妊娠合并超难治性癫痫持续状态1例并文献复习

<正>由于超难治性癫痫持续状态在神经内科重症监护室有较高的发病率和死亡率,临床表现为对常规抗癫痫药物不敏感,需静脉应用麻醉药物,且麻醉药物治疗癫痫持续状态(SE)超过24 h仍无法终止或复发。由于目前国内外缺乏大宗样本报道,易被临床医师忽视。本文报告一例妊娠合并超难治性癫痫持续状态1例并复习相关文献,对其进行探讨以期尽快终止癫痫发作,提高该类患者的诊治率。     

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(EMS...     

难治性癫痫持续状态的药物治疗进展

难治性癫痫持续状态(RSE)是指使用常规抗癫痫治疗不能控制的持续癫痫发作超过1h的状态,有效控制癫痫发作是挽救患者生命、改善其预后的关键。此文回顾分析了2003-2005年国内外治疗RSE的有关文献,将其所用药物用法、用量及作用机制做一综述。     

难治性癫痫持续状态患者的脑电图特征

目的 探究难治性癫痫持续状态(RSE)患者的脑电图(EEG)特征.方法 将60例全面惊厥性癫痫持续状态(GCSE)患者根据抗癫痫药物(AEDs)疗效分为RSE和非难治性癫痫持续状态(NRSE),比较两组患者EEG模式的差异.结果 所有患者中,与NRSE组比较,RSE组患者发作期EEG呈持续性放电比例更高,差异具有统计学意义(OR=5.44,95%CI=1.24~23.96,P=0.04).50例EGG呈间歇性演变的患者中,与NRSE组比较,RSE组患者发作间歇期EEG呈周期性放电与痫样放电的比例较高,差异有统计学意义(OR=29.75,4.12;95%CI=3.19~277.32,1.09~15.58;P<0.05);而RSE组患者发作后EEG为正常模式的比例较低,差异具有统计学意义(OR=0.11,95%CI=0.01~0.91,P=0.04).结论 GCSE患者如EEG出现持续性放电、周期性放电、发作间期痫样放电,应引起临床的高度重视,给以强化抗惊厥治疗.     

难治性癫痫持续状态的治疗进展

<正>癫痫持续状态(status epilepticus,SE)的发病率为10~61/10万,是神经科仅次于急性脑血管病的危急重症。即使给予足够、及时、恰当的抗癫痫药物以及病因治疗等综合处理,仍有约三分之一的患者发作难以控制,进展为难治性癫痫持续状态(refractor]ystatus epilepticus,RSE),其死亡率达16%~39%[1。RSE尚无统一定义,目前比较得到公认,在文献报道中应用较广泛的定义是:给予足够剂量的2~3种一     

难治性全面性癫痫持续状态的临床研究

目的 结合献研究12例难治性全面性癫痫持续状态(RSE)的治疗。方法 对患的病因、临床资料、治疗、预后进行分析。结果 12例RSE患控制6例，显效2例，有效2例，无效2例，总有效率83．3％，死亡3例，病死率25％。结论 RSE是神经系统危急症，积极有效的治疗可减少其对中枢神经系统的损害，改善患的预后，缩短住院时间。硫贲妥钠、异丙酚、利多卡因等是治疗RSE的有效药物。     

利多卡因在难治性癫痫持续状态中的应用

目的 认识利多卡因在难治性癫痫持续状态中的作用。方法 对10例难治性强直阵挛发作癫痫持续状态患者持续静脉注射利多卡因，观察其疗效及副作用。结果 9例患者在给药24小时内终止发作，1例在36小时内终止发作。1例出现房性早搏，1例出现窦性心律不齐。结论 利多卡因静脉注射能有效控制难治性癫痫持续状态。     

癫痫持续状态的临床研究新进展

癫痫持续状态是临床上常见的急症 ,癫痫病史、抗癫痫药物水平降低、低龄是其最重要的危险因素 ;高热、肺水肿、心律失常是其急性并发症 ;国外推荐劳拉西泮作为首选治疗药物。本文就近年来有关的临床研究进展做一综述     

癫痫持续状态的诊疗进展

癫痫持续状态（SE）是一类发病率、致残率和致死率极高的神经危重症疾病。随着研究的不断深入,人们对SE的机制及持续发作造成的多系统损伤有了进一步的了解,早期发现及快速终止发作成为SE治疗的关键。然而由于缺少可靠的循证医学证据,目前对癫痫持续状态的管理及治疗策略仍存在较大争议。本文通过对近年来文献的回顾,针对癫痫持续状态概念及分类的更新、流行病学、诊断和药物治疗作一综述。     

Phenobarbital in super-refractory status epilepticus (PIRATE): A retrospective,multicenter analysis

Objective

Super-refractory status epilepticus (SRSE) is an enduring or recurring SE after 24 h or more of general anesthesia. This study aimed to evaluate the efficacy and safety of phenobarbital (PB) for the treatment of SRSE.

Methods

This retrospective, multicenter study included neurointensive care unit (NICU) patients with SRSE treated with PB between September 2015 and September 2020 from six participating centers of the Initiative of German NeuroIntensive Trial Engagement (IGNITE) to evaluate the efficacy and safety of PB treatment for SRSE. The primary outcome measure was seizure termination. In addition, we evaluated maximum reached serum levels, treatment duration, and clinical complications using a multivariate generalized linear model.

Results

Ninety-one patients were included (45.1% female). Seizure termination was achieved in 54 patients (59.3%). Increasing serum levels of PB were associated with successful seizure control (per μg/mL: adjusted odds ratio [adj.OR] = 1.1, 95% confidence interval [CI] 1.0–1.2, p < .01). The median length of treatment in the NICU was 33.7 [23.2–56.6] days across groups. Clinical complications occurred in 89% (n = 81) of patients and included ICU-acquired infections, hypotension requiring catecholamine therapy, and anaphylactic shock. There was no association between clinical complications and treatment outcome or in-hospital mortality. The overall average modified Rankin scale (mRS) at discharge from the NICU was 5 ± 1. Six patients (6.6%) reached mRS ≤3, of whom five were successfully treated with PB. In-hospital mortality was significantly higher in patients in whom seizure control could not be achieved.

Significance

We observed a high rate in attainment of seizure control in patients treated with PB. Success of treatment correlated with higher dosing and serum levels. However, as one would expect in a cohort of critically ill patients with prolonged NICU treatment, the rate of favorable clinical outcome at discharge from the NICU remained extremely low. Further prospective studies evaluating long-term clinical outcome of PB treatment as well as an earlier use of PB at higher doses would be of value.     

Deep brain stimulation of the anterior nucleus of the thalamus in a patient with super-refractory convulsive status epilepticus

We report the first patient to die from refractory convulsive status epilepticus (SE) after the removal of a stimulator. The removal occurred after a two-year period of successful control of super-refractory convulsive SE with deep brain stimulation of the bilateral anterior nucleus of the thalamus (ANT-DBS). The female patient, born in 1990, suffered from high fever and seizures, and was diagnosed with viral encephalitis in 2005. After four weeks of medical treatment, she recovered with no neurological disabilities, but suffered from monthly seizures. Ten years later, the patient presented with convulsive SE, while four months pregnant in February of 2015. Her SE remained super-refractory to drugs despite the termination of pregnancy. Therefore, ANT-DBS was performed in March of 2015. The patient became SE-free following activation of an ANT-DBS stimulator. However, the stimulation treatment was terminated according to the family's request when a tremor developed two years after the treatment had begun. Subsequently, four SE episodes occurred and the tremor did not improve. The stimulator and electrodes were removed in August of 2017. The patient died of an uncontrolled SE two months later. This case demonstrates the effectiveness of ANT-DBS for emergency super-refractory convulsive SE with both positive and negative outcomes.     

Clinical features and outcome of super-refractory status epilepticus: A retrospective analysis in West China

PurposeData about super-refractory status epilepticus (SRSE) are scarce. This study aimed to assess the clinical features and outcome of patients with SRSE.MethodClinical features of all SRSE patients admitted to the Neurologic Intensive Care Unit (NICU)/Neurology Department of West China Hospital, Sichuan University, between January 2010 and August 2013, were retrospectively analyzed. Outcome at discharge, at the three-month and long-term follow-ups were evaluated using the Glasgow Outcome Scale (GOS). Possible predictors of mortality and outcome were also evaluated.ResultsThirteen patients with SRSE were included. Young patients with encephalitis accounted for the majority of the series (61.5%). In-hospital mortality was 15.4% (2/13), and the three-month mortality was 36.4% (4/11; two patients ceasing therapy were excluded). At the long-term follow-up, 18.2% of patients improved and 45.5% of patients recovered. Patients of older age and those with multiple complications had higher mortality compared with those of younger age and those with fewer complications. For survivors, functional outcome had significantly improved at three-month follow-up (GOS score = 4.1 ± 1.2) compared to that at discharge (GOS score = 3.1 ± 1.2, P < 0.05). Long duration of anesthesia, etiology of encephalitis and positive neuroimaging findings tended to be associated with poor functional outcome.ConclusionWe conclude that the typical patient susceptible to development of SRSE in West China is a young patient with encephalitis. Older age and multiple complications increase the risk of death. Most patients can survive with aggressive therapy, and their functional outcome improves over time.     

老年惊厥性癫痫持续状态28例临床分析

目的观察老年惊厥性癫痫持续状态(CSE)的临床特点。方法收集神经重症监护室(NICU)年龄≥60岁的CSE患者28例,回顾性分析其临床特点。结果脑血管病为28例老年CSE的首位病因。接受抗癫痫药物治疗后,CSE症状控制的中位时间为0.9 h,其中16例患者在1 h内症状控制,12例为难治性癫痫持续状态(RSE)。28例患者中,存活16例、死亡12例。死亡者与存活者相比,合并中枢神经系统新发疾病(P=0.027)和RSE的比例显著不同(P=0.027)。结论老年CSE患者基础情况差,病因多样,合并有中枢神经系统新发疾病或有RSE者的死亡率高。     

成人顽固性癫痫持续状态的临床分析

目的 探讨成人顽固性癫痫持续状态（RSE）的危险因素、临床特点、治疗及预后。方法 54例癫痫持续状态（SE）．58次发作事件，分为RSE组和非顽固性癫痫持续状态（NRSE）组．对病因、诱因、临床表现、辅助检查、预后等进行对比分析。结果 RSE占SE的43．1％，病毒性脑炎是RSE最主要的病因（P=0．001），相反，既往癫痫发作在NRSE中更常见（P=0．000），相应地药物治疗的改变引起的SE多为NRSE（P=-0．003）；RSE组GCS评分及预后较NRSE组均差（均P=0．000）。结论 SE经一、二线抗癫痫药治疗后仍有很大一部分难以控制，病毒性脑炎是导致RSE的一个重要病因，其预后较差．目前对RSE的治疗还缺乏十分合理的方案。     

SENSE registry for status epilepticus

Evidence is scarce regarding the treatment of status epilepticus (SE). Only a few large randomized controlled trials have been published. Therefore, we set up a multicenter registry to prospectively document treatment practice in several different large hospitals in German‐speaking countries. Over a period of more than 4 years, we were able to document 1179 episodes of 1049 patients who were treated for SE in 1 of the 8 participating centers in Germany, Austria, and Switzerland. Median age was 70 years. The most frequent etiology was remote (32%), followed by acute (31%), or a mixture of acute and remote factors (10%). Semiology was generalized convulsive in 44%, focal motor in 27%, and nonconvulsive in 30%. Only a few patients did not have relevant comorbidities. Median latency between SE onset and first treatment was 1 hour (median). Three hundred ninety‐three (32%) of the patients were treated within 30 minutes after onset. The first treatment step consisted of benzodiazepines in more than 80%, and in levetiracetam in 15%. Five hundred eleven patients (49%) were refractory (defined as ongoing SE after application of benzodiazepine and 1 intravenous anticonvulsant). Further analysis of these registry data may be important for hypothesis generation and trial design for treatment of status epilepticus.     

The ketogenic diet for super-refractory status epilepticus patients in intensive care units

Objectives

Super-refractory status epilepticus (SRSE) is one of the most challenging issues in intensive care units (ICUs) in that it is associated with high morbidity and mortality. Although the ketogenic diet (KD) has been reported to be effective in treating of SRSE, the use of the diet as therapy can be complicated by concomitant medical problems specific to critically ill patients. In this study, we aimed to describe our experience of the KD for SRSE patients in ICUs.

Neuromodulation techniques for status epilepticus: A review

BackgroundElectroconvulsive therapy (ECT), Vagal Nerve Stimulation (VNS), Transcranial Magnetic Stimulation (TMS) and Deep Brain Stimulation (DBS) are neuromodulation therapies that have been used to treat Status Epilepticus (SE).ObjectiveReview the literature about the efficacy and safety of neuromodulation therapies in SE in humans.MethodsWe searched studies in PubMed, Scopus, Google Scholar and Science Direct (inception to June 2018). Four review authors independently selected the studies, extracted data and assessed the methodological quality of the studies using the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, PRISMA guidelines, Oxford and GRADE scales, and Murad et al., 2018 methodological quality and synthesis of case series and case reports.ResultsWe analyzed 27 articles (45 patients) with 4 different neuromodulation therapies. In ECT we found 80% rate of disruption of SE and 5% of adverse events was reported. Using iVNS 15/16 (93.7%) patients resolved the SE. All patients who underwent TMS and DBS aborted SE, however, 50% of patients with DBS had severe adverse events.ConclusionsCase series and case reports suggest that neuromodulation therapies can abort SE in 80–100% of patients (Oxford scale and GRADE were level 4 and D) with a wide range of adverse effects, which claims for prospective studies on the relationship be-tween efficacy and safety.     

Nonconvulsive status epilepticus

Nonconvulsive status epilepticus (NCSE) is a heterogeneous disorder with multiple subtypes. Although attempts have been made to define and classify this disorder, there is yet no universally accepted definition or classification that encompasses all subtypes or electroclinical scenarios. Developing such a classification scheme is becoming increasingly important, because NCSE is more common than previously thought, with a bimodal peak, in children and the elderly. Recent studies have also shown a high incidence of NCSE in the critically ill. Although strong epidemiological data are lacking, NCSE constitutes about 25-50% of all cases of status epilepticus. For the purposes of this review, we propose an etiological classification for NCSE including NCSE in metabolic disorders, NCSE in coma, NCSE in acute cerebral lesions, and NCSE in those with preexisting epilepsy with or without epileptic encephalopathy. NCSE is still underrecognized, yet potentially fatal if untreated. Diagnosis can be established using an electroencephalogram (EEG) in most cases, sometimes requiring continuous monitoring. However, in comatose patients, diagnosis can be difficult, and the EEG can show a variety of rhythmic or periodic patterns, some of which are of unclear significance. Although some subtypes of NCSE are easily treatable, such as absence status epilepticus, others do not respond well to treatment, and debate exists over how aggressively clinicians should treat NCSE. In particular, the appropriate treatment of NCSE in patients who are critically ill and/or comatose is not well established, and large-scale trials are needed. Overall, further work is needed to better define NCSE, to determine which EEG patterns represent NCSE, and to establish treatment paradigms for different subtypes of NCSE.