Catatonia Mimicking Nonconvulsive Status Epilepticus

Summary: Nonconvulsive status epilepticus (NCSE) and catatonia share many clinical features and distinguishing between them on the basis of the physical examination may be difficult and even impossible. Although several reports have been made of NCSE simulating catatonia, there are no published cases of catatonia mimicking NCSE. We report a 24-year-old woman whose initial examination was notable for a fixed stare, no response to voice or command, gaze preference, tonic head posturing, constant stereotypic chewing movements, profuse foamy salivation, and a dramatic response to the parenteral administration of benzodiazepines (BZDs). She was initially misdiagnosed as having NCSE. EEG, however, was normal. We believe this is the first published report of catatonia simulating NCSE. The EEG may be more useful than the clinical examination in distinguishing NCSE from catatonia.     

Magnetic Resonance Imaging and Spectroscopy Findings After Focal Status Epilepticus

Summary: The etiology of cerebral abnormalities after focal status epilepticus (SE) is unknown. Possible causes include hypoxia and the excessive release of excitatory amino acids. Magnetic resonance imaging (MRI) of a 21–year-old patient with "cryptogenic" continuous motor seizures showed swelling and signal hyperintensity of the contralateral panetotemporal cortex, the thalamus, and the ipsilateral cerebellum on T₂-weighted images. These regions are connected by glutamatergic pathways. Proton magnetic resonance spectroscopy (MRS) of the cortical lesion yielded a signal peak at the resonance frequency of 2.29 ppm, suggesting a focal increase of glutamate or its degradation product glutamine. At 3–month follow-up, structural alterations had disappeared, but the N-acetylaspartatelcholine ratio was still reduced in the previously abnormal area. These findings are the first to demonstrate the contribution of MRS to pathophysiologic studies of focal SE in humans and, in combination with the pattern of imaging abnormalities, support a major role of glutamate for seizure-related brain damage.     

Nonconvulsive Status Epilepticus: High Incidence of Complex Partial Status

Nonconvulsive status epilepticus may be subdivided into generalized (absence) status and complex partial status. The latter is regarded as a rarity, whereas the former constitutes the dominant part of the hitherto reported cases. We report 10 consecutive cases of adult patients with nonconvulsive status epilepticus, all documented by ictal electroencephalographic (EEG) recordings. Five had a complex partial status; the origin of the complex partial status appeared to be frontal in four of these patients. Three had recurrent complex partial seizures with incomplete recovery between seizures, and two had more continuous symptoms. One of the latter exhibited neither motor phenomena nor automatisms. The effect of diazepam or clonazepam was immediate in all 10 cases though transient in eight. A lasting control of the status was not achieved in six patients until i.v. phenytoin was added. The difficulties in the differentiation between complex partial status and absence status despite ictal EEG recordings are discussed, illustrated by a case with seizure discharges of a focal onset which rapidly generalized. The study indicates that complex partial status may be more common and the clinical expressions of absence status more variable than hitherto recognized.     

Dimensions of adolescent subjective social status within the school community: Description and correlates

School pupils strive to meet both school-defined and social goals, and the structure of adolescent self-concept is multidimensional, including both academic and non-academic self-perceptions. However, subjective social status within the school community has been represented as a single dimension. Scottish 15-year olds participating in a school-based survey (N = 3194) rated their own status, compared to their school year-group, via images of seven 10-rung ladders. These generated a very high response rate, and factor analysis distinguished three dimensions: (1) ladders representing “popular”, “powerful”, “respected”, “attractive or stylish” and “trouble-maker”; (2) “doing well at school” and “[not] a trouble-maker”; and (3) “sporty”. Unique relationships with variables representing more objective and/or self-report behavioural measures suggest these dimensions are markers of “peer”, “scholastic” and “sports” status. These analyses suggest multiple dimensions of adolescent social hierarchy can be very simply measured and contribute towards the development of more robust instruments within this area.     

Status epilepticus in the elderly

Children and the elderly (≥60 years of age) have the highest incidence of status epilepticus (SE). Because of their general health, elderly individuals are much more likely than younger (<60 years of age) persons to have more severe consequences from seizures. The incidence of SE is 15.5/100 000 in the 60‐69 age group, 21.5/100 000 in the 70‐79 age group and 25.9/100 000 in persons 80 and older. The most common cause in the elderly is acute symptomatic, with stroke and hypoxia the most frequent. The overall mortality of SE is quite high and occurs early, often within the first few days, and is related to the cause, with mortality of more than 80% in persons with anoxia. Although the cause of SE is an important factor in mortality, the aging body and brain may contribute to an unfavorable outcome. Treatment in the elderly is essentially the same as in younger adults with benzodiazepines (lorazepam, diazepam, clonazepam) and longer acting antiseizure drugs (phenytoin, fosphenytoin, valproate, levetiracetam, and lacosamide. At this time there are no evidence‐based studies regarding Axis 2 (etiology) and Axis 4 (age). All current interventions for SE involve antiseizure drugs that were developed for treatment of chronic epilepsy. Treatments should be developed that are more specific for the various etiologies and involve drugs that work on the underlying cause of the SE.     

脑炎后癫痫持续状态进展为难治性癫痫持续状态及超级难治性癫痫持续状态的早期预测因素

目的探讨脑炎后癫痫持续状态(SE)进展为难治性SE(RSE)及超级RSE(SRSE)的早期预测因素。方法根据疾病进展情况将89例脑炎后SE患者分为非RSE组、RSE组及SRSE组。比较各组临床资料。结果非RSE组、RSE组及SRSE组年龄、SE严重程度评分量表(STESS)评分、基于流行病学SE病死率评分(EMSE)评分、脑炎-非惊厥性癫痫持续状态(NCSE)-地西泮抵抗-影像异常-气管插管(END-IT)评分、GCS评分、急性生理与慢性健康评分Ⅱ(APACHEⅡ)及影像学特征、昏迷中的NCSE、对苯二氮艹卓类药物无反应、静脉撤药发作、气管插管、应用血管活性药物比率差异均有统计学意义(P<0.05~0.01)。多因素Logistic回归分析发现,EMSE(OR=1.176,95%CI:0.984~1.405,P=0.075)、静脉撤药发作(OR=10.164,95%CI:1.825~56.603,P=0.008)和昏迷中的NCSE(OR=7.577,95%CI:1.337~42.940,P=0.022)是SE演变为RSE和SRSE的早期预测因素。结论EMSE超过42.5分、静脉撤药发作和是否为昏迷中的NCSE是SE患者进展为难治性的早期预测因素。     

癫痫持续状态及其治疗──附168例报告

本文报告168例癫痫持续状态．年龄13～72岁，平均47．64±17．83岁。男性119例，女性49例．其中强直一阵挛持续状态117例，阵挛－强宜－阵挛持续状态39例，强直持续状态10例及复杂性部份型癫痫持续状态－精神运动癫痫持续状态2例。本组治疗分为苯巴比妥钠肌注组132例，安定静脉注射组66例．两组在控制癫痫持续状态时为27．48±11．36分钟对31．93±10．47分钟，t＝2．21，P＜0．05。本病诊断正确，处理及时，预后良好。     

Inadequate benzodiazepine dosing may result in progression to refractory and non‐convulsive status epilepticus

Aims. Status epilepticus (SE) is defined as ongoing seizures lasting longer than five minutes or multiple seizures without recovery. Benzodiazepines (BZDs) are first‐line agents for the management of SE. Our objective was to evaluate BZD dosing in SE patients and its effects on clinical/electrographic outcomes. Methods. A retrospective analysis was conducted from a prospective database of SE patients admitted to a university‐based neurocritical care unit. The initial presentation and progression to refractory SE (RSE) and non‐convulsive SE (NCSE) with coma was evaluated. Outcome measures included length of stay (LOS), rates of intubation, ventilator‐dependent days, and Glasgow outcome scale (GOS). The lorazepam equivalent (LE) dosage of BZDs administered was calculated and we analysed variations in progression if 4 mg or more of LE (adequate BZDs) was administered. Results. Among 100 patients, the median dose of LE was 3 mg (IQR: 2–5 mg). Only 31% of patients received adequate BZDs. Only 18.9% of patients with NCSE without coma received adequate BZDs (p=0.04). Among patients progressing to RSE, 75.4% had not received adequate BZDs (p=0.04) and among patients developing NCSE with coma, 80.6% did not receive adequate BZDs (p=0.07). Escalating doses of BZDs were associated with a decrease in cumulative incidences of RSE (correlation coefficient r=‐0.6; p=0.04) and NCSE with coma (correlation coefficient r=‐0.7; p=0.003). Outcome measures were not influenced by BZD dosing. Conclusion. The majority of our patients were not adequately dosed with BZDs. Inadequate BZD dosing progressed to RSE and had a tendency to lead to NCSE with coma. Our study demonstrates the need to develop a hospital‐wide protocol to guide first responders in the management of SE.     

EFNS guideline on the management of status epilepticus in adults

The objective of the current article was to review the literature and discuss the degree of evidence for various treatment strategies for status epilepticus (SE) in adults. We searched MEDLINE and EMBASE for relevant literature from 1966 to January 2005 and in the current updated version all pertinent publications from January 2005 to January 2009. Furthermore, the Cochrane Central Register of Controlled Trials (CENTRAL) was sought. Recommendations are based on this literature and on our judgement of the relevance of the references to the subject. Recommendations were reached by informative consensus approach. Where there was a lack of evidence but consensus was clear, we have stated our opinion as good practice points. The preferred treatment pathway for generalised convulsive status epilepticus (GCSE) is intravenous (i.v.) administration of 4–8 mg lorazepam or 10 mg diazepam directly followed by 18 mg/kg phenytoin. If seizures continue more than 10 min after first injection, another 4 mg lorazepam or 10 mg diazepam is recommended. Refractory GCSE is treated by anaesthetic doses of barbiturates, midazolam or propofol; the anaesthetics are titrated against an electroencephalogram burst suppression pattern for at least 24 h. The initial therapy of non‐convulsive SE depends on type and cause. Complex partial SE is initially treated in the same manner as GCSE. However, if it turns out to be refractory, further non‐anaesthetising i.v. substances such levetiracetam, phenobarbital or valproic acid should be given instead of anaesthetics. In subtle SE, in most patients, i.v. anaesthesia is required.     

EFNS guideline on the management of status epilepticus

The objective of the current paper was to review the literature and discuss the degree of evidence for various treatment strategies for status epilepticus (SE) in adults. We searched MEDLINE and EMBASE for relevant literature from 1966 to January 2005. Furthermore, the Cochrane Central Register of Controlled Trials (CENTRAL) was sought. Recommendations are based on this literature and on our judgement of the relevance of the references to the subject. Recommendations were reached by informative consensus approach. Where there was a lack of evidence but consensus was clear we have stated our opinion as good practice points. The preferred treatment pathway for generalised convulsive status epilepticus (GCSE) is intravenous (i.v.) administration of 4 mg of lorazepam or 10 mg of diazepam directly followed by 15-18 mg/kg of phenytoin or equivalent fosphenytoin. If seizures continue for more than 10 min after first injection another 4 mg of lorazepam or 10 mg of diazepam is recommended. Refractory GCSE is treated by anaesthetic doses of midazolam, propofol or barbiturates; the anaesthetics are titrated against an electroencephalogram burst suppression pattern for at least 24 h. The initial therapy of non-convulsive SE depends on the type and the cause. In most cases of absence SE, a small i.v. dose of lorazepam or diazepam will terminate the attack. Complex partial SE is initially treated such as GCSE, however, when refractory further non-anaesthetising substances should be given instead of anaesthetics. In subtle SE i.v. anaesthesia is required.