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.     

Treatment of refractory complex-partial status epilepticus with propofol: case report

PURPOSE: We report a case of a 65-year-old woman who had a subarachnoid and intraventricular hemorrhage secondary to rupture of an anterior communicating artery aneurysm and developed nonconvulsive status epilepticus of the complex-partial type, refractory to phenytoin (PHT), phenobarbital (PB), valproate (VPA), and lorazepam (LZP). METHODS: Three weeks after diagnosis of nonconvulsive status epilepticus, general anesthesia was induced with propofol and titrated to burst suppression on the electroencephalogram (EEG). RESULTS: During propofol infusion, the serum VPA level declined markedly, and despite >3 g daily doses, did not return to the therapeutic range, until several days after propofol was discontinued. Continuous propofol infusion was stopped after 7 days, and the patient recovered consciousness. Despite further complications, she gradually regained normal function and was discharged home 4 months after surgery. CONCLUSIONS: This is the first case of nonconvulsive status epilepticus successfully treated with propofol.     

2例非惊厥癫痫持续状态患者的临床特征及脑电图分析

非惊厥性癫痫持续状态（Nonconvulsive Status Epilepticus,NCSE）年发病率为5.6～18.3/10万[1],约占癫痫持续状态的一半,并非罕见,以往由于对其认识不足和诊断标准不一致[2],常被误诊或漏诊,得不到及时有效的治疗.不同类型的NCSE,临床表现和脑电图特点各不相同[3].现将首都医科大学宣武医院神经内科2012年7～10月收治的2例NCSE患者的临床特征及脑电图结果报道如下.     

Amplitude-integrated EEG revealed nonconvulsive status epilepticus in children with non-accidental head injury

ObjectiveWe describe the clinical course and amplitude-integrated EEG findings in three children with non-accidental head injury and discuss on the importance of continuous aEEG monitoring in infants.MethodsNCSE was defined as a continuous 30-min seizure or briefer seizures occurring consecutively comprising at least 30 min of any 1-h period. Non-accidental head injury was diagnosed on the basis of neuroimaging findings such as subdural hemorrhage. Antiepileptic treatment was performed with continuous amplitude-integrated EEG monitoring.ResultsThe age of the patients ranged from 48 days to nine months. All of them had loss of consciousness and seizures on presentation. Nonconvulsive status epilepticus without clinical symptoms were recognized in all patients. Vigorous antiepileptic treatment against nonconvulsive status epilepticus was made in two patients, whereas nonconvulsive status epilepticus disappeared within one hour without additional treatment in one.ConclusionsOur experience indicates that nonconvulsive status epilepticus were not uncommon in children with non-accidental head injury. Continuous amplitude-integrated EEG monitoring will be one of the useful methods in encephalopathic children in order to estimate seizure burden objectively and to treat seizures appropriately.     

Successful neurosurgical treatment of childhood complex partial status epilepticus with focal resection

The treatment of complex partial status epilepticus continues to be controversial, especially with regard to the intensity of the treatment. Medical therapy and drug-induced coma are sometimes required. Rarely this may not be effective. A healthy 4-year old girl was first seen in complex partial status epilepticus. She had a 1-year history of cryptogenic partial-onset seizures. Detailed magnetic resonance imaging (MRI) studies were normal. Her course was refractory to multiple medical therapies and multiple subpial transection (MST). An urgent epilepsy surgery evaluation resulted in a focal cortical resection being performed over the right mesial parietal region with resultant seizure freedom and no significant neurologic deficit 2 years later. This patient illustrates the need to consider occult focal cortical dysplasia as a cause of nonconvulsive status epilepticus (NCSE) in children, and if it is not responsive to medical management, the utility of performing an urgent epilepsy surgery evaluation.     

Persistent Nonconvulsive Status Epilepticus After the Control of Convulsive Status Epilepticus

Summary: Purpose: Convulsive status epilepticus (CSE) is a major medical and neurological emergency that is associated with significant morbidity and mortality. Despite this high morbidity and mortality, most acute care facilities in the United States cannot evaluate patients with EEG monitoring during or immediately after SE. The present study was initiated to determine whether control of CSE by standard treatment protocols was sufficient to terminate electrographic seizures. Methods: One hundred sixty-four prospective patients were evaluated at the Medical College of Virginia/VCU Status Epilepticus Program. Continuous EEG monitoring was performed for a minimum of 24 h after clinical control of CSE. SE and seizure types were defined as described previously. A standardized data form entry system was compiled for each patient and used to evaluate the data collected. Results: After CSE was controlled, continuous EEG monitoring demonstrated that 52% of the patients had no after-SE ictal discharges (ASIDS) and manifested EEG patterns of generalized slowing, attenuation, periodic lateralizing epileptiform discharges (PLEDS), focal slowing, and/or burst suppression. The remaining 48% demonstrated persistent electrographic seizures. More than 14% of the patients manifested nonconvulsive SE (NCSE) predominantly of the complex partial NCSE seizure (CPS) type (2). These patients were comatose and showed no overt clinical signs of convulsive activity. Clinical detection of NCSE in these patients would not have been possible with routine neurological evaluations without use of EEG monitoring. The clinical presentation, mortality, morbidity, and demographic information on this population are reported. Conclusions: Our results demonstrate that EEG monitoring after treatment of CSE is essential to recognition of persistent electrographic seizures and NCSE unresponsive to routine therapeutic management of CSE. These findings also suggest that EEG monitoring immediately after control of CSE is an important diagnostic test to guide treatment plans and to evaluate prognosis in the management of SE.     

Significance of atypical triphasic waves for diagnosing nonconvulsive status epilepticus

The aim of the study described here was to analyze findings in 15 cases who were admitted with nonconvulsive status epilepticus (NCSE) and whose EEGs featured atypical triphasic waves (ATWs). We also investigated whether ATWs are useful for diagnosing this condition. Mental status was assessed, and EEGs were recorded during/after the antiepileptic drug treatment. Eight patients had metabolic disorders and nine had intracranial pathology. The ATWs were unilateral focal in 5 cases and bilaterally asymmetrical focal in 10 cases. In 11 of the 15 cases, the ATWs disappeared and mental status improved after treatment. NCSE should be considered in any individual who presents in an acute confusional state and whose EEG reveals either unilateral or bilaterally asymmetric ATWs.     

Predictors of refractoriness in a Turkish status epilepticus data bank

Refractory status epilepticus (RSE) is known to constitute approximately 10–50% of all cases of status epilepticus (SE) and is associated with significant morbidity and mortality. In the present study, data from a prospectively collected SE database were analyzed. Patients with RSE (defined as a SE episode requiring a second line of intravenous treatment following intravenous phenytoin) were compared with patients with nonrefractory SE (NRSE); 290 episodes of SE were identified, of which 108 (38%) were defined as RSE. Univariate analysis revealed that age, female gender, SE type, SE duration, and acute etiology were associated with refractoriness, whereas electroencephalographic patterns were not. Nonconvulsive SE, which is probably associated with delays in treatment initiation, was a predictor of RSE, although it was not retained as a predictor in multivariate analysis. In the latter analysis, female gender (odds ratio: 1.815, 95% CI: 1.053–3.126) and acute etiology (odds ratio: 0.619, 95% CI: 0.429–0.894) were shown to be the only significant independent predictors of refractoriness.     

Cefepime-Induced Nonconvulsive Status Epilepticus: Case Report and Review

Introduction  A case of cefepime-induced nonconvulsive status epilepticus in a 15-year-old child with end stage renal disease on hemodialysis is reported. Clinical symptoms and EEG dramatically improved 48 h after discontinuation of cefepime. Methods  Twenty-five cases of nonconvulsive status epilepticus associated with cefepime that have been reported in the literature are reviewed. Results  The average age was 60 years [15–86], our patient is the second pediatric patient reported, and 56% of cases occurred in women. The cefepime dosage was adjusted to the renal function in 5 cases. All except 1 patient have impaired renal function (CRF: 17 cases, ARF: 7 cases). The symptoms start 1–15 days after starting cefepime, mean 6 days. The outcome was good after discontinuation of cefepime therapy and anticonvulsant treatment, but lethal outcome was also reported in 2 cases. One fatality was related to status epilepticus. Conclusion  The clinicians’ awareness must be increased about cefepime-induced nonconvulsive status epilepticus.     

Overview of Landau–Kleffner syndrome: early treatment,tailored education and therapy improve outcome

Landau–Kleffner syndrome (LKS) is a rare epilepsy occurring in children usually between the ages of three and nine years, characterised by dramatic loss of language skills in association with epileptiform activity over the language centres during sleep. It may be associated with convulsive seizures and additional difficulties with behaviour, social interaction, motor skills and cognition. Early treatment to suppress the EEG abnormalities can at least partially reverse this regression in 60–70% but usually needs to be continued for some years. Management focuses on restoring communication so that the child continues to engage and learn. Therapy and education support are essential and need to be very flexible as the child's profile can fluctuate dramatically and may include signing when they cannot access language and may require considerable opportunities for consolidation and overlearning. The epileptiform activity usually resolves by puberty, often with continuing recovery in skills for some years that will benefit from ongoing support. Many have persisting deficits as adults which are more severe with earlier age of onset and a longer epileptiform period. It is important to recognise LKS as early multi-disciplinary management may improve outcomes.