Factors associated with the duration of the postictal state after a generalized convulsion

Clinical and intracranial electrophysiological signatures of post-operative and post-ictal delirium

OBJECTIVES

(1) Gain insight into the mechanisms of postoperative delirium (POD). (2) Determine mechanistic overlap with post-ictal delirium (PID). Epilepsy patients undergoing intracranial electrophysiological monitoring can experience both POD and PID, and thus are suitable subjects for these investigations.

METHODS

POD was assessed daily after surgery. PID was assessed following seizures. Resting state data were collected following delirium assessments, during a control period, and during sleep. Slow-wave activity (SWA: 1-4 Hz) and resting state functional connectivity were compared between different time points and according to delirium status.

RESULTS

POD was present in 6 of 20 participants. Post-operatively, SWA was globally elevated in all participants but highest in POD+ participants. POD+ participants exhibited altered functional connectivity compared to POD-. These differences persisted even after resolution of delirium. PID was present in 7 of 15 participants and was predicted by seizures involving prefrontal cortex. PID+ participants exhibited higher post-ictal SWA versus PID-; no differences in functional connectivity were observed. Post-operative and post-ictal SWA was comparable to sleep in some participants.

CONCLUSIONS

Elevated SWA may predispose patients to both post-operative and post-ictal delirium and may indicate overlapping mechanisms.

SIGNIFICANCE

Delirium treatments focused on SWA may be most effective for ameliorating cognitive symptoms.

Relationship between continuous EEG monitoring findings and prognostic factors in patients with status epilepticus

BACKGROUND AND PURPOSE

Little information is available regarding the use of continuous electroencephalography (cEEG) monitoring findings to predict the prognosis of patients with status epilepticus, which could aid in prognostication. This study investigated the relationship between cEEG monitoring findings and various prognostic indicators in patients with status epilepticus.

METHODS

We reviewed the clinical profiles and cEEG monitoring data of 28 patients with status epilepticus over a ten-year period. Patient demographics, etiology, EEG features, duration of hospital stay, number of antiseizure medications, and outcome measures were analyzed. Functional outcomes were assessed using the modified Rankin Scale (mRS), which evaluates the degree of daily living impairment and dependence on others resulting from neurological injury.

RESULTS

Patients exhibiting electrographic status epilepticus (ESE) demonstrated significantly longer duration of status epilepticus (77.75 ± 58.25 vs. 39.86 ± 29.81 h, p = 0.024) and total length of hospital stay (13.00 ± 6.14 vs. 8.14 ± 5.66 days, p = 0.038) when compared to those with ictal-interictal continuum (IIC). Individuals who displayed any increase in modified Rankin Scale (mRS) score between their premorbid state and discharge also had significantly longer duration of status epilepticus (74.09 ± 34.94 vs. 51.56 ± 54.25 h, p = 0.041) and total length of hospital stay (15.89 ± 6.05 vs. 8.05 ± 4.80 days, p = 0.004) when compared to those who showed no difference. The most prevalent etiology of status epilepticus in our study was chronic structural brain lesions.

CONCLUSIONS

This suggests that ESE may serve as a predictor of prolonged duration of status epilepticus and increased hospitalization among patients with status epilepticus.

Developing feasible person-centred care alternatives to emergency department responses for adults with epilepsy: a discrete choice analysis mixed-methods study

Background

Calls have been made for paramedics to have some form of care pathway that they could use to safely divert adults with epilepsy away from emergency departments and instigate ambulatory care improvements. Different configurations are possible. To know which to prioritise for implementation/evaluation, there is a need to determine which are acceptable to service users and likely National Health Service-feasible.

Objective(s)

(1) Identify configurations being considered, (2) understand service users' views of them and current provision, (3) identify what sort of care service users want and (4) determine which configuration(s) is considered to achieve optimal balance in meeting users' preference and being National Health Service-feasible.

Design

Service providers were surveyed to address objective 1. Interviews with service users addressed objective 2. Objective 3 was addressed by completing discrete choice experiments. These determined users' care preferences for different seizure scenarios. Objective 4 was addressed by completing 'knowledge exchange' workshops. At these, stakeholders considered the findings on users' stated preferences and judged different pathway configurations against Michie's 'acceptability, practicability, effectiveness, affordability, side-effects and equity' feasibility criteria.

Setting

This project took place in England. The survey recruited representatives from neurology and neuroscience centres and from urgent and emergency care providers. For the interviews, recruitment occurred via third-sector support groups. Recruitment for discrete choice experiments occurred via the North West Ambulance Service NHS Trust and public advert. Workshop participants were recruited from neurology and neuroscience centres, urgent and emergency care providers, support groups and commissioning networks.

Participants

Seventy-two services completed the survey. Interviews were conducted with 25 adults with epilepsy (and 5 relatives) who had emergency service contact in the prior 12 months. Discrete choice experiments were completed by 427 adults with epilepsy (and 167 relatives) who had ambulance service contact in the prior 12 months. Workshops were completed with 27 stakeholders.

Results

The survey identified a range of pathway configurations. They differed in where they would take the patient and their potential to instigate ambulatory care improvements. Users had been rarely consulted in designing them. The discrete choice experiments found that users want a configuration of care markedly different to that offered. Across the seizure scenarios, users wanted their paramedic to have access to their medical records; for an epilepsy specialist (e.g. an epilepsy nurse, neurologist) to be available to advise; for their general practitioner to receive a report; for the incident to generate an appointment with an epilepsy specialist; for the care episode to last < 6 hours; and there was a pattern of preference to avoid conveyance to emergency departments and stay where they were. Stakeholders judged this configuration to be National Health Service-feasible within 5-10 years, with some elements being immediately deployable.

Limitations

The discrete choice experiment sample was broadly representative, but those reporting recent contact with an epilepsy specialist were over-represented.

Conclusions

Users state they want a configuration of care that is markedly different to current provision. The configuration they prefer was, with support and investment, judged to likely be National Health Service-feasible. The preferred configuration should now be developed and evaluated to determine its actual deliverability and efficacy.

Study registration

The study is registered as researchregistry4723.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/05/62) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 24. See the NIHR Funding and Awards website for further award information.

Late onset epilepsy and stroke: Diagnosis, pathogenesis and prevention

The association of stroke and late-onset epilepsy (LOE) is discussed with special regard to its diagnosis, pathogenesis, and prevention. In addition to epidemiological data, including those from different age groups, the mechanisms for the development of acute symptomatic and remote symptomatic seizures are reviewed. The risk factors associated with seizures and post-stroke epilepsy (PSE) are considered, along with the methodological limitations of the study. For future research, the distinction between acute and remote symptomatic seizure before or after seven days from stroke onset should be reviewed because different acute symptomatic seizures (ASSs) themselves can entail a variable PSE risk. The definition of LOE by age is hitherto inconsistent. Comparing adult lifespan epochs, it is evident that stroke and seizures exhibit similar prevalence profiles. Young adulthood, old adulthood, and elderly epochs may be relevant for the differentiation of LOE subtype by age, vascular comorbidity, and other characteristics. A step-scheme strategy as a possible contribution to cerebrovascular prevention approaches is proposed.

Developing an alternative care pathway for emergency ambulance responses for adults with epilepsy: A Discrete Choice Experiment to understand which configuration service users prefer. Part of the COLLABORATE project

INTRODUCTION

To identify service users' preferences for an alternative care pathway for adults with epilepsy presenting to the ambulance service.

METHODS

Extensive formative work (qualitative, survey and knowledge exchange) informed the design of a stated preference discrete choice experiment (DCE). This hypothetical survey was hosted online and consisted of 12 binary choices of alternative care pathways described in terms of: the paramedic's access to medical records/ 'care plan', what happens next (described in terms of conveyance), time, availability of epilepsy specialists today, general practitioner (GP) notification and future contact with epilepsy specialists. DCE scenarios were described as: (i) typical seizure at home. (ii) typical seizure in public, (iii) atypical seizure. Respondents were recruited by a regional English ambulance service and by national public adverts. Participants were randomised to complete 2 of the 3 DCEs.

RESULTS

People with epilepsy (PWE; n = 427) and friends/family (n = 167) who completed the survey were representative of the target population. PWE preferred paramedics to have access to medical records, non-conveyance, to avoid lengthy episodes of care, availability of epilepsy specialists today, GP notification, and contact with epilepsy specialists within 2-3 weeks. Significant others (close family members or friends) preferred PWE experiencing an atypical seizure to be conveyed to an Urgent Treatment Centre and preferred shorter times. Optimal configuration of services from service users' perspective far out ranked current practice (rank 230/288 possible configurations).

DISCUSSION

Preferences differ to current practice but have minimal variation by seizure type or stakeholder. Further work on feasibility of these pathways in England, and potentially beyond, is required.

Transient postictal dysphagia in older adults with focal structural epilepsy

OBJECTIVE

Seizures can cause transient neurological symptoms, such as hemiparesis and aphasia. However, temporary swallowing changes leading to postictal dysphagia have not been previously described. Therefore, this study evaluated the presence of swallowing disorders following seizure. In addition, dysphagia severity and duration of any recovery from dysphagic symptoms were investigated.

METHODS

The local clinical database of all fiberoptic endoscopic evaluation of swallowing (FEES) examinations performed from 2008 to 2019 was screened for patients diagnosed with seizures, but excluding patients with intensive care unit admission or intubation >24 h. Patient charts were evaluated to identify preexisting dysphagia or potential concurrent medical causes for dysphagia, including hyponatremia, increased intracranial pressure, sepsis, or other encephalopathies associated with infections, or other possible causes at the time of admission. Patients receiving >.5 defined daily doses of benzodiazepines or neuroleptics were also excluded. Age, sex, seizure semiology and etiology, comorbidities, concurrent pneumonia, and dysphagia course during hospitalization were evaluated as predictors of the occurrence of dysphagia or its potential duration.

RESULTS

We identified 41 patients with dysphagia following a seizure, without evidence of any concurrent cause of swallowing dysfunction. These patients all presented with focal structural epilepsy, they had a mean age of 79 ± 11.3 years (range = 44-95 years), and 21 were women. The mean Elixhauser Comorbidity Score was 4.8. Hospital-acquired pneumonia was detected in 21 patients (51.2%). FEES diagnosed mild and severe dysphagia in 21 (51.2%) and 20 (48.8%) patients, respectively. Dysphagia improved significantly (p = .001) during hospitalization, persisting for an average of 3.9 days (median = 3 days, SD = 2.07 days, range = 1-8 days).

SIGNIFICANCE

Dysphagia is a potential transient neurological deficit following seizure. Our findings suggest that older patients, with focal structural epilepsy, are at risk for postictal dysphagia. Further studies are needed to ascertain the prevalence, complications, and predictors of postictal dysphagia. Dysphagia screening may improve early detection in patients with relevant risk factors, as well as reduce the occurrence of aspiration pneumonia.

Factors affecting seizure recurrence in the emergency department

Background

Information on Emergency Department (ED) follow-up of patients presenting with epileptic seizures is limited.

Objectives

It was planned to investigate the factors affecting the recurrence of epileptic seizures in the follow-up of patients presenting to the ED with the complaint of epileptic seizures.

Materials and methods

This prospective, observational, single-center study was carried out in an adult population presenting to the ED. The study included patients older than 18 years of age presenting to the ED with the complaint of epileptic seizures.

Results

Of the 205 patients included in the study, 68 (33.2%) had seizure recurrence during the 6 h. In the univariable analysis, advanced age, prolonged post-ictal duration, increased seizure duration, generalized tonic clonic seizure, alcohol consumption within past 24 h, hypertension, coronary artery disease, Alzheimer's disease, prior ischemic cerebrovascular disease, low Glascow Coma Scale (GCS), high glucose, high C-Reactive Protein, high phosphorus, low potassium, high blood urea nitrogen, high lactate, increased anion gap, high osmolarity were statistically significant in predicting recurrent seizure recurrence within 6 h. According to the logistic regression, postictal duration, GCS score, and age were independent predictors in our model. The cut-off value of postictal duration in predicting seizure recurrence at the highest sensitivity (66.2%) and specificity (89.8%) was 22.5 min.

Conclusion

A prolonged postictal state, low GCS score, advanced age may be an indication of seizure recurrence. Therefore, patients with a long postictal duration, low GCS score, advanced age should be followed up more carefully in terms of recurrent seizures in the ED.

Changes in postictal cerebral perfusion are related to the duration of electroconvulsive therapy-induced seizures

OBJECTIVE

Postictal symptoms may result from cerebral hypoperfusion, which is possibly a consequence of seizure-induced vasoconstriction. Longer seizures have previously been shown to cause more severe postictal hypoperfusion in rats and epilepsy patients. We studied cerebral perfusion after generalized seizures elicited by electroconvulsive therapy (ECT) and its relation to seizure duration.

METHODS

Patients with a major depressive episode who underwent ECT were included. During treatment, 21-channel continuous electroencephalogram (EEG) was recorded. Arterial spin labeling magnetic resonance imaging scans were acquired before the ECT course (baseline) and approximately 1 h after an ECT-induced seizure (postictal) to quantify global and regional gray matter cerebral blood flow (CBF). Seizure duration was assessed from the period of epileptiform discharges on the EEG. Healthy controls were scanned twice to assess test-retest variability. We performed hypothesis-driven Bayesian analyses to study the relation between global and regional perfusion changes and seizure duration.

RESULTS

Twenty-four patients and 27 healthy controls were included. Changes in postictal global and regional CBF were correlated with seizure duration. In patients with longer seizure durations, global decrease in CBF reached values up to 28 mL/100 g/min. Regional reductions in CBF were most prominent in the inferior frontal gyrus, cingulate gyrus, and insula (up to 35 mL/100 g/min). In patients with shorter seizures, global and regional perfusion increased (up to 20 mL/100 g/min). These perfusion changes were larger than changes observed in healthy controls, with a maximum median global CBF increase of 12 mL/100 g/min and a maximum median global CBF decrease of 20 mL/100 g/min.

SIGNIFICANCE

Seizure duration is a key factor determining postictal perfusion changes. In future studies, seizure duration needs to be considered as a confounding factor due to its opposite effect on postictal perfusion.

Seizure-induced neutrophil adhesion in brain capillaries leads to a decrease in postictal cerebral blood flow

Cerebral hypoperfusion has been proposed as a potential cause of postictal neurological dysfunction in epilepsy, but its underlying mechanism is still unclear. We show that a 30% reduction in postictal cerebral blood flow (CBF) has two contributing factors: the early hypoperfusion up to ∼30 min post-seizure was mainly induced by arteriolar constriction, while the hypoperfusion that persisted for over an hour was due to increased capillary stalling induced by neutrophil adhesion to brain capillaries, decreased red blood cell (RBC) flow accompanied by constriction of capillaries and venules, and elevated intercellular adhesion molecule-1 (ICAM-1) expression. Administration of antibodies against the neutrophil marker Ly6G and against LFA-1, which mediates adhesive interactions with ICAM-1, prevented neutrophil adhesion and recovered the prolonged CBF reductions to control levels. Our findings provide evidence that seizure-induced neutrophil adhesion to cerebral microvessels via ICAM-1 leads to prolonged postictal hypoperfusion, which may underlie neurological dysfunction in epilepsy.

Seizure duration predicts postictal electroencephalographic recovery after electroconvulsive therapy-induced seizures

OBJECTIVE

We aim to provide a quantitative description of the relation between seizure duration and the postictal state using features extracted from the postictal electroencephalogram (EEG).

METHODS

Thirty patients with major depressive disorder treated with electroconvulsive therapy (ECT) were studied with continuous EEG before, during, and after ECT-induced seizures. EEG recovery was quantified as the spectral difference between postictal and baseline EEG using the temporal brain symmetry index (BSI). The postictal temporal EEG evolution was modeled with a single exponential. The parameters of the model, including the time constant τ, describe the change and speed of postictal EEG recovery. The change from baseline EEG at t = 60 minutes post-seizure (ΔBSI) was calculated from the exponential fit. Postictal clinical reorientation time (ROT) was clinically established. A multivariate generalized multi-level Bayesian model was estimated with seizure duration and ROT as predictors of τ and ΔBSI.

RESULTS

EEG features of 290 seizures and postictal states were used for analyses. The model faithfully described the dynamics of the postictal EEG in nearly all patients. Seizure duration was associated with the recovery time constant, τ, and ΔBSI. ROT was associated with τ, but not with ΔBSI.

CONCLUSIONS

Longer seizures are associated with slower postictal EEG recovery and more enduring EEG changes compared to baseline.

SIGNIFICANCE

Quantitative EEG allows objective assessment of the postictal state.

Epileptic Prodromes: Insights from Surveying 196 Patients and 150 Caregivers

OBJECTIVE

Uncontrolled epilepsy creates a constant source of worry for patients and puts them at a high risk of injury. Identifying recurrent "premonitory" symptoms of seizures and using them to recalibrate seizure prediction algorithms may improve prediction performances. This study aimed to investigate patients' ability to predict oncoming seizures based on preictal symptoms.

METHODS

Through an online survey, demographics and clinical characteristics (e.g., seizure frequency, epilepsy duration, and postictal symptom duration) were collected from people with epilepsy and caregivers across Canada. Respondents were asked to answer questions regarding their ability to predict seizures through warning symptoms. A total of 196 patients and 150 caregivers were included and were separated into three groups: those who reported warning symptoms within the 5 minutes preceding a seizure, prodromes (symptoms earlier than 5 minutes before seizure), and no warning symptoms.

RESULTS

Overall, 12.2% of patients and 12.0% of caregivers reported predictive prodromes ranging from 5 minutes to more than 24 hours before the seizures (median of 2 hours). The most common were dizziness/vertigo (28%), mood changes (26%), and cognitive changes (21%). Statistical testing showed that respondents who reported prodromes also reported significantly longer postictal recovery periods compared to those who did not report predictive prodromes (P < 0.05).

CONCLUSION

Findings suggest that patients who present predictive seizure prodromes may be characterized by longer patient-reported postictal recovery periods. Studying the correlation between seizure severity and predictability and investigating the electrical activity underlying prodromes may improve our understanding of preictal mechanisms and ability to predict seizures.

Impact of Seizure Recurrence on 1-Year Functional Outcome and Mortality in Patients With Poststroke Epilepsy

BACKGROUND AND OBJECTIVES

The functional outcome and mortality of post-stroke epilepsy (PSE) patients have not been assessed in a prospective study. Previous reports have suggested that PSE patients may suffer from prolonged functional deterioration following a seizure. In the current study, we prospectively investigated the functional outcome and mortality of PSE patients and analyzed the impact of seizure recurrence on the outcomes.

METHODS

This is part of the Prognosis of Post-Stroke Epilepsy (PROPOSE) study, a multicenter, prospective observational cohort study, where 392 PSE patients (at least one unprovoked seizure more than 7 days after the onset of the last symptomatic stroke) were followed for at least 1 year at eight hospitals in Japan. The current study included only PSE patients with a first-ever seizure and assessed their functional decline and mortality at 1 year. Functional decline was defined as an increase in modified Rankin Scale (mRS) score at 1 year compared to baseline, excluding death. The associations between seizure recurrence and the outcomes were analyzed statistically.

RESULTS

A total of 211 patients (median age of 75 years; median mRS score of 3) were identified. At 1 year, 50 patients (23.7%) experienced seizure recurrence. Regarding outcomes, 25 patients (11.8%) demonstrated functional decline, and 20 (9.5%) had died. Most patients died of pneumonia or cardiac disease (seven patients each), and no known causes of death were directly related to recurrent seizures. Seizure recurrence was significantly associated with functional decline (odds ratio 2.96 [95% CI 1.25-7.03], P=0.01), even after adjusting for potential confounders (adjusted odds ratio 3.26 [95% CI 1.27-8.36], P=0.01), but not with mortality (odds ratio 0.79 [95% CI 0.18-2.61], P=0.79). Moreover, there was a significant trend where patients with more recurrent seizures were more likely to have functional decline (8.7%, 20.6%, and 28.6% in none, 1, and 2 or more recurrent seizures, respectively; P=0.006).

DISCUSSION

One-year functional outcome and mortality of PSE patients were poor. Seizure recurrence was significantly associated with functional outcome, but not with mortality. Further studies are needed to ascertain whether early and adequate anti-seizure treatment can prevent the functional deterioration of PSE patients.

Duration of postictal impaired awareness after bilateral tonic-clonic seizures: EEG and patient characteristics

OBJECTIVE

Ictal and postictal phenomena that may impact the duration of postictal impaired awareness have not been well studied. Postictal unresponsiveness invariably occurs following bilateral tonic-clonic seizures (BTCS). Bilateral tonic-clonic seizures are a major risk factor for sudden unexpected death in epilepsy (SUDEP). We quantify the effects of seizure characteristics on postictal recovery of awareness following BTCS. Factors include: the total seizure duration, the duration of the tonic phase of a BTCS, presence of postictal generalized EEG suppression (PGES), duration of postictal tonic electromyographic discharge, peri-ictal respiratory dysfunction, patient age, duration of epilepsy, and gender.

METHODS

Fifty-eight patients admitted to the epilepsy monitoring unit with BTCS were studied. Forty-one had unilateral onset temporal seizures. The remainder had bitemporal onsets, extratemporal onsets, undetermined onsets, or were generalized at onset. Following the first BTCS, time to initial recovery of awareness and its possible association with patient and seizure characteristics as well as peri-ictal respiratory dysfunction were evaluated. The presence or absence of postictal agitation was noted.

RESULTS

The severity of respiratory dysfunction and seizure characteristics were not associated with time to initial recovery of awareness. A shorter time to recovery of awareness was significantly associated with a younger age (p = 0.007). Postictal agitation was more common in males (p = 0.023).

SIGNIFICANCE

Focal seizures may impair awareness by active inhibition of subcortical arousal mechanisms. Focal seizures progressing to bilateral tonic-clonic seizures (BTCS) result in further widespread cerebral dysfunction impacting postictal awareness. MRI studies show accelerated brain aging in patients with temporal lobe epilepsy. Our findings suggest that patient age, as a surrogate marker for the lifetime burden of seizures, results in a progressive worsening in time to recovery after BTCS by an increasing negative impact on networks involved in arousal.

Phase-Amplitude Coupling Features Accurately Classify Multiple Sub-States Within a Seizure Episode

Epilepsy is frequently characterized by convulsive seizures, which are often followed by a postictal EEG suppression state (PGES). The ability to automatically detect and monitor seizure progression and postictal state can allow for early warning of seizure onset, timely intervention in seizures themselves, as well as identification of major complications in epilepsy such as status epilepticus and sudden unexpected death in epilepsy (SUDEP). To test whether it is possible to reliably differentiate these ictal and postictal states, we investigated 52 seizure records (both intracranial and scalp EEG) from 19 patients. Phase-amplitude cross-frequency coupling was calculated for each recording and used as an input to a convolutional neural network model, achieving the mean accuracy of 0.890.09 across all classes, with the worst class accuracy of 0.73 for one of the later ictal sub-states. When the trained model was applied to SUDEP patient data, it classified seizure recordings as primarily interictal and PGES-like state (70% and 26%, respectively), highlighting the fact that in SUDEP patients seizures primarily exist in postictal states and don't show the ictal sub-state evolution. These results suggest that using frequency coupling markers with a machine learning algorithm can reliably identify ictal and postictal sub-states, which can open up opportunities for novel monitoring and management approaches in epilepsy.

Factors Associated with Prolonged Impairment of Consciousness in Adult Patients Admitted for Seizures: A Comprehensive Single-center Study

Seizures are common neurological emergencies that occasionally cause prolonged impairment of consciousness. The aim of this retrospective single-center study is to clarify factors associated with prolonged impairment of consciousness for admitted adult patients investigating patient backgrounds, blood tests, electroencephalographic patterns, and MRI findings. The patients who were admitted to the hospital due to epileptic seizures were classified into two groups: (1) early recovery group, in which patients recovered their consciousness within 6 hr, and (2) delayed recovery group, in which patients showed impairment of consciousness more than 6 hr. Factors associated with prolonged impairment of consciousness were compared between these groups. In this study, 42 cases (33 patients), with a mean age of 67.8 years, were included. Fifteen cases (13 patients) and 27 cases (20 patients) were classified into the early and delayed recovery groups, respectively. The populations of older patients and patients from a nursing home were significantly higher in the delayed recovery group. With regard to radiological analyses, a high grade of periventricular hyperintensity (PVH), high Evans index score, and enlarged bilateral atrial widths were significantly associated with prolonged impairment of consciousness. Multivariable analyses showed that a high grade of PVH was significantly associated with delayed recovery of consciousness independent of age and status epilepticus. In conclusion, we proposed that diffuse white matter degeneration around the lateral ventricles contributes to prolonged impairment of consciousness.

The postictal state - What do we know?

This narrative review provides a broad and comprehensive overview of the most important discoveries on the postictal state over the past decades as well as recent developments. After a description and definition of the postictal state, we discuss postictal sypmtoms, their clinical manifestations, and related findings. Moreover, pathophysiological advances are reviewed, followed by current treatment options.

Sudden unresponsive patient with normal vital signs: what is going on?

PURPOSE OF REVIEW

To summarize the differential diagnosis and diagnostic approach of sudden unresponsiveness with normal vital signs in various settings, including the ICU.

RECENT FINDINGS

Sudden unresponsiveness may be either transient or persistent, and may result from primary brain diseases or nonstructural systemic conditions. Life-threatening causes should always be discriminated from those more benign. Regional epidemiology, for example regarding intoxications, and evolving therapeutic management, for example for ischemic stroke, should always be taken into account for optimal opportunity for rapid diagnosis and best management.

SUMMARY

Sudden unresponsiveness with normal vital signs should trigger immediate and focused diagnostic evaluation to find or exclude those conditions requiring urgent, and possibly life-saving, management.