituximab) for follicular B-cell lymphoma. Six months later, hypermetabolic retroperitoneal lymph nodes were found on a PET scan, suggesting relapse or persistent disease activity. A lymph node biopsy confirmed transformation to Hodgkin lymphoma. The patient received a first cycle of ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, dacarbazine) 1 month prior to presentation. Two weeks before presentation, she was briefly hospitalized for a deep venous thrombosis of the left arm and chemotherapy-induced pancytopenia. The patient's sister reported that the patient had complained of mild fatigue and nausea following her second cycle of ABVD, administered 6 days prior to presentation. Her home medications were apixaban, dexlansoprazole, citalopram, rosuvastatin, pregabalin, prophylactic trimethoprim-sulfobactam, valaciclovir, and filgrastim. She did not use illicit drugs or alcohol. On presentation, the patient's vital signs were normal. She did not exhibit signs of meningismus, she was alert but was disoriented in all spheres, she uttered incomprehensible sentences, and she was mildly agitated. No cranial nerve deficits were observed. She exhibited paratonia, moved all 4 limbs forcefully, and withdrew to painful stimuli symmetrically. Deep tendon reflexes were normal and she had flexor plantar responses. No abnormal movements were observed. Her general physical examination was unremarkable. Laboratory investigations revealed stable pancytopenia, respiratory alkalosis (pH 7.65), and elevated ammonia (NH 3) levels (221 μmol/L). Liver enzymes and liver function tests were normal. Noncontrast brain CT scan and MRI did not show any abnormalities, apart from significant motion artifact. An abdominal ultrasound ruled out biliary duct obstruction and portosystemic shunt. Lumbar puncture was delayed as the patient's anticoagulation had to be withheld. In the context of known immunosuppression, she was empirically treated for infectious meningoencephalitis *These authors contributed equally to this work.