Cenobamate has now been launched in India. For us neurologists, the practical question is: how should we use it in our OPD? I would first consider it in an adult with confirmed focal epilepsy who continues to have seizures despite two appropriately chosen, adequately used antiseizure medicines. Before that, recheck the diagnosis, adherence and previous treatment trials. The efficacy data deserve attention. In the newer Asian randomized trial, 30.1% of patients receiving 200 mg/day were seizure-free during the six-week maintenance phase, compared with 2.6% on placebo. That result applies to patients who reached the maintenance analysis. Sustained control over months and years remains the outcome we want. How would I start? 12.5 mg once daily for two weeks, followed by 25, 50, 100 and 150 mg, each for two weeks, before the usual maintenance target of 200 mg/day. Do not accelerate this schedule. Serious hypersensitivity reactions, including DRESS, occurred with faster titration during early development. Slow titration does not make the risk zero. Then look carefully at the existing prescription. Clobazam needs particular attention. Cenobamate can increase its active metabolite and cause prolonged sleepiness. Depending on the clobazam dose, reduction may need to begin before symptoms appear. Phenytoin and phenobarbital levels can rise. Check levels and adjust. With lacosamide, additive effects can produce dizziness and unsteadiness even without a major change in its blood level. So if the patient becomes sleepy or starts walking unsteadily, review the entire combination before deciding which medicine to reduce. Check baseline liver function. The 2025 US prescribing information added a warning about serious liver injury, including liver failure. Repeat testing when clinically indicated. Explain the warning symptoms clearly: fever, rash, facial swelling or swollen glands need urgent assessment. Jaundice or dark urine also needs prompt evaluation. Review cardiac history. Familial short-QT syndrome is a contraindication. Discuss pregnancy plans and contraception, because oral hormonal contraceptives may become less effective. I would review the patient at each titration step, looking at seizures, alertness, balance and tolerability. And I would continue epilepsy-surgery evaluation where indicated, alongside the medication trial. My prescription would include the cenobamate schedule, the planned adjustments to existing medicines, and the next review date. #Cenobamate #Epilepsy #Neurology #DrugResistantEpilepsy #MedX

An EVD patient develops fever. Sensorium is worse. CSF: WBC ↑, protein ↑, glucose ↓. Ventriculitis? Possible. But after IVH, SAH or neurosurgery, CSF may already be bloody and inflammatory. So I don't treat one CSF report. I go back to the bedside. Was the patient improving, and has something changed? New fever? More drowsy? EVD output falling? ICP behaving differently? Then look at the CSF trend, not just today's WBC. Differential? Glucose? Gram stain? Culture? And remember: if antibiotics were already given, a negative culture is less reassuring. Now look at something equally important: The EVD. Fever + worsening sensorium + falling EVD output may be ventriculitis... with hydrocephalus. No antibiotic will open a blocked drain. If infection is likely, send cultures and start appropriate empirical therapy, usually: Vancomycin + an antipseudomonal β-lactam, guided by local resistance patterns. But if the EVD/shunt itself is infected, antibiotics are only half the story. Think source control. And if CSF remains positive despite apparently appropriate treatment, don't reflexively add another stronger antibiotic. Ask: Is the hardware infected? Is CSF draining properly? Is the organism covered? Is enough drug reaching the ventricle? Intraventricular antibiotics have a role in selected difficult infections. They are not routine. My bedside rule: Don't treat the CSF report. Treat the infection. Look at the drain. Keep the CSF flowing. Sometimes the key to ventriculitis is recognising what antibiotics cannot fix. #NeuroICU #Ventriculitis #NeurocriticalCare #Neurology #NeuroX #MedX