Refractory status epilepticus

Refractory status epilepticus (RSE) is a common problem in intensive care units and emergency departments. The important risk factor predisposing patients with SE to RSE is delay in receiving treatment. Self-sustaining SE is associated with progressive, time-dependent development of pharmacoresistance. Early termination of convulsive SE by aggressive treatment is the best way to prevent RSE. RSE once develop, requires more aggressive treatment as it is associated with higher mortality and morbidity. To date, no randomized controlled trials have been done for RSE. The most experience exists with coma inducing agents like pentobarbital, midazolam and propofol. New evidence suggests for the possible role of newer AEDs.     

Convulsive status epilepticus after ischemic stroke and intracerebral hemorrhage: frequency,predictors, and impact on outcome in a large administrative dataset

Objective  

Relatively little is known about the epidemiology of generalized convulsive status epilepticus (GCSE) in acute ischemic and hemorrhagic stroke. We examined the occurrence of GCSE in acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) using a large discharge database.     

Refractory status epilepticus: diagnosis, therapy, course, and prognosis

Status epilepticus (SE) is a frequent neurological emergency with an annual incidence of 10-20/100,000 individuals. The overall mortality is about 10-20%. Patients present with long-lasting fits or series of epileptic seizures or extended stupor and coma. Furthermore, patients with SE can suffer from a number of systemic complications possibly also due to side effects of the medical treatment. In the beginning, standardized treatment algorithms can successfully stop most SE. A minority of SE cases prove however to be refractory against the initial treatment and require intensified pharmacologic intervention with nonsedating anticonvulsive drugs or anesthetics. In some partial SE, nonpharmacological approaches (e.g., epilepsy surgery) have been used successfully. This paper reviews scientific evidence of the diagnostic approach, therapeutic options, and course of refractory SE, including nonpharmacological treatment.     

Psychogenic status epilepticus in children: psychiatric and other risk factors

The authors studied six children with repetitive psychogenic seizures severe enough to mimic status epilepticus. All received IV antiepileptic drugs in an emergency setting. Most had a family history of epilepsy. Affective and anxiety disorders predominated as comorbid psychiatric diagnoses. Acutely stressful situations precipitated all episodes of nonepileptic status epilepticus. With aggressive psychotherapeutic intervention and pharmacologic treatment of their underlying psychiatric diagnosis, the patients improved.     

Refractory status epilepticus: A prospective observational study

Purpose: Status epilepticus (SE) that is resistant to two antiepileptic compounds is defined as refractory status epilepticus (RSE). In the few available retrospective studies, estimated RSE frequency is between 31% and 43% of patients presenting an SE episode; almost all seem to require a coma induction for treatment. We prospectively assessed RSE frequency, clinical predictors, and outcome in a tertiary clinical setting. Methods: Over 2 years we collected 128 consecutives SE episodes (118 patients) in adults. Clinical data and their relationship to outcome (mortality and return to baseline clinical conditions) were analyzed. Results: Twenty‐nine of 128 SE episodes (22.6%) were refractory to first‐ and second‐line antiepileptic treatments. Severity of consciousness impairment and de novo episodes were independent predictors of RSE. RSE showed a worse outcome than non‐RSE (39% vs. 11% for mortality; 21% vs. 63% for return to baseline clinical conditions). Only 12 patients with RSE (41%) required coma induction for treatment. Discussion: This prospective study identifies clinical factors predicting the onset of SE refractoriness. RSE appears to be less frequent than previously reported in retrospective studies; furthermore, most RSE episodes were treated outside the intensive care unit (ICU). Nonetheless, we confirm that RSE is characterized by high mortality and morbidity.     

癫痫持续状态危险因素及神经化学的改变

癫痫持续状态是内科常见的急症,了解其常见的危险因素有利于病因的明确.其发生过程中的神经化学改变如γ氨基丁酸活性的变化,谷氨酸、离子通道及相关炎性因子的改变正逐渐被认识.明确神经化学的变化将有助有癫痫持续状态发病机制的研究和干预手段的改进.     

Refractory status epilepticus: effect of treatment aggressiveness on prognosis

BACKGROUND: Administration of antiepileptic drugs for coma induction in refractory status epilepticus (RSE) has not been widely studied. Moreover, the effect on outcome of electroencephalographic (EEG) burst suppression remains unclear. OBJECTIVE: To investigate whether various coma-inducing options are associated with different prognoses after RSE. DESIGN: Retrospectively assessed case series. SETTING: Two tertiary referral hospitals in Boston, Mass. PATIENTS: Among 127 consecutive episodes (107 patients) of status epilepticus, we identified episodes that were refractory to first-line and second-line antiepileptic drugs, needing induced coma with barbiturates, propofol, or midazolam for clinical management. MAIN OUTCOME MEASURES: Short-term mortality and prevalence of return to functional baseline after the acute episode of status epilepticus were analyzed in relation to demographic and clinical variables and to treatment option (antiepileptic agents and EEG burst suppression). RESULTS: Forty-nine episodes of RSE (47 patients) were found, occurring more frequently in incident than in recurrent episodes of status epilepticus (P = .06). Mortality was 23% for patients with RSE and 8% for those without RSE (P = .05). Return to baseline occurred more often in the non-RSE group (P = .04). In 20 (61%) of 33 monitored episodes, EEG burst suppression was achieved. Demographic data, clinical variables, and outcome did not differ significantly with the various coma-inducing agents or between episodes with and without EEG burst suppression. CONCLUSIONS: Refractory status epilepticus is more prevalent in incident than in recurrent status epilepticus and is associated with higher mortality; clinical status is less likely to return to baseline than with non-RSE. Outcome was independent of the specific coma-inducing agents used and the extent of EEG burst suppression, suggesting that the underlying cause represents its main determinant.     

Childhood convulsive status epilepticus: epidemiology, management and outcome

Convulsive status epilepticus (CSE) in childhood is a medical emergency and its aetiology and outcome mean that it should be studied separately from adult CSE. The incidence in developed countries is between 17 and 23/100,000 with a higher incidence in younger children. Febrile CSE is the commonest single group with a good prognosis in sharp distinction to CSE related to central nervous system infections which have a high mortality. The aim of treatment is to intervene at 5 min and studies indicate that intravenous (i.v.) lorazepam may be a better first-line treatment than rectal diazepam and i.v. phenytoin a better second-line treatment than rectal paraldehyde. An epidemiological study strongly supports the development of prehospital treatment with buccal midazolam becoming a widely used but unlicensed option in the community. More than two doses of benzodiazepines increase the rate of respiratory depression without obvious benefit. The 1 year recurrence rate is 17% and the hospital mortality is about 3%.     

Refractory status epilepticus due to SMART syndrome

IntroductionStroke-like migraine attacks after radiation therapy (SMART) is a late-onset complication of brain irradiation of unknown physiopathology. Our aim was to present three patients with SMART syndrome who had clinical and neuroimage studies suggestive of status epilepticus.PatientsPatient 1. A 69-year-old woman, who was treated with radiation therapy 14 years before her first admission to the Neurology Department, presented with several episodes of headache, speech disturbances, and weakness of left limbs with altered awareness.Patient 2. A 49-year-old man, who was treated with whole brain radiation 20 years before the onset of symptoms, developed some episodes consisting of headache and numbness of the right side of face and right arm; the latest episodes were accompanied by visual disturbances followed by generalized tonic–clonic seizures.Patient 3. A 40-year-old man, who received cranial irradiation 20 years before, suffered three episodes of behavioral disturbance, aphasia, headache, and visual aura followed by left homonymous hemianopia.ResultsAll three patients suffered seizures mostly with visual aura. Electroencephalography showed interictal epileptiform discharges or focal slowing. Brain magnetic resonance image (MRI), positron emission tomography (PET), or ictal-single-photon emission computed tomography (SPECT) showed focal cortical hyperperfusion. Focal diffusion restriction and focal gadolinium-enhancement were observed on MRI. All patients were treated with antiepileptic drugs, being effective in one of them. One patient needed anesthesic coma, and the other patient responded to therapy with corticosteroids.ConclusionsTaking into account clinical evolution and ictal neuroimaging studies, status epilepticus could explain the origin of these episodes in SMART syndrome. Although most patients have reversible symptoms, in some cases, aggressive treatment to avoid sequelae is needed.This article is part of a Special Issue entitled “Status Epilepticus”.     

Predicting outcome of status epilepticus

BackgroundStatus epilepticus (SE) is a frequent neurological emergency complicated by high mortality and often poor functional outcome in survivors. The aim of this study was to review available clinical scores to predict outcome.MethodsLiterature review. PubMed Search terms were “score”, “outcome”, and “status epilepticus” (April 9th 2015). Publications with abstracts available in English, no other language restrictions, or any restrictions concerning investigated patients were included.ResultsTwo scores were identified: “Status Epilepticus Severity Score — STESS” and “Epidemiology based Mortality score in SE — EMSE”. A comprehensive comparison of test parameters concerning performance, options, and limitations was performed. Epidemiology based Mortality score in SE allows detailed individualization of risk factors and is significantly superior to STESS in a retrospective explorative study. In particular, EMSE is very good at detection of good and bad outcome, whereas STESS detecting bad outcome is limited by a ceiling effect and uncertainty of correct cutoff value. Epidemiology based Mortality score in SE can be adapted to different regions in the world and to advances in medicine, as new data emerge. In addition, we designed a reporting standard for status epilepticus to enhance acquisition and communication of outcome relevant data. A data acquisition sheet used from patient admission in emergency room, from the EEG lab to intensive care unit, is provided for optimized data collection.ConclusionStatus Epilepticus Severity Score is easy to perform and predicts bad outcome, but has a low predictive value for good outcomes. Epidemiology based Mortality score in SE is superior to STESS in predicting good or bad outcome but needs marginally more time to perform. Epidemiology based Mortality score in SE may prove very useful for risk stratification in interventional studies and is recommended for individual outcome prediction. Prospective validation in different cohorts is needed for EMSE, whereas STESS needs further validation in cohorts with a wider range of etiologies.This article is part of a Special Issue entitled “Status Epilepticus”.     

Neurotrophic factors and status epilepticus

Because of their strong effects on cell survival and on synaptic function, neurotrophic factors (NTFs) have been hypothesized to be involved in some aspects of status epilepticus (SE) and in its possible consequences. This hypothesis has been explored mainly for 2 NTFs, namely fibroblast growth factor 2 (FGF‐2) and brain‐derived neurotrophic factor (BDNF). This article focuses on these 2 NTFs. I first summarize their biologic features and then describe existing evidence supporting their implication in SE and its outcomes. Available data support a direct implication of FGF‐2 and BDNF in SE and in its consequences. However, these NTFs have been found to exert some contrasting effects, for example, to favor seizures but protect from cell damage. A better understanding of the mechanisms of FGF‐2 and BDNF biosynthesis and signaling will be therefore instrumental for the development of therapeutic strategies that are not compromised by paradoxical side effects.     

Clinical risk factors for non-convulsive status epilepticus during emergent electroencephalogram

PurposeEmergent electroencephalograms (EmEEG) are performed to exclude non-convulsive status epilepticus (NCSE) but are resource-intensive. Prior studies have identified a seizure or seizures in the acute setting preceding the EmEEG request as a risk factor of NCSE but few other consistent clinical risk factors have been identified. We aimed to identify clinical risk factors for NCSE in EmEEGsMethodsWe conducted a retrospective analysis of consecutive patients who underwent EmEEG to exclude NCSE over a 20-month period. One blinded investigator extracted clinical information from patient case records using a standardized form. Patients were grouped using EmEEG results into those with and without NCSE. We analyzed differences between these two groups.ResultsA total of 2333 EEGs were performed over the study period, 215 (9.3%) were EmEEGs ordered to exclude NCSE. 21 patients (9.8%) of the 215 patients were found to have NCSE. Three independent clinical risk factors for NCSE were identified – seizure(s) in the acute setting, ocular movements (nystagmus and/or gaze deviation) and ongoing CNS infection. The presence of seizure(s) in the acute setting showed the highest adjusted odds ratio (OR = 8.8, 95% CI 2.0–39.4, p = 0.005). In addition, prevalence of NCSE increased as more clinical risk factors were present.ConclusionSeizures in the acute setting, ocular movements and ongoing CNS infection are associated with NCSE. By using these risk factors at the bedside, clinicians can prioritize patients for EmEEG, recognizing that risk of NCSE increases as more clinical risk factors are present.