1
|
Purwien L, Schubert-Bast S, Kieslich M, Ronellenfitsch MW, Merker M, Czabanka M, Willems LM, Rosenow F, Strzelczyk A. Trends and Differences in Status Epilepticus Treatment of Children and Adults Over 10 Years: A Comparative Study of Medical Records (2012-2021) from a University Hospital in Germany. CNS Drugs 2023; 37:993-1008. [PMID: 37979095 PMCID: PMC10667152 DOI: 10.1007/s40263-023-01049-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Over the last decade, significant advancements have been made in status epilepticus (SE) management, influenced by landmark trials such as ESETT and RAMPART. The objectives of this study were to explore the evolution of drug treatments for patients with SE, to investigate its association with outcomes and mortality, and to evaluate differences in treatment patterns between adults and children for a potential shift in medication trends due to the above mentioned trials. METHODS The medical records of patients with SE treated at University Hospital Frankfurt between 2012 and 2021 were evaluated for medication trends and outcomes. Children and adults were analyzed separately and jointly. RESULTS This study included 1151 SE episodes in 1021 patients (mean age = 53.3 ± 28.3 years; 52.5 % female [n = 533]). The overall percentage of patients with SE treated prehospital was stable over the last decade. More than half (53.6 %) of children were treated prehospital, compared with less than one-third (26.7 %) of adults. Prehospital midazolam use increased over time, while diazepam use decreased. Lorazepam was the most commonly used benzodiazepine in hospitals in 2012-2013, used in 40.8 % of all episodes. However, its use declined to 27.2 % in 2020-2021, while midazolam use increased to 44.0 %. While the use of older antiseizure medications (ASMs) such as phenobarbital (p = 0.02), phenytoin (p < 0.001), and valproate (p < 0.001) decreased, the use of newer ASMs such as levetiracetam and lacosamide significantly increased (p < 0.001). Propofol and continuous midazolam infusion remained the most used third-line therapy drugs. Overall mortality was 16.5 % at discharge and 18.9 % at 30 days. Mortality rates did not change between 2012 and 2021. CONCLUSION Midazolam has become the preferred benzodiazepine in pre- and in-hospital settings, both in children and adults. The same applies to the increased use of levetiracetam and lacosamide over time in children and adults, while phenobarbital, phenytoin, and valproate use decreased. Continuous midazolam infusion and propofol remain the most frequently used anesthetic drugs. Mortality and outcome remain stable despite changes in medication patterns.
Collapse
Affiliation(s)
- Leonore Purwien
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Susanne Schubert-Bast
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Department of Child and Adolescent Medicine, Neuropediatrics, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Matthias Kieslich
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Department of Child and Adolescent Medicine, Neuropediatrics, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael W Ronellenfitsch
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
- Dr. Senckenberg Institute of Neuro-oncology, Goethe-University Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Michael Merker
- Department of Child and Adolescent Medicine, Neuropediatrics, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Center of Neurology and Neurosurgery, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
| |
Collapse
|
2
|
Pan Y, Feng Y, Peng W, Cai Y, Ding J, Wang X. Timing matters: there are significant differences in short-term outcomes between two time points of status epilepticus. BMC Neurol 2022; 22:348. [PMID: 36104657 PMCID: PMC9472412 DOI: 10.1186/s12883-022-02868-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/30/2022] [Indexed: 11/12/2022] Open
Abstract
Background In 2015, the International League Against Epilepsy proposed a new conceptual definition of status epilepticus (SE) with two operational dimensions (t1 and t2) to guide emergency treatment. The purpose of this study was to compare clinical characteristics and prognoses of patients at these two different time points. Methods We conducted a prospective observational cohort study of consecutive adults diagnosed with SE. In case of convulsive SE, t1 is 5 min and t2 is 30 min, whereas in case of focal SE with impaired consciousness, t1 is 10 min, t2 is 60 min. Data on clinical characteristics, including age, gender, history of prior seizures, neuroimaging, semiology, duration, and etiology of SE, were collected. The primary outcome was mortality, with seizure recurrence as a secondary measure, and functional status as tertiary outcome of enrolled patients at 3 months after SE onset. Results We screened one hundred patients with SE, with a median age of 66 years and 61% were male. Fifty-six (56.0%) patients reached t1 of SE, while 44 (44.0%) reached t2 of SE. Convulsive SE (52.0%, n = 52) was more common than focal SE with impaired consciousness (48.0%, n = 48). Status epilepticus secondary to an acute symptomatic process was the most common (50%, n = 50). Patients meeting t2 of SE demonstrated a remarkably increased risk of mortality (unadjusted analysis-RR 3.606, 95%CI 1.552–8.376, p = 0.003; adjusted analysis-RR 2.924, 95%CI 1.221–7.003, p = 0.016) and unfavorable functional status (unadjusted analysis-RR 1.803, 95%CI 1.280–2.539, p = 0.001; adjusted analysis-RR 1.664, 95%CI 1.184–2.340, p = 0.003) at 3 months compared to those who only reached t1 of SE. Patients reaching t2 of SE were more likely to experience seizure recurrence, however, there was no significant difference between the two cohorts. Conclusions Our study provides strong support for the new definition of SE. Patients meeting t2 of SE tend to have a remarkably increased risk of mortality and unfavorable functional outcomes compared to those who only reached t1 of SE. Furthermore, patients were likely to experience seizure recurrence after undergoing an episode of SE. Physicians must be educated about prompt recognition and appropriate management of SE. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02868-y.
Collapse
|
3
|
Llauradó A, Campos D, Quintana M, Ballvé A, Fonseca E, Abraira L, Giffreu A, Toledo M, Santamarina E. Reponse of second-line treatment in focal status epilepticus: A tertiary hospital experience. Epilepsy Res 2022; 185:106988. [PMID: 35907324 DOI: 10.1016/j.eplepsyres.2022.106988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/02/2022] [Accepted: 07/16/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the response to various antiseizure medications (ASMs) in the treatment of focal status epilepticus (SE) in the established phase, and the effect of administering several ASMs prior to sedation. METHODS All SE cases in patients aged > 16 years treated with non-BZDs ASMs were prospectively collected in our centre from February 2011 to April 2019. In total, 281 episodes were analysed. RESULTS Median age at SE onset was 65.1 years; 47 % were focal motor and 53 % focal non-motor episodes. SE cessation was achieved in 79 % episodes with second-line drugs, whereas a third line (anesthetics) was required in 47 episodes. SE cessation was achieved in only 27 % with the first ASM, 48 % with the second, and 51 % with the third. Prompt resolution of the SE episode with a first or second ASM was associated with a better outcome than episodes requiring a larger number of drugs (p = 0.024). The first option in our sample was levetiracetam in 70 % of cases. Among the total of non-responding SE cases treated with levetiracetam as the first ASM option, 107 were subsequently given lacosamide (seizure cessation in 53.3 %) and 34 valproic acid (seizure cessation in 29.4 %) (p = 0.015). CONCLUSION Our findings further support the notion that early termination of SE with a first or second ASM confers a better functional outcome. The large difference in response between the first ASM and consecutive ones suggests that the sum of different ASMs might be the key to resolving focal SE.
Collapse
Affiliation(s)
| | - Daniel Campos
- Epilepsy Unit. Hospital Vall Hebron, Barcelona, Spain
| | | | | | - Elena Fonseca
- Epilepsy Unit. Hospital Vall Hebron, Barcelona, Spain
| | - Laura Abraira
- Epilepsy Unit. Hospital Vall Hebron, Barcelona, Spain
| | | | - Manuel Toledo
- Epilepsy Unit. Hospital Vall Hebron, Barcelona, Spain
| | | |
Collapse
|
4
|
Benzodiazepines in the Management of Seizures and Status Epilepticus: A Review of Routes of Delivery, Pharmacokinetics, Efficacy, and Tolerability. CNS Drugs 2022; 36:951-975. [PMID: 35971024 PMCID: PMC9477921 DOI: 10.1007/s40263-022-00940-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 02/05/2023]
Abstract
Status epilepticus (SE) is an acute, life-threatening medical condition that requires immediate, effective therapy. Therefore, the acute care of prolonged seizures and SE is a constant challenge for healthcare professionals, in both the pre-hospital and the in-hospital settings. Benzodiazepines (BZDs) are the first-line treatment for SE worldwide due to their efficacy, tolerability, and rapid onset of action. Although all BZDs act as allosteric modulators at the inhibitory gamma-aminobutyric acid (GABA)A receptor, the individual agents have different efficacy profiles and pharmacokinetic and pharmacodynamic properties, some of which differ significantly. The conventional BZDs clonazepam, diazepam, lorazepam and midazolam differ mainly in their durations of action and available routes of administration. In addition to the common intravenous, intramuscular and rectal administrations that have long been established in the acute treatment of SE, other administration routes for BZDs-such as intranasal administration-have been developed in recent years, with some preparations already commercially available. Most recently, the intrapulmonary administration of BZDs via an inhaler has been investigated. This narrative review provides an overview of the current knowledge on the efficacy and tolerability of different BZDs, with a focus on different routes of administration and therapeutic specificities for different patient groups, and offers an outlook on potential future drug developments for the treatment of prolonged seizures and SE.
Collapse
|
5
|
Huertas González N, Barros González A, Hernando Requejo V, Díaz Díaz J. Focal status epilepticus: a review of pharmacological treatment. NEUROLOGÍA (ENGLISH EDITION) 2021; 37:757-766. [DOI: 10.1016/j.nrleng.2019.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 02/27/2019] [Indexed: 11/16/2022] Open
|
6
|
Gutiérrez‐Viedma Á, Parejo‐Carbonell B, Romeral‐Jiménez M, Sanz‐Graciani I, Serrano‐García I, Cuadrado M, García‐Morales I. Therapy delay in status epilepticus extends its duration and worsens its prognosis. Acta Neurol Scand 2021; 143:281-289. [PMID: 33075155 DOI: 10.1111/ane.13363] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/03/2020] [Accepted: 10/09/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Timing in status epilepticus (SE) attention is probably the most relevant modifiable prognostic factor and may influence SE duration and prognosis. We aimed to describe the precise relationship between management timing, duration, and prognosis of SE. METHODS Observational longitudinal prospective study on a cohort of all patients diagnosed with SE admitted to our tertiary hospital from September 2017 to August 2019, with a 3-month follow-up. Univariate and multivariable analyses were performed to identify clinical and timing variables associated with SE duration and prognosis. RESULTS Eighty-three SE affecting 76 patients were included. Median age was 73 years, 61.4% were women, median baseline modified Rankin Scale (mRS) was 2, and 55.4% had prior epilepsy. In the out-of-hospital group (n = 50), median time to emergencies was 1.3 h and to hospital admission 2.8 h. In the global series, median time to neurologist was 4.3 h, and median time to therapy initiation was 4.5 h. These four times positively correlated with SE duration (all Spearman's rho coefficient >0.5, all p < .001). SE median duration was 24 h and was extended 1.2 h for each hour of treatment delay. A longer SE duration was associated with increased mortality and morbidity, both at hospital discharge and at 3-month follow-up (both p < .05). After 3 months, mortality was 30.1%, while recovery to baseline mRS occurred in 39.5%, with an overall median mRS of 4. CONCLUSIONS There were pervasive delays in all phases of SE attention, which conditioned a longer SE duration, and this led to increased long-term morbimortality.
Collapse
Affiliation(s)
- Álvaro Gutiérrez‐Viedma
- Servicio de Neurología Hospital Universitario Fundación Jiménez Díaz Madrid Spain
- Departamento de Medicina Facultad de Medicina Universidad Complutense de Madrid Madrid Spain
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz Madrid Spain
- Unidad de Epilepsia Servicio de Neurología Hospital Clínico San Carlos Madrid Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
| | - Beatriz Parejo‐Carbonell
- Unidad de Epilepsia Servicio de Neurología Hospital Clínico San Carlos Madrid Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
| | - María Romeral‐Jiménez
- Unidad de Epilepsia Servicio de Neurología Hospital Clínico San Carlos Madrid Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
| | - Isabel Sanz‐Graciani
- Unidad de Epilepsia Servicio de Neurología Hospital Clínico San Carlos Madrid Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
| | - Irene Serrano‐García
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
- Unidad de Metodología de Investigación y Epidemiología Clínica Servicio de Medicina Preventiva Hospital Clínico San Carlos Madrid Spain
| | - María‐Luz Cuadrado
- Departamento de Medicina Facultad de Medicina Universidad Complutense de Madrid Madrid Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
- Servicio de Neurología Hospital Clínico San Carlos Madrid Spain
| | - Irene García‐Morales
- Departamento de Medicina Facultad de Medicina Universidad Complutense de Madrid Madrid Spain
- Unidad de Epilepsia Servicio de Neurología Hospital Clínico San Carlos Madrid Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
- Programa de Epilepsia Servicio de Neurología Hospital Ruber Internacional Madrid Spain
| |
Collapse
|
7
|
Vossler DG, Bainbridge JL, Boggs JG, Novotny EJ, Loddenkemper T, Faught E, Amengual-Gual M, Fischer SN, Gloss DS, Olson DM, Towne AR, Naritoku D, Welty TE. Treatment of Refractory Convulsive Status Epilepticus: A Comprehensive Review by the American Epilepsy Society Treatments Committee. Epilepsy Curr 2020; 20:245-264. [PMID: 32822230 PMCID: PMC7576920 DOI: 10.1177/1535759720928269] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose: Established tonic–clonic status epilepticus (SE) does not stop in one-third
of patients when treated with an intravenous (IV) benzodiazepine bolus
followed by a loading dose of a second antiseizure medication (ASM). These
patients have refractory status epilepticus (RSE) and a high risk of
morbidity and death. For patients with convulsive refractory status
epilepticus (CRSE), we sought to determine the strength of evidence for 8
parenteral ASMs used as third-line treatment in stopping clinical CRSE. Methods: A structured literature search (MEDLINE, Embase, CENTRAL, CINAHL) was
performed to identify original studies on the treatment of CRSE in children
and adults using IV brivaracetam, ketamine, lacosamide, levetiracetam (LEV),
midazolam (MDZ), pentobarbital (PTB; and thiopental), propofol (PRO), and
valproic acid (VPA). Adrenocorticotropic hormone (ACTH), corticosteroids,
intravenous immunoglobulin (IVIg), magnesium sulfate, and pyridoxine were
added to determine the effectiveness in treating hard-to-control seizures in
special circumstances. Studies were evaluated by predefined criteria and
were classified by strength of evidence in stopping clinical CRSE (either as
the last ASM added or compared to another ASM) according to the 2017
American Academy of Neurology process. Results: No studies exist on the use of ACTH, corticosteroids, or IVIg for the
treatment of CRSE. Small series and case reports exist on the use of these
agents in the treatment of RSE of suspected immune etiology, severe
epileptic encephalopathies, and rare epilepsy syndromes. For adults with
CRSE, insufficient evidence exists on the effectiveness of brivaracetam
(level U; 4 class IV studies). For children and adults with CRSE,
insufficient evidence exists on the effectiveness of ketamine (level U; 25
class IV studies). For children and adults with CRSE, it is possible that
lacosamide is effective at stopping RSE (level C; 2 class III, 14 class IV
studies). For children with CRSE, insufficient evidence exists that LEV and
VPA are equally effective (level U, 1 class III study). For adults with
CRSE, insufficient evidence exists to support the effectiveness of LEV
(level U; 2 class IV studies). Magnesium sulfate may be effective in the
treatment of eclampsia, but there are only case reports of its use for CRSE.
For children with CRSE, insufficient evidence exists to support either that
MDZ and diazepam infusions are equally effective (level U; 1 class III
study) or that MDZ infusion and PTB are equally effective (level U; 1 class
III study). For adults with CRSE, insufficient evidence exists to support
either that MDZ infusion and PRO are equally effective (level U; 1 class III
study) or that low-dose and high-dose MDZ infusions are equally effective
(level U; 1 class III study). For children and adults with CRSE,
insufficient evidence exists to support that MDZ is effective as the last
drug added (level U; 29 class IV studies). For adults with CRSE,
insufficient evidence exists to support that PTB and PRO are equally
effective (level U; 1 class III study). For adults and children with CRSE,
insufficient evidence exists to support that PTB is effective as the last
ASM added (level U; 42 class IV studies). For CRSE, insufficient evidence
exists to support that PRO is effective as the last ASM used (level U; 26
class IV studies). No pediatric-only studies exist on the use of PRO for
CRSE, and many guidelines do not recommend its use in children aged <16
years. Pyridoxine-dependent and pyridoxine-responsive epilepsies should be
considered in children presenting between birth and age 3 years with
refractory seizures and no imaging lesion or other acquired cause of
seizures. For children with CRSE, insufficient evidence exists that VPA and
diazepam infusion are equally effective (level U, 1 class III study). No
class I to III studies have been reported in adults treated with VPA for
CRSE. In comparison, for children and adults with established convulsive SE
(ie, not RSE), after an initial benzodiazepine, it is likely that loading
doses of LEV 60 mg/kg, VPA 40 mg/kg, and fosphenytoin 20 mg PE/kg are
equally effective at stopping SE (level B, 1 class I study). Conclusions: Mostly insufficient evidence exists on the efficacy of stopping clinical CRSE
using brivaracetam, lacosamide, LEV, valproate, ketamine, MDZ, PTB, and PRO
either as the last ASM or compared to others of these drugs.
Adrenocorticotropic hormone, IVIg, corticosteroids, magnesium sulfate, and
pyridoxine have been used in special situations but have not been studied
for CRSE. For the treatment of established convulsive SE (ie, not RSE), LEV,
VPA, and fosphenytoin are likely equally effective, but whether this is also
true for CRSE is unknown. Triple-masked, randomized controlled trials are
needed to compare the effectiveness of parenteral anesthetizing and
nonanesthetizing ASMs in the treatment of CRSE.
Collapse
Affiliation(s)
| | - Jacquelyn L Bainbridge
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | | | - Edward J Novotny
- 384632University of Washington, Seattle, WA, USA.,Seattle Children's Center for Integrative Brain Research, Seattle, WA, USA
| | | | | | | | - Sarah N Fischer
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - David S Gloss
- Charleston Area Medical Center, Charleston, West Virginia, VA, USA
| | | | - Alan R Towne
- 6889Virginia Commonwealth University, Richmond, VA, USA
| | | | | |
Collapse
|
8
|
Tuppurainen KM, Ritvanen JG, Mustonen H, Kämppi LS. Predictors of mortality at one year after generalized convulsive status epilepticus. Epilepsy Behav 2019; 101:106411. [PMID: 31668580 DOI: 10.1016/j.yebeh.2019.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 07/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Status epilepticus (SE) is a life-threatening neurologic emergency, which requires prompt medical treatment. Little is known of the long-term survival of SE. The aim of this study was to investigate which factors influence 90 days and 1-year mortality after SE. MATERIALS AND METHODS This retrospective study includes all consecutive adult (>16 years) patients (N = 70) diagnosed with generalized convulsive SE (GCSE) in Helsinki University Central Hospital (HUCH) emergency department (ED) over 2 years. We defined specific factors including patient demographics, GCSE characteristics, treatment, complications, delays in treatment, and outcome at hospital discharge and determined their relation to 90 days and 1-year mortality after GCSE by using logistic regression models. Survival analyses at 1 year after GCSE were performed with Cox proportional hazards regression analysis. RESULTS In-hospital mortality was 7.1%. Mortality rate was 14.3% at 90 days and 24.3% at 1 year after GCSE. In the univariate logistic regression analysis, Status Epilepticus Severity Score > 4 (STESS) (ODDS = 7.30, p = 0.012), worse-than-baseline condition at hospital discharge (ODDS = 3.5, p = 0.006), long delays in attaining seizure freedom (ODDS = 2.2, p = 0.041), and consciousness (ODDS = 3.4, p = 0.014) were risk factors for mortality at 90 days whereas epilepsy (ODDS = 0.2, p = 0.014) and Glasgow Outcome Scale (GOS) >3 at hospital discharge (ODDS = 0.05, p = 0.006) were protective factors. Risk factors for mortality at 1 year were STESS >4 (ODDS = 5.1, p = 0.028), use of vasopressors (ODDS = 8.2, p = 0.049), and worse-than-baseline condition at discharge (ODDS = 7.8, p = 0.010) while GOS >3 (ODDS = 0.2, p = 0.005) was protective. The univariate survival analysis at 1 year confirmed the significant findings regarding parameters STESS >4 (Hazard ratio (HR) = 4.1, p = 0.009), worse-than-baseline condition (HR = 6.2, p = 0.015), GOS >3 (HR = 0.2, p = 0.004) at hospital discharge and epilepsy (HR = 0.4, p = 0.044). Additionally, diagnostic delay over 6 h (HR = 3.8, p = 0.022) and Complication Burden Index (CBI) as an ordinal variable (0-2, 3-6, >6) (HR = 2.7, p = 0.027) were predictive for mortality. In the multivariate survival analysis, STESS > 4 (HR = 5.1, p = 0.007), CBI (HR = 3.2, p = 0.025, ordinal variable), diagnostic delay over 6 h (HR = 7.2, p = 0.003), and worse-than-baseline condition at hospital discharge (HR = 5.8, p = 0.027) were all independent risk factors for mortality at 1 year. CONCLUSIONS Severe form of SE, delayed recognition of GCSE, high number of complications during treatment period, and poor condition at hospital discharge are all independent predictors of long-term mortality. Most of these factors are also associated with mortality at 90 days, though at that point, delays in treatment seem to have a greater impact on prognosis than at 1 year. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures.
Collapse
Affiliation(s)
- Kati Marjatta Tuppurainen
- Clinical Neurosciences, Neurology, University of Helsinki and Department of Neurology, Helsinki University Central Hospital, Finland.
| | - Jaakko Gabriel Ritvanen
- Clinical Neurosciences, Neurology, University of Helsinki and Department of Neurology, Helsinki University Central Hospital, Finland.
| | - Harri Mustonen
- Department of Surgery, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.
| | - Leena Sinikka Kämppi
- Clinical Neurosciences, Neurology, University of Helsinki and Department of Neurology, Helsinki University Central Hospital, Finland.
| |
Collapse
|
9
|
Neligan A, Noyce AJ, Gosavi TD, Shorvon SD, Köhler S, Walker MC. Change in Mortality of Generalized Convulsive Status Epilepticus in High-Income Countries Over Time: A Systematic Review and Meta-analysis. JAMA Neurol 2019; 76:897-905. [PMID: 31135807 DOI: 10.1001/jamaneurol.2019.1268] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Status epilepticus (SE) is associated with significant morbidity and mortality. Since the late 1990s, a more aggressive management of prolonged convulsive seizures lasting longer than 5 minutes has been advocated. Objective To determine if convulsive SE mortality has decreased during a time of increasing advocacy for out-of-hospital treatment and escalating and earlier treatment protocols for prolonged seizures and SE. Data Source This systemic review and meta-analysis on studies focused on the mortality of convulsive status epilepticus was conducted by searching MEDLINE, Embase, PsychINFO, CINAHL Plus, and the Cochrane Database of Systematic Reviews between January 1, 1990, and June 30, 2017. Study Selection Studies were excluded if they had fewer than 30 participants (<20 for refractory SE), were limited to SE of single specific etiology or an evaluation of a single treatment modality, or were studies of nonconvulsive SE. Data Extraction and Synthesis Data were abstracted and their quality was assessed via a modified Newcastle-Ottawa scale independently by 2 reviewers (A.N. and T.D.G.) using the Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines. Data were pooled using a random-effects model. Main Outcomes and Measures The main outcome measure was in-hospital mortality or 30-day case fatality expressed as proportional mortality. Results Sixty-one studies were included in the analysis. The pooled mortality ratios were 15.9% (95% CI, 12.7-19.2) for adult studies, 13.0% (95% CI, 7.2-19.0) for all-age population studies, 3.6% (95% CI, 2.0%-5.2%) for pediatric studies, and 17.3% (95% CI, 9.8-24.7) for refractory SE studies, with very high between-study heterogeneity. We found no evidence of a change in prognosis over time nor by the definition of SE used. Conclusions and Relevance The mortality of convulsive SE is higher in adults than in children and there was no evidence for improved survival over time. Although there are many explanations for these findings, they can be explained by aetiology of SE being the major determinant of mortality. However, there are potential confounders, including differences in case ascertainment and study heterogeneity. This meta-analysis highlights the need for strict international guidelines for the study of this condition.
Collapse
Affiliation(s)
- Aidan Neligan
- Homerton University Hospital NHS Foundation Trust, Homerton Row, London, England.,University College London Queen Square Institute of Neurology, Queen Square, London, England.,Preventive Neurology Unit, Wolfson Institute of Preventative Medicine, Queen Mary University of London, London, England
| | - Alastair John Noyce
- University College London Queen Square Institute of Neurology, Queen Square, London, England.,Preventive Neurology Unit, Wolfson Institute of Preventative Medicine, Queen Mary University of London, London, England
| | | | - Simon D Shorvon
- University College London Queen Square Institute of Neurology, Queen Square, London, England
| | - Sebastian Köhler
- Maastricht University Medical Centre, School for Mental Health and Neuroscience, Alzheimer Centre Limburg, Maastricht, the Netherlands
| | - Matthew C Walker
- University College London Queen Square Institute of Neurology, Queen Square, London, England
| |
Collapse
|
10
|
Huertas González N, Barros González A, Hernando Requejo V, Díaz Díaz J. Focal status epilepticus: a review of pharmacological treatment. Neurologia 2019; 37:S0213-4853(19)30044-1. [PMID: 31072691 DOI: 10.1016/j.nrl.2019.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/29/2019] [Accepted: 02/27/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Status epilepticus (SE) is a neurological emergency associated with high morbidity and mortality. One prognostic factor is the type of SE. The purpose of this review is to analyse the most recent recommendations of different scientific societies and expert groups on the treatment of SE, and the latest studies, to assess the literature on the management of focal SE. METHODS We searched PubMed for studies published between 1 August 2008 and 1 August 2018 on the pharmacological treatment of focal SE and its different types in adults. RESULTS We identified 29 publications among reviews, treatment guidelines, meta-analyses, clinical trials, and case series on the treatment of SE. Only 3 of them accounted for whether SE was focal or generalised; 4 focused exclusively on focal SE, and 7 differentiated between convulsive and non-convulsive SE and also record the presence of focal seizures. Treatment recommendations for focal SE do not differ from those of generalised SE in stages I and II: initially intravenous lorazepam or diazepam, if the intravenous route is available, and otherwise intramuscular midazolam, followed by intravenous phenytoin, valproate, levetiracetam, or lacosamide if seizures persist. Use of anaesthetic drugs should be delayed for as long as possible in patients with refractory focal SE. CONCLUSIONS The available scientific evidence is insufficient to claim that pharmacological treatment of focal SE should be different from treatment for generalised SE. More studies with a greater number of patients are needed.
Collapse
Affiliation(s)
- N Huertas González
- Servicio de Neurología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España.
| | - A Barros González
- Servicio de Neurología, Sankt Katharinen Hospital, Frechen, Alemania
| | - V Hernando Requejo
- Servicio de Neurología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España
| | - J Díaz Díaz
- Servicio de Neurología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España
| |
Collapse
|
11
|
Kellinghaus C, Rossetti AO, Trinka E, Lang N, May TW, Unterberger I, Rüegg S, Sutter R, Strzelczyk A, Tilz C, Uzelac Z, Rosenow F. Factors predicting cessation of status epilepticus in clinical practice: Data from a prospective observational registry (SENSE). Ann Neurol 2019; 85:421-432. [PMID: 30661257 DOI: 10.1002/ana.25416] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 01/15/2019] [Accepted: 01/15/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate the initial termination rate of status epilepticus (SE) in a large observational study and explore associated variables. METHODS Data of adults treated for SE were collected prospectively in centers in Germany, Austria, and Switzerland, during 4.5 years. Incident episodes of 1,049 patients were analyzed using uni- and multivariate statistics to determine factors predicting cessation of SE within 1 hour (for generalized convulsive SE [GCSE]) and 12 hours (for non-GCSE) of initiating treatment. RESULTS Median age at SE onset was 70 years; most frequent etiologies were remote (32%) and acute (31%). GCSE was documented in 43%. Median latency between SE onset and first treatment was 30 minutes in GCSE and 150 minutes in non-GCSE. The first intravenous compound was a benzodiazepine in 86% in GCSE and 73% in non-GCSE. Bolus doses of the first treatment step were lower than recommended by current guidelines in 76% of GCSE patients and 78% of non-GCSE patients. In 319 GCSE patients (70%), SE was ongoing 1 hour after initiating treatment and in 342 non-GCSE patients (58%) 12 hours after initiating treatment. Multivariate Cox regression demonstrated that use of benzodiazepines as first treatment step and a higher cumulative dose of anticonvulsants within the first period of treatment were associated with shorter time to cessation of SE for both groups. INTERPRETATION In clinical practice, treatment guidelines were not followed in a substantial proportion of patients. This underdosing correlated with lack of cessation of SE. Our data suggest that sufficiently dosed benzodiazepines should be used as a first treatment step. ANN NEUROL 2019;85:421-432.
Collapse
Affiliation(s)
- Christoph Kellinghaus
- Department of Neurology, Klinikum Osnabrück, Osnabrück, Germany.,Epilepsy Center Münster-Osnabrück, Campus Osnabrück, Osnabrück, Germany
| | - Andrea O Rossetti
- Department of Clinical Neurosciences, CHUV and University of Lausanne, Lausanne, Switzerland
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.,Centre for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Nicolas Lang
- Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | - Iris Unterberger
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Medical Intensive Care Units and Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Adam Strzelczyk
- Epilepsy Center Hessen-Marburg, Department of Neurology, University Hospitals and Philipps-University Marburg, Marburg, Germany.,Epilepsy Center Frankfurt Rhein-Main, Department of Neurology, University Hospital Frankfurt and Goethe University, Frankfurt, Germany
| | - Christian Tilz
- Department of Neurology, Krankenhaus Barmherzige Brüder, Regensburg, Germany
| | - Zeljko Uzelac
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | - Felix Rosenow
- Epilepsy Center Hessen-Marburg, Department of Neurology, University Hospitals and Philipps-University Marburg, Marburg, Germany.,Epilepsy Center Frankfurt Rhein-Main, Department of Neurology, University Hospital Frankfurt and Goethe University, Frankfurt, Germany
| |
Collapse
|
12
|
Kämppi L, Mustonen H, Kotisaari K, Soinila S. The essence of the first 2.5 h in the treatment of generalized convulsive status epilepticus. Seizure 2018; 55:9-16. [DOI: 10.1016/j.seizure.2017.12.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/20/2017] [Accepted: 12/27/2017] [Indexed: 12/29/2022] Open
|
13
|
Hill CE, Parikh AO, Ellis C, Myers JS, Litt B. Timing is everything: Where status epilepticus treatment fails. Ann Neurol 2017; 82:155-165. [PMID: 28681473 DOI: 10.1002/ana.24986] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/07/2017] [Accepted: 06/25/2017] [Indexed: 12/27/2022]
Abstract
Status epilepticus is an emergency; however, prompt treatment of patients with status epilepticus is challenging. Clinical trials, such as the ESETT (Established Status Epilepticus Treatment Trial), compare effectiveness of antiepileptic medications, and rigorous examination of effectiveness of care delivery is similarly warranted. We reviewed the medical literature on observed deviations from guidelines, clinical significance, and initiatives to improve timely treatment. We found pervasive, substantial gaps between recommended and "real-world" practice with regard to timing, dosing, and sequence of antiepileptic therapy. Applying quality improvement methodology at the institutional level can increase adherence to guidelines and may improve patient outcomes. Ann Neurol 2017;82:155-165.
Collapse
Affiliation(s)
- Chloe E Hill
- Department of Neurology, University of Pennsylvania, Philadelphia, PA.,Center for Healthcare Improvement and Patient Safety, University of Pennsylvania, Philadelphia, PA
| | - Alomi O Parikh
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
| | - Colin Ellis
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
| | - Jennifer S Myers
- Center for Healthcare Improvement and Patient Safety, University of Pennsylvania, Philadelphia, PA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Brian Litt
- Department of Neurology, University of Pennsylvania, Philadelphia, PA.,Department of Bioengineering, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
14
|
Sánchez Fernández I, Gaínza-Lein M, Loddenkemper T. Nonintravenous rescue medications for pediatric status epilepticus: A cost-effectiveness analysis. Epilepsia 2017. [DOI: 10.1111/epi.13812] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
- Department of Child Neurology; Hospital Sant Joan de Déu; Universidad de Barcelona; Barcelona Spain
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
- Universidad Austral de Chile; Valdivia Chile
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology; Department of Neurology; Boston Children's Hospital; Harvard Medical School; Boston Massachusetts U.S.A
| |
Collapse
|
15
|
Redecker J, Wittstock M, Rösche J. The efficacy of different kinds of intravenously applied antiepileptic drugs in the treatment of status epilepticus. How can it be determined? Epilepsy Behav 2017; 71:35-38. [PMID: 28460320 DOI: 10.1016/j.yebeh.2017.03.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Revised: 03/07/2017] [Accepted: 03/07/2017] [Indexed: 11/18/2022]
Abstract
We explored the influence of four different efficacy criteria on the results of observational studies concerning the treatment of status epilepticus (SE) and its subtypes. We compared and contrasted the results of four different efficacy criteria for the effectiveness of phenytoin, valproate, levetiracetam, and lacosamide. Criterion 1=the last antiepileptic drug (AED) administered before SE termination. Criterion 2=the last drug introduced into the antiepileptic therapy within 72h before the cessation of SE and without changes in dosage or number of the co-medication. Criterion 3=the last drug introduced into the antiepileptic therapy or increased in dose within 24h before termination of the SE without changes in the co-medication. Criterion 4=the last drug introduced into the antiepileptic therapy within 72h before the cessation of SE even allowing changes in the co-medication. We used two-tailed χ2-tests with the Yates adjustment for small samples to evaluate statistical differences between efficacy rates of different AEDs in the entire group and in subgroups of SE according to the second level of subdivisions in axis 1 and according to axis 2 of the new ILAE classification. A total of 145 treatment episodes in 124 patients (47 male, 77 female) were evaluated. There were 23 significant differences in efficacy according to the different criteria. Only criteria 1 and 3 led to significant results in our analysis. When incorporating theoretical considerations and the results of this study, criterion 3 seems to be the most appropriate measure for the evaluation of efficacy of an AED in the treatment of SE, because it seems to be more reasonable than criterion 1.
Collapse
Affiliation(s)
| | | | - Johannes Rösche
- Department of Neurology, University of Rostock, Germany; Swiss Epilepsy-center, Zurich, Switzerland.
| |
Collapse
|
16
|
[Can treatment with anesthetic anticonvulsive drugs worsen outcome in status epilepticus?]. Med Klin Intensivmed Notfmed 2017; 113:108-114. [PMID: 28251258 DOI: 10.1007/s00063-017-0269-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 09/25/2016] [Accepted: 01/27/2017] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND OBJECTIVES Nowadays, there is an ongoing discussion about the risks and benefits of anesthetic treatment concerning outcome in status epilepticus (SE). Therefore, we performed a retrospective database analysis to examine the influence of treatment with anesthetic drugs and narcosis in SE on mortality and disability. METHODS All treatment episodes of SE at the Department of Neurology of the University of Rostock between 01 January 2000 and 31 December 2009 were evaluated. SE severity before treatment, mortality, and disability at discharge were taken into account. RESULTS Of 167 treatment episodes of SE, 34 included treatment with anesthetic anticonvulsive drugs and narcosis. In the treatment episodes with use of anesthetic anticonvulsive drugs and narcosis, there was a more than twofold increased risk for death compared to the other treatment episodes. However, due to sample size this difference was not significant (p = 0.09). Cardiopulmonary complications were the cause of death in 4 of 5 patients dying during treatment episodes with anesthetic anticonvulsive drugs and narcosis. At discharge, disability as measured with the Modified Rankin Scale was higher in patients treated with anesthetic anticonvulsive drugs and narcosis than in the others (p = 0.03). A subgroup analysis revealed that especially in patients with nonconvulsive SE with impaired consciousness treatment with narcosis was associated with a higher rate of new deficits or mortality (p = 0.012). CONCLUSIONS Especially when considering narcosis for treatment of nonconvulsive SE, risks and benefits should be carefully weighed. When treating SE with anesthetic drugs and narcosis, everything has to be done to avoid cardiopulmonary complications.
Collapse
|
17
|
Cheng JY. Latency to treatment of status epilepticus is associated with mortality and functional status. J Neurol Sci 2016; 370:290-295. [PMID: 27772779 DOI: 10.1016/j.jns.2016.10.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 09/01/2016] [Accepted: 10/05/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Status epilepticus (SE) is a life-threatening neurologic emergency. Despite advances in management, in-hospital mortality remains unchanged. This is partly due to the pharmacoresistance which develops the longer that seizures persist. Therefore, rapid antiseizure medication (ASM) administration may represent a beneficial treatment option. The purpose of this study was to determine: 1) whether in-hospital mortality is reduced with shorter latencies to initial treatment of SE with an ASM (LTSE); and 2) the critical time frame during which LTSE is associated with reduced in-hospital mortality. MATERIALS AND METHODS This was a retrospective, single-center study of adults diagnosed with SE between 1/1/2005 and 10/31/2012. Demographic characteristics included seizure history, etiology, semiology, and duration. Subjects were assigned to LTSE groups at the time frames of 5, 10, 30 and 60min. The primary outcome was in-hospital mortality, with poor functional status (mRS 3-6) as a secondary measure. Pearson's chi-square, Mann-Whitney-U, two-sample-t-tests, and binary logistic regression analysis were used as appropriate, with p<0.05. RESULTS In unadjusted analysis, LTSE>30min demonstrated increased risk of mortality (OR 2.06, CI 1.01-4.17, p=0.046) and poor functional status (OR 2.48, CI 1.05-5.85, p=0.038) compared to LTSE≤30min. Increased mortality risk remained after adjusting for SE duration (OR 2.07, CI 1.01-4.26, p=0.047) and nonconvulsive seizures (OR 2.28, CI 1.08-4.80, p=0.03). Compared to subjects treated within 60min, those treated after 60min were at increased risk of poor functional status, regardless of the presence of nonconvulsive seizures (OR 2.96, CI 1.14-7.73, p=0.026). In addition, when acute symptomatic SE was stratified by cardiac versus non-cardiac etiologies, subjects with non-cardiac acute symptomatic SE demonstrated worse functional outcome when treated after 60min (OR 7.20, CI 1.13-46.07, p=0.037). CONCLUSIONS Treatment of SE within 30min of onset is associated with reduced risk of in-hospital mortality and poor functional status, although this may be attenuated by acute symptomatic seizures related to cardiac arrest. This represents a therapeutic option which has the potential to benefit patient outcomes.
Collapse
Affiliation(s)
- Jocelyn Y Cheng
- NYU Langone Comprehensive Epilepsy Center, NYU School of Medicine, 223 E. 34th Street, New York, NY 10016, USA; Drexel University College of Medicine, Department of Neurology, 245 N. 15th Street, MS 423, Philadelphia, PA 19102, USA.
| |
Collapse
|
18
|
Crisis afásica simulando un ataque cerebrovascular isquémico agudo en el Servicio de Neurología del Hospital de San José de Bogotá DC. REPERTORIO DE MEDICINA Y CIRUGÍA 2016. [DOI: 10.1016/j.reper.2016.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
19
|
Abstract
OPINION STATEMENT Convulsive status epilepticus (CSE) is a medical emergency with an associated high mortality and morbidity. It is defined as a convulsive seizure lasting more than 5 min or consecutive seizures without recovery of consciousness. Successful management of CSE depends on rapid administration of adequate doses of anti-epileptic drugs (AEDs). The exact choice of AED is less important than rapid treatment and early consideration of reversible etiologies. Current guidelines recommend the use of benzodiazepines (BNZ) as first-line treatment in CSE. Midazolam is effective and safe in the pre-hospital or home setting when administered intramuscularly (best evidence), buccally, or nasally (the latter two possibly faster acting than intramuscular (IM) but with lower levels of evidence). Regular use of home rescue medications such as nasal/buccal midazolam by patients and caregivers for prolonged seizures and seizure clusters may prevent SE, prevent emergency room visits, improve quality of life, and lower health care costs. Traditionally, phenytoin is the preferred second-line agent in treating CSE, but it is limited by hypotension, potential arrhythmias, allergies, drug interactions, and problems from extravasation. Intravenous valproate is an effective and safe alternative to phenytoin. Valproate is loaded intravenously rapidly and more safely than phenytoin, has broad-spectrum efficacy, and fewer acute side effects. Levetiracetam and lacosamide are well tolerated intravenous (IV) AEDs with fewer interactions, allergies, and contraindications, making them potentially attractive as second- or third-line agents in treating CSE. However, data are limited on their efficacy in CSE. Ketamine is probably effective in treating refractory CSE (RCSE), and may warrant earlier use; this requires further study. CSE should be treated aggressively and quickly, with confirmation of treatment success with epileptiform electroencephalographic (EEG), as a transition to non-convulsive status epilepticus is common. If the patient is not fully awake, EEG should be continued for at least 24 h. How aggressively to treat refractory non-convulsive SE (NCSE) or intermittent non-convulsive seizures is less clear and requires additional study. Refractory SE (RSE) usually requires anesthetic doses of anti-seizure medications. If an auto-immune or paraneoplastic etiology is suspected or no etiology can be identified (as with cryptogenic new onset refractory status epilepticus, known as NORSE), early treatment with immuno-modulatory agents is now recommended by many experts.
Collapse
|
20
|
|
21
|
Delays and Factors Related to Cessation of Generalized Convulsive Status Epilepticus. EPILEPSY RESEARCH AND TREATMENT 2015; 2015:591279. [PMID: 26347816 PMCID: PMC4546976 DOI: 10.1155/2015/591279] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 07/13/2015] [Indexed: 11/17/2022]
Abstract
Introduction. This study was designed to identify the delays and factors related to and predicting the cessation of generalized convulsive SE (GCSE). Methods. This retrospective study includes 70 consecutive patients (>16 years) diagnosed with GCSE and treated in the emergency department of a tertiary hospital over 2 years. We defined cessation of SE stepwise using clinical seizure freedom, achievement of burst-suppression, and return of consciousness as endpoints and calculated delays for these cessation markers. In addition 10 treatment delay parameters and 7 prognostic and GCSE episode related factors were defined. Multiple statistical analyses were performed on their relation to cessation markers. Results. Onset-to-second-stage-medication (p = 0.027), onset-to-burst-suppression (p = 0.005), and onset-to-clinical-seizure-freedom (p = 0.035) delays correlated with the onset-to-consciousness delay. We detected no correlation between age, epilepsy, STESS, prestatus period, type of SE onset, effect of the first medication, and cessation of SE. Conclusion. Our study demonstrates that rapid administration of second-stage medication and early obtainment of clinical seizure freedom and burst-suppression predict early return of consciousness, an unambiguous marker for the end of SE. We propose that delays in treatment chain may be more significant determinants of SE cessation than the previously established outcome predictors. Thus, streamlining the treatment chain is advocated.
Collapse
|
22
|
Löscher W. Single versus combinatorial therapies in status epilepticus: Novel data from preclinical models. Epilepsy Behav 2015; 49:20-5. [PMID: 25819944 DOI: 10.1016/j.yebeh.2015.02.027] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 02/22/2015] [Indexed: 12/30/2022]
Abstract
Drug-refractory status epilepticus (RSE) is a major medical emergency with a mortality of up to 40% and the risk of severe long-term consequences. The mechanisms involved in RSE are incompletely understood. Animal models are important in developing treatment strategies for more effective termination of SE and prevention of its long-term outcomes. The pilocarpine and lithium-pilocarpine rat models are widely used in this respect. In these models, resistance to diazepam and other antiseizure drugs (ASDs) develops during SE so that an SE that is longer than 30 min is difficult to suppress. Furthermore, because all ASDs used in SE treatment are much more rapidly eliminated by rodents than by humans, SE recurs several hours after ASD treatment. Long-term consequences include hippocampal damage, behavioral alterations, and epilepsy with spontaneous recurrent seizures. In this review, different rational polytherapies for SE, which are more effective than monotherapies, are discussed, including a novel polytherapy recently developed by our group. Based on data from diverse seizure models, we hypothesized that cholinergic mechanisms are involved in the mechanisms underlying ASD resistance of SE. We, therefore, developed an intravenous drug cocktail, consisting of diazepam, phenobarbital, and the anticholinergic scopolamine. This drug combination irreversibly terminated SE when administered 60, 90, or 120 min after SE onset. The efficacy of this cocktail in terminating SE was comparable with the previously reported efficacy of polytherapies with the glutamate receptor antagonist ketamine. Furthermore, when injected 60 min after SE onset, the scopolamine-containing cocktail prevented development of epilepsy and hippocampal neurodegeneration, which was not observed with high doses of diazepam or a combination of phenobarbital and diazepam. Our data add to the existing preclinical evidence that rational polytherapy can be more effective than monotherapy in the treatment of SE and that combinatorial therapy may offer a clinically useful option for the treatment of RSE. This article is part of a Special Issue entitled "Status Epilepticus".
Collapse
Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, 30559 Hannover, Germany; Center for Systems Neuroscience, 30559 Hannover, Germany.
| |
Collapse
|
23
|
Alvarez V, Lee JW, Drislane FW, Westover MB, Novy J, Dworetzky BA, Rossetti AO. Practice variability and efficacy of clonazepam, lorazepam, and midazolam in status epilepticus: A multicenter comparison. Epilepsia 2015; 56:1275-85. [PMID: 26140660 DOI: 10.1111/epi.13056] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Benzodiazepines (BZD) are recommended as first-line treatment for status epilepticus (SE), with lorazepam (LZP) and midazolam (MDZ) being the most widely used drugs and part of current treatment guidelines. Clonazepam (CLZ) is also utilized in many countries; however, there is no systematic comparison of these agents for treatment of SE to date. METHODS We identified all patients treated with CLZ, LZP, or MDZ as a first-line agent from a prospectively collected observational cohort of adult patients treated for SE in four tertiary care centers. Relative efficacies of CLZ, LZP, and MDZ were compared by assessing the risk of developing refractory SE and the number of antiseizure drugs (ASDs) required to control SE. RESULTS Among 177 patients, 72 patients (40.62%) received CLZ, 82 patients (46.33%) LZP, and 23 (12.99%) MDZ; groups were similar in demographics and SE characteristics. Loading dose was considered insufficient in the majority of cases for LZP, with a similar rate (84%, 95%, and 87.5%) in the centers involved, and CLZ was used as recommended in 52% of patients. After adjustment for relevant variables, LZP was associated with an increased risk of refractoriness as compared to CLZ (odds ratio [OR] 6.4, 95% confidence interval [CI] 2.66-15.5) and with an increased number of ASDs needed for SE control (OR 4.35, 95% CI 1.8-10.49). SIGNIFICANCE CLZ seems to be an effective alternative to LZP and MDZ. LZP is frequently underdosed in this setting. These findings are highly relevant, since they may impact daily practice.
Collapse
Affiliation(s)
- Vincent Alvarez
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Neurology, Valais Hospital, Sion, Switzerland
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Frank W Drislane
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Jan Novy
- Department of Clinical Neurosciences, CHUV and University of Lausanne, Lausanne, Switzerland
| | - Barbara A Dworetzky
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Andrea O Rossetti
- Department of Clinical Neurosciences, CHUV and University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
24
|
Shangguan Y, Liao H, Wang X. Clonazepam in the treatment of status epilepticus. Expert Rev Neurother 2015; 15:733-40. [DOI: 10.1586/14737175.2015.1056781] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
25
|
Redecker J, Wittstock M, Benecke R, Rösche J. Efficacy of perampanel in refractory nonconvulsive status epilepticus and simple partial status epilepticus. Epilepsy Behav 2015; 45:176-9. [PMID: 25819947 DOI: 10.1016/j.yebeh.2015.01.036] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Revised: 01/27/2015] [Accepted: 01/28/2015] [Indexed: 12/24/2022]
Abstract
We provide some evidence concerning the efficacy of perampanel (PER) in refractory status epilepticus (SE). We retroactively identified patients with SE treated in our department by searching for the term "status epilepticus" in the electronic archive of medical records. We present and analyze in this paper the subset of data of the patients treated with PER. We analyzed ten episodes of SE in nine patients. At the first administration, PER was given in a dosage of 6mg to most of our patients (7 of 10). On average, PER was administered as the 6th antiepileptic drug (AED) (range: 2-10). Depending on the criterion for efficacy, PER appears effective for the termination of SE in 2 to 6 (of 10) episodes. Unfortunately, safety data for the administration of PER with loading doses needed for the treatment of SE are lacking. Because of this, PER should be used very carefully in refractory SE and only after first-line treatment options have failed.
Collapse
Affiliation(s)
- Juliane Redecker
- Klinik und Poliklinik für Neurologie, Universität Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany.
| | - Matthias Wittstock
- Klinik und Poliklinik für Neurologie, Universität Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany.
| | - Reiner Benecke
- Klinik und Poliklinik für Neurologie, Universität Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany.
| | - Johannes Rösche
- Klinik und Poliklinik für Neurologie, Universität Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany.
| |
Collapse
|