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Rubinos C. Emergent Management of Status Epilepticus. Continuum (Minneap Minn) 2024; 30:682-720. [PMID: 38830068 DOI: 10.1212/con.0000000000001445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Status epilepticus is a neurologic emergency that can be life- threatening. The key to effective management is recognition and prompt initiation of treatment. Management of status epilepticus requires a patient-specific-approach framework, consisting of four axes: (1) semiology, (2) etiology, (3) EEG correlate, and (4) age. This article provides a comprehensive overview of status epilepticus, highlighting the current treatment approaches and strategies for management and control. LATEST DEVELOPMENTS Administering appropriate doses of antiseizure medication in a timely manner is vital for halting seizure activity. Benzodiazepines are the first-line treatment, as demonstrated by three randomized controlled trials in the hospital and prehospital settings. Benzodiazepines can be administered through IV, intramuscular, rectal, or intranasal routes. If seizures persist, second-line treatments such as phenytoin and fosphenytoin, valproate, or levetiracetam are warranted. The recently published Established Status Epilepticus Treatment Trial found that all three of these drugs are similarly effective in achieving seizure cessation in approximately half of patients. For cases of refractory and super-refractory status epilepticus, IV anesthetics, including ketamine and γ-aminobutyric acid-mediated (GABA-ergic) medications, are necessary. There is an increasing body of evidence supporting the use of ketamine, not only in the early phases of stage 3 status epilepticus but also as a second-line treatment option. ESSENTIAL POINTS As with other neurologic emergencies, "time is brain" when treating status epilepticus. Antiseizure medication should be initiated quickly to achieve seizure cessation. There is a need to explore newer generations of antiseizure medications and nonpharmacologic modalities to treat status epilepticus.
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Rubinos C, Bruzzone MJ, Viswanathan V, Figueredo L, Maciel CB, LaRoche S. Electroencephalography as a Biomarker of Prognosis in Acute Brain Injury. Semin Neurol 2023; 43:675-688. [PMID: 37832589 DOI: 10.1055/s-0043-1775816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
Electroencephalography (EEG) is a noninvasive tool that allows the monitoring of cerebral brain function in critically ill patients, aiding with diagnosis, management, and prognostication. Specific EEG features have shown utility in the prediction of outcomes in critically ill patients with status epilepticus, acute brain injury (ischemic stroke, intracranial hemorrhage, subarachnoid hemorrhage, and traumatic brain injury), anoxic brain injury, and toxic-metabolic encephalopathy. Studies have also found an association between particular EEG patterns and long-term functional and cognitive outcomes as well as prediction of recovery of consciousness following acute brain injury. This review summarizes these findings and demonstrates the value of utilizing EEG findings in the determination of prognosis.
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Affiliation(s)
- Clio Rubinos
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
| | | | - Vyas Viswanathan
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
| | - Lorena Figueredo
- Department of Neurology, University of Florida, Gainesville, Florida
| | - Carolina B Maciel
- Department of Neurology, University of Florida, Gainesville, Florida
| | - Suzette LaRoche
- Department of Neurology, University of North Carolina, Chapel Hill, North Carolina
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Margraf NG, Dargvainiene J, Theel E, Leypoldt F, Lieb W, Franke A, Berger K, Kuhle J, Kuhlenbaeumer G. Neurofilament light (NfL) as biomarker in serum and CSF in status epilepticus. J Neurol 2023; 270:2128-2138. [PMID: 36624182 PMCID: PMC10025237 DOI: 10.1007/s00415-022-11547-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE We explored the potential of neurofilament light chain (NfL) in serum and cerebrospinal fluid as a biomarker for neurodestruction in status epilepticus. METHODS In a retrospective analysis, we measured NfL in serum and cerebrospinal fluid samples of patients with status epilepticus using a highly sensitive single-molecule array technique (Simoa). Status epilepticus was diagnosed according to ILAE criteria. Additionally, we employed an alternative classification with more emphasis on the course of status epilepticus. We used data from three large control groups to compare NfL in status epilepticus versus neurologically healthy controls. RESULTS We included 28 patients (mean age: 69.4 years, SD: 15 years) with a median status duration of 44 h (IQR: 80 h). Twenty-one patients (75%) suffered from convulsive status epilepticus and seven (25%) from non-convulsive status epilepticus. Six patients died (21%). Cerebrospinal fluid and serum NfL concentrations showed a high correlation (r = 0.73, p < 0.001, Pearson). The main determinant of NfL concentration was the status duration. NfL concentrations did not differ between convulsive status epilepticus and convulsive status epilepticus classified according to the ILAE or to the alternative classification without and with adjusting for status duration and time between status onset and sampling. We found no association of NfL concentration with death, treatment refractoriness, or prognostic scores. CONCLUSION The results suggest that neurodestruction in status epilepticus measured by NfL is mainly determined by status duration, not status type nor therapy refractoriness. Therefore, our results suggest that regarding neurodestruction convulsive and non-convulsive status epilepticus are both neurological emergencies of comparable urgency.
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Affiliation(s)
- Nils G Margraf
- Department of Neurology, University Hospital Schleswig-Holstein (UKSH), Christian-Albrechts-University (CAU), Arnold-Heller-Str. 3, 24105, Kiel, Germany.
| | - Justina Dargvainiene
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein (UKSH), Christian-Albrechts-University (CAU), Kiel, Germany
| | - Emily Theel
- Department of Neurology, University Hospital Schleswig-Holstein (UKSH), Christian-Albrechts-University (CAU), Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Frank Leypoldt
- Department of Neurology, University Hospital Schleswig-Holstein (UKSH), Christian-Albrechts-University (CAU), Arnold-Heller-Str. 3, 24105, Kiel, Germany
- Institute of Clinical Chemistry, University Hospital Schleswig-Holstein (UKSH), Christian-Albrechts-University (CAU), Kiel, Germany
| | - Wolfgang Lieb
- Institute of Epidemiology and Biobank PopGen, University Hospital Schleswig-Holstein (UKSH), Christian-Albrechts-University (CAU), Kiel, Germany
| | - Andre Franke
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel and University Hospital Schleswig-Holstein, Kiel, Germany
| | - Klaus Berger
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Jens Kuhle
- Multiple Sclerosis Centre, Neurology, Departments of Head, Spine and Neuromedicine, Biomedicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
- Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), University Hospital and University of Basel, Basel, Switzerland
| | - Gregor Kuhlenbaeumer
- Department of Neurology, University Hospital Schleswig-Holstein (UKSH), Christian-Albrechts-University (CAU), Arnold-Heller-Str. 3, 24105, Kiel, Germany
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Swarnalingam E, Woodward K, Esser M, Jacobs J. Management and prognosis of pediatric status epilepticus. ZEITSCHRIFT FÜR EPILEPTOLOGIE 2022. [DOI: 10.1007/s10309-022-00538-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Background
Pediatric status epilepticus is a neurological emergency with the potential for severe developmental and neurological consequences. Prompt diagnosis and management are necessary.
Objectives
To outline the existing best available evidence for managing pediatric and neonatal status epilepticus, in the light of emerging randomized controlled studies. We also focus on short and long-term prognoses.
Materials and methods
This is a systematic overview of the existing literature.
Results
Status epilepticus, its treatment, and prognosis are usually based on the continuation of seizure activity at 5 and 30 min. Refractory and super-refractory status epilepticus further complicates management and requires continuous EEG monitoring with regular reassessment and adjustment of therapy. Benzodiazepines have been accepted as the first line of treatment on the basis of reasonable evidence. Emerging randomized controlled trials demonstrate equal efficacy for parenterally administered phenytoin, levetiracetam, and valproic acid as second-line agents. Beyond this, the evidence for third-line options is sparse. However, encouraging evidence for midazolam and ketamine exists with further data required for immunological, dietary, and surgical interventions.
Conclusion
Our overview of the management of pediatric and neonatal status epilepticus based on available evidence emphasizes the need for evidence-based guidelines to manage status epilepticus that fails to respond to second-line treatment.
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Vallecoccia MS, Martinotti A, Siddi C, Dominedò C, Cingolani E. Use of Unconventional Therapies in Super-refractory Status Epilepticus: A Case Report and Literature Review. Clin EEG Neurosci 2022; 53:70-73. [PMID: 33233961 DOI: 10.1177/1550059420975612] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Super-refractory status epilepticus (SRSE) is a life-threatening condition characterized by the persistence or recurrence of seizures despite the use of first- and second-line antiepileptic drugs and the continuous infusion of anesthetics for more than 24 hours. This has always been a challenge for the physician, given the high mortality and morbidity related to this condition. Unfortunately, there are currently no definitive data to guide the therapy, since most of the therapeutic approaches regarding SRSE come from anecdotal evidence. Here, we present a case report of long-persisting new-onset SRSE treated with unconventional therapies recently reported to be successful such as ketamine, ketogenic diet, and tocilizumab, that could have played an important role in the management of this patient. A review of the literature regarding those is also included. SRSE has been reported to have long hospital length of stay, with a small percentage of patients returning to baseline functional status. Moreover, recent evidence showed that functional and cognitive outcome could depend on seizure duration, so prolonged duration of epileptic activity with abnormalities on the magnetic resonance imaging (MRI) could be seen as a reason to discontinue treatment. However, despite many weeks of seizures and a noncomforting MRI, our patient was discharged with a good functional status.
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Affiliation(s)
| | | | - Chiara Siddi
- Department of Shock and Trauma Center, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Cristina Dominedò
- Department of Shock and Trauma Center, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Emiliano Cingolani
- Department of Shock and Trauma Center, S. Camillo-Forlanini Hospital, Rome, Italy
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Battaglia DI, Gambardella ML, Veltri S, Contaldo I, Chillemi G, Veredice C, Quintiliani M, Leoni C, Onesimo R, Verdolotti T, Radio FC, Martinelli D, Trivisano M, Specchio N, Dravet C, Tartaglia M, Zampino G. Epilepsy and BRAF Mutations: Phenotypes, Natural History and Genotype-Phenotype Correlations. Genes (Basel) 2021; 12:genes12091316. [PMID: 34573299 PMCID: PMC8470450 DOI: 10.3390/genes12091316] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/11/2021] [Accepted: 08/23/2021] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Cardiofaciocutaneous syndrome (CFCS) is a rare developmental disorder caused by upregulated signaling through the RAS-mitogen-activated protein kinase (MAPK) pathway, mostly resulting from de novo activating BRAF mutations. Children with CFCS are prone to epilepsy, which is a major life-threatening complication. The aim of our study was to define the natural history of epilepsy in this syndrome and exploring genotype-phenotype correlations. METHODS We performed an observational study, including 34 patients with molecularly confirmed diagnosis (11 males, mean age: 15.8 years). The mean follow-up period was 9.2 years. For all patients, we performed neurological examination, cognitive assessment when possible, neuroimaging, electrophysiological assessment and systematic assessment of epilepsy features. Correlation analyses were performed, taking into account gender, age of seizure onset, EEG features, degree of cognitive deficits, type of mutation, presence of non-epileptic paroxysmal events and neuroimaging features. RESULTS Epilepsy was documented in 64% of cases, a higher prevalence compared to previous reports. Patients were classified into three groups based on their electroclinical features, long-term outcome and response to therapy. A genotype-phenotype correlation linking the presence/severity of epilepsy to the nature of the structural/functional consequences of mutations was observed, providing a stratification based on genotype to improve the clinical management of these patients.
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Affiliation(s)
- Domenica I. Battaglia
- Child Neurology and Psychiatry Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy; (M.L.G.); (S.V.); (I.C.); (C.V.); (C.D.)
- Dipartimento Scienze della Vita, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.Q.); (G.Z.)
- Correspondence:
| | - Maria Luigia Gambardella
- Child Neurology and Psychiatry Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy; (M.L.G.); (S.V.); (I.C.); (C.V.); (C.D.)
| | - Stefania Veltri
- Child Neurology and Psychiatry Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy; (M.L.G.); (S.V.); (I.C.); (C.V.); (C.D.)
| | - Ilaria Contaldo
- Child Neurology and Psychiatry Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy; (M.L.G.); (S.V.); (I.C.); (C.V.); (C.D.)
| | - Giovanni Chillemi
- Department for Innovation in Biological Agro-Food and Forest Systems (DIBAF), University of Tuscia, 01100 Viterbo, Italy;
- Institute of Biomembranes, Bioenergetics and Molecular Biotechnologies, Centro Nazionale delle Ricerche, 70126 Bari, Italy
| | - Chiara Veredice
- Child Neurology and Psychiatry Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy; (M.L.G.); (S.V.); (I.C.); (C.V.); (C.D.)
| | - Michela Quintiliani
- Dipartimento Scienze della Vita, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.Q.); (G.Z.)
| | - Chiara Leoni
- Center for Rare Disease and Congenital Defects, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy; (C.L.); (R.O.)
| | - Roberta Onesimo
- Center for Rare Disease and Congenital Defects, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy; (C.L.); (R.O.)
| | - Tommaso Verdolotti
- Department of Radiology Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy;
| | - Francesca Clementina Radio
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, 00146 Rome, Italy; (F.C.R.); (M.T.)
| | - Diego Martinelli
- Division of Metabolism, Ospedale Pediatrico Bambino Gesù, IRCCS, 00165 Rome, Italy;
| | - Marina Trivisano
- Department of Neuroscience, Ospedale Pediatrico Bambino Gesù, IRCCS, 00165 Rome, Italy; (M.T.); (N.S.)
| | - Nicola Specchio
- Department of Neuroscience, Ospedale Pediatrico Bambino Gesù, IRCCS, 00165 Rome, Italy; (M.T.); (N.S.)
| | - Charlotte Dravet
- Child Neurology and Psychiatry Unit, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy; (M.L.G.); (S.V.); (I.C.); (C.V.); (C.D.)
| | - Marco Tartaglia
- Genetics and Rare Diseases Research Division, Ospedale Pediatrico Bambino Gesù, IRCCS, 00146 Rome, Italy; (F.C.R.); (M.T.)
| | - Giuseppe Zampino
- Dipartimento Scienze della Vita, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (M.Q.); (G.Z.)
- Center for Rare Disease and Congenital Defects, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, 00168 Rome, Italy; (C.L.); (R.O.)
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Lee SK. Diagnosis and Treatment of Status Epilepticus. J Epilepsy Res 2020; 10:45-54. [PMID: 33659195 PMCID: PMC7903042 DOI: 10.14581/jer.20008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/10/2020] [Accepted: 11/24/2020] [Indexed: 12/03/2022] Open
Abstract
The definition of status epilepticus (SE) was revised recently in accordance with the various evidences of neuronal injury and changes in clinical settings. Currently, the most acceptable duration of continuous seizure activity is 5 minutes. In 2015, the International League Against Epilepsy Task Force, which was convened to develop a definition and classification of SE, presented a new classification based on four axes: 1) semiology, 2) etiology, 3) electroencephalogram (EEG) correlates, and 4) age. The essential element of nonconvulsive SE (NCSE) is the presence of neurological abnormalities induced by a prolonged epileptic process. The definition of refractory SE involves either clinical or electrographic seizures that persist after adequate doses of an initial benzodiazepine and acceptable second-line antiseizure drugs. The use of EEG is critical in the diagnosis and treatment of NCSE. However, there are a wide range of EEG abnormalities in NCSE. Both the Neurocritical Care Society and the American Epilepsy Society have suggested a paradigm for treating convulsive SE (CSE). The first-line treatment of CSE with benzodiazepine is well-established. The second-line treatment comprises intravenous (IV) doses of fosphenytoin (phenytoin), valproate, phenobarbital, levetiracetam, or midazolam. Although fosphenytoin (phenytoin) and valproate are commonly used in NCSE, the effectiveness of antiepileptic drugs (AEDs) on NCSE has not been well studied. New AEDs such as IV levetiracetam and lacosamide can also be used to treat NCSE with fewer side effects and drug-drug interactions. For refractory SE, general anesthesia with IV midazolam, propofol, pentobarbital, or thiopental could be applied. Use of ketamine, megadose phenobarbital therapy, and multiple combinations of various AEDs including high doses of oral AEDs can also be considered. New-onset refractory status epilepticus (NORSE) and its subcategory, febrile infection-related epilepsy syndrome, involve autoimmune processes. AEDs alone are poorly effective in the treatment of SE in autoimmune encephalitis. Immunotherapy such as steroids, immunoglobulin, rituximab, or tocilizumab can be effective.
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Affiliation(s)
- Sang Kun Lee
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
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The Unease When Using Anesthetics for Treatment-Refractory Status Epilepticus: Still Far Too Many Questions. J Clin Neurophysiol 2020; 37:399-405. [DOI: 10.1097/wnp.0000000000000606] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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VanHaerents S, Gerard EE. Epilepsy Emergencies: Status Epilepticus, Acute Repetitive Seizures, and Autoimmune Encephalitis. Continuum (Minneap Minn) 2019; 25:454-476. [PMID: 30921018 DOI: 10.1212/con.0000000000000716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW This article reviews epilepsy emergencies, including status epilepticus, acute repetitive seizures, autoimmune encephalitis, and the current perspective on their diagnosis and treatment. RECENT FINDINGS Recent guidelines on the treatment of status epilepticus from the Neurocritical Care Society in 2012 and the American Epilepsy Society in 2016 highlight areas of consensus in the treatment of status epilepticus as well as areas of uncertainty. The TRENdS (Treatment of Recurrent Electrographic Nonconvulsive Seizures) trial is the first prospective randomized clinical trial to evaluate the efficacy of IV antiseizure medications in controlling nonconvulsive seizures on continuous EEG. It demonstrated that IV lacosamide is noninferior to fosphenytoin in this setting. Autoimmune encephalitis is an increasingly recognized cause of new-onset seizures or status epilepticus. Recently described scoring systems, the Antibody Prevalence in Epilepsy score and the Response to Immunotherapy in Epilepsy score, can help in the assessment of autoimmune encephalitis. SUMMARY Status epilepticus, acute repetitive seizures, and autoimmune encephalitis are neurologic emergencies. For all these conditions, rapid and appropriate treatment may influence patient prognosis and mitigate neuronal injury. For convulsive status epilepticus, there is reasonable consensus on the initial steps that need to be taken. There is less agreement about the management of acute repetitive seizures and nonconvulsive status epilepticus. An increasingly recognized etiology of status epilepticus is autoimmune encephalitis, which may not be as rare as previously thought.
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Das AS, Lee JW, Rosenthal ES, Vaitkevicius H. Successful Wean Despite Emergence of Ictal-Interictal EEG Patterns During the Weaning of Prolonged Burst-Suppression Therapy for Super-Refractory Status Epilepticus. Neurocrit Care 2019; 29:452-462. [PMID: 29948999 DOI: 10.1007/s12028-018-0552-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
BACKGROUND Management of refractory status epilepticus (SE) commonly involves the induction of burst suppression using intravenous anesthetic agents. However, the endpoints of these therapies are not well defined. Weaning anesthetic agents are complicated by the emergence of electroencephalogram (EEG) patterns along the ictal-interictal continuum (IIC), which have uncertain significance given that IIC patterns may worsen cerebral metabolism and oxygenation, have a dissociation between scalp and depth EEG recordings, or may indicate a late stage of SE itself. Determining the significance of IIC patterns in the unique context of anesthetic weaning is important to prevent the potential for unnecessarily prolonging anesthetic coma. METHODS Among 118 individuals with SE, we retrospectively identified a series of patients who underwent at least 24 h of burst-suppression therapy, experienced two or more weaning trials, and developed IIC patterns during anesthetic weaning. Anesthetic titration strategies during the emergence of these patterns were examined. RESULTS Each of the six individuals who met inclusion criteria experienced aggressive weaning despite the emergence of IIC patterns. The IIC patterns that were encountered during anesthetic weaning (including generalized and lateralized periodic discharges) are described in detail. Favorable outcomes were reported in each subject. CONCLUSION IIC patterns encountered during anesthetic weaning may be transitional and warrant observation, allowing for the emergence of more definitive clinical or electrographic results. The metabolic impact of these IIC patterns on brain activity is uncertain, but weaning strategies that treat IIC as a surrogate of recurrent SE risk further prolonging anesthetic management and its known toxicity. We speculate that these patterns may have a context-specific association with SE relapse, with less-risk conferred when these patterns are observed during the weaning of anesthetic agents after prolonged burst-suppression therapy. Other electrographic features aside from this clinical context may discriminate the risk of SE relapse, such as EEG background activity.
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Affiliation(s)
- Alvin S Das
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.,Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Jong Woo Lee
- Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Eric S Rosenthal
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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Niquet J, Lumley L, Baldwin R, Rossetti F, Suchomelova L, Naylor D, Estrada IBF, Schultz M, Furtado MDA, Wasterlain CG. Rational polytherapy in the treatment of cholinergic seizures. Neurobiol Dis 2019; 133:104537. [PMID: 31454548 DOI: 10.1016/j.nbd.2019.104537] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/25/2019] [Accepted: 07/18/2019] [Indexed: 10/26/2022] Open
Abstract
The initiation and maintenance phases of cholinergic status epilepticus (SE) are associated with maladaptive trafficking of synaptic GABAA and glutamate receptors. The resulting pharmacoresistance reflects a decrease in synaptic GABAA receptors and increase in NMDA and AMPA receptors, which tilt the balance between inhibition and excitation in favor of the latter. If these changes are important to the pathophysiology of SE, both should be treated, and blocking their consequences should have therapeutic potential. We used a model of benzodiazepine-refractory SE (RSE) (Tetz et al., 2006) and a model of soman-induced SE to test this hypothesis. Treatment of RSE with combinations of the GABAAR agonists midazolam or diazepam and the NMDAR antagonists MK-801 or ketamine terminated RSE unresponsive to high-dose monotherapy with benzodiazepines, ketamine or other antiepileptic drugs (AEDs). It also reduced RSE-associated neuronal injury, spatial memory deficits and the occurrence of spontaneous recurrent seizures (SRS), tested several weeks after SE. Treatment of sc soman-induced SE similarly showed much greater reduction of EEG power by a combination of midazolam with ketamine, compared to midazolam monotherapy. When treating late (40 min after seizure onset), there may not be enough synaptic GABAAR left to be able to restore inhibition with maximal GABAAR stimulation, and further benefit is derived from the addition of an AED which increases inhibition or reduces excitation by a non-GABAergic mechanism. The midazolam-ketamine-valproate combination is effective in terminating RSE. 3-D isobolograms demonstrate positive cooperativity between midazolam, ketamine and valproate, without any interaction between the toxicity of these drugs, so that the therapeutic index is increased by combination therapy between GABAAR agonist, NMDAR antagonist and selective AEDs. We compared this drug combination based on the receptor trafficking hypothesis to treatments based on clinical practice. The midazolam-ketamine-valproate combination is far more effective in stopping RSE than the midazolam-fosphenytoin-valproate combination inspired from clinical guidelines. Furthermore, sequential administration of midazolam, ketamine and valproate is far less effective than simultaneous treatment with the same drugs at the same dose. These data suggest that we should re-evaluate our traditional treatment of RSE, and that treatment should be based on pathophysiology. The search for a better drug has to deal with the fact that most monotherapy leaves half the problem untreated. The search for a better benzodiazepine should acknowledge the main cause of pharmacoresistance, which is loss of synaptic GABAAR. Future clinical trials should consider treating both the failure of inhibition and the runaway excitation which characterize RSE, and should include an early polytherapy arm.
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Affiliation(s)
- Jerome Niquet
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Lucille Lumley
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense (USAMRICD), 8350 Ricketts Point Rd., Aberdeen Proving Ground, MD 21010, USA
| | - Roger Baldwin
- Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Franco Rossetti
- Military Psychiatry and Neuroscience Department, Walter Reed Army institute of Research, Silver Spring, MD, USA
| | - Lucie Suchomelova
- Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - David Naylor
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ireri Betsabe Franco Estrada
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Mark Schultz
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense (USAMRICD), 8350 Ricketts Point Rd., Aberdeen Proving Ground, MD 21010, USA
| | - Marcio de Araujo Furtado
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense (USAMRICD), 8350 Ricketts Point Rd., Aberdeen Proving Ground, MD 21010, USA; Military Psychiatry and Neuroscience Department, Walter Reed Army institute of Research, Silver Spring, MD, USA
| | - Claude G Wasterlain
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Brain Research Institute, David Geffen School of Medicine at UCLA, Los Angeles, CA., USA.
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Horváth L, Fekete I, Molnár M, Válóczy R, Márton S, Fekete K. The Outcome of Status Epilepticus and Long-Term Follow-Up. Front Neurol 2019; 10:427. [PMID: 31105639 PMCID: PMC6498966 DOI: 10.3389/fneur.2019.00427] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/08/2019] [Indexed: 12/17/2022] Open
Abstract
Objective: This study was to investigate the outcome of status epilepticus (SE) associated with antiepileptic therapy during SE and in follow-up period, risk factors including age, co-morbidities, pre-existing epilepsy, and etiology in the East-Hungarian region. Methods: A prospective cross-sectional database was compiled from outpatient files between 2013 and 2017. Follow-up ended on 30.06.2018. Results: One hundred and thirty five episodes (male: 68, 50.4%) were evaluated, mean age and follow-up time being 64.1 ± 13.9 years and 39.9 ± 14.2 months, respectively. Of the 89 patients with pre-existing epilepsy, 34 failed to visit the outpatient unit regularly. Case fatality rate was 25.2% and 31 patients (30.7%) died after discharge due to co-morbidities; their mean survival time was 10.44 ± 8 months. Focal, generalized and combined type epilepsies were diagnosed in 67 patients (49.6%), 47 patients (34.8%), and 21 patients (15.6%) of SE, respectively. Nine patients had non-convulsive SE (NCSE). Mean seizure-free period was 6.8 ± 6.9 months. Patients taking carbamazepine (20.9%; OR: 0.37, 95%CI: 0.16–0.82; p = 0.018), levetiracetam (27.5%; OR: 0.51, 95%CI: 0.27–0.97; p = 0.041), or valproate (11.1%; OR: 0.18, 95%CI: 0.05–0.61; p = 0.0043) were expected to achieve seizure freedom after SE. The worst outcome was linked to advanced age, etiology, new onset status epilepticus, NCSE, and focal status epilepsy. Conclusion: This study highlights the importance of regular care and patient follow-up.
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Affiliation(s)
- László Horváth
- Department of Pharmaceutical Surveillance and Economy, Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - István Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Márk Molnár
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Réka Válóczy
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Sándor Márton
- Faculty of Art, Institute of Political Science and Sociology, University of Debrecen, Debrecen, Hungary
| | - Klára Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Gofton TE, Gaspard N, Hocker SE, Loddenkemper T, Hirsch LJ. New onset refractory status epilepticus research: What is on the horizon? Neurology 2019; 92:802-810. [PMID: 30894443 DOI: 10.1212/wnl.0000000000007322] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 01/17/2019] [Indexed: 12/14/2022] Open
Abstract
New-onset refractory status epilepticus (NORSE) is a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurologic disorder, with new onset of refractory status epilepticus (RSE) that does not resolve after 2 or more rescue medications, without a clear acute or active structural, toxic, or metabolic cause. Febrile infection-related epilepsy syndrome is a subset of NORSE in which fever began at least 24 hours prior to the RSE. Both terms apply to all age groups. Until recently, NORSE was a poorly recognized entity without a consistent definition or approach to care. We review the current state of knowledge in NORSE and propose a roadmap for future collaborative research. Research investigating NORSE should prioritize the following 4 domains: (1) clinical features, etiology, and pathophysiology; (2) treatment; (3) adult and pediatric evaluation and management approaches; and (4) public advocacy, professional education, and family support. We consider international collaboration and multicenter research crucial in achieving these goals.
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Affiliation(s)
- Teneille E Gofton
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT.
| | - Nicolas Gaspard
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Sara E Hocker
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Tobias Loddenkemper
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Lawrence J Hirsch
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
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Koffman L, Yan Yiu H, Farrokh S, Lewin J, Geocadin R, Ziai W. Ketamine infusion for refractory status epilepticus: A case report of cardiac arrest. J Clin Neurosci 2017; 47:149-151. [PMID: 29107412 DOI: 10.1016/j.jocn.2017.10.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 10/10/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Refractory status epilepticus (RSE) has a high mortality rate and is often difficult to treat. When traditional therapies fail ketamine may be considered. There are limited reports of adverse cardiac events with the use of ketamine for RSE and no reports of cardiac arrest in this context. OBJECTIVE Evaluate the occurrence of cardiac arrhythmias associated with the use of ketamine for RSE. METHODS Retrospective chart review of nine patients who underwent ketamine infusion for RSE. RESULTS Etiology of refractory status epilepticus included autoimmune/infectious process (Zeiler et al., 2014), ischemic stroke (Bleck, 2005) and subarachnoid hemorrhage (Bleck, 2005). Of the nine patients who received ketamine, two had documented cardiac events; one remained clinically stable and the other developed multiple arrhythmias, including recurrent episodes of asystole. Once ketamine was discontinued the latter patient stabilized with the addition of anti arrhythmic therapy. CONCLUSION Ketamine is utilized to treat refractory status epilepticus, but should be used with caution in patients with subarachnoid hemorrhage, as there may be an increased risk of life threatening arrhythmias and cardiac arrest.
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Affiliation(s)
- Lauren Koffman
- Dept of Neurological Sciences, Rush University Medical Center, Chicago, IL, United States.
| | - Ho Yan Yiu
- Critical Care and Surgery Pharmacy, The Johns Hopkins Hospital, United States.
| | - Salia Farrokh
- Critical Care and Surgery Pharmacy, The Johns Hopkins Hospital, United States.
| | - John Lewin
- Critical Care and Surgery Pharmacy, The Johns Hopkins Hospital, United States.
| | - Romergryko Geocadin
- Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, United States.
| | - Wendy Ziai
- Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, United States.
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Sutter R, De Marchis GM, Semmlack S, Fuhr P, Rüegg S, Marsch S, Ziai WC, Kaplan PW. Anesthetics and Outcome in Status Epilepticus: A Matched Two-Center Cohort Study. CNS Drugs 2017; 31:65-74. [PMID: 27896706 DOI: 10.1007/s40263-016-0389-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The use of anesthetics has been linked to poor outcome in patients with status epilepticus (SE). This association, however, may be confounded, as anesthetics are mostly administered in patients with more severe SE and critical illnesses. OBJECTIVE To minimize treatment-selection bias, we assessed the association between continuously administered intravenous anesthetic drugs (IVADs) and outcome in SE patients by a matched two-center study design. METHODS This cohort study was performed at the Johns Hopkins Bayview Medical Center, Baltimore, MD, USA and the University Hospital Basel, Basel, Switzerland. All consecutive adult SE patients from 2005 to 2013 were included. Odds ratios (ORs) for death and unfavorable outcome (Glasgow Outcome Score [GOS] 1-3) associated with administration of IVADs were calculated. To account for confounding by known outcome determinants (age, level of consciousness, worst seizure type, acute/fatal etiology, mechanical ventilation, and SE duration), propensity score matching and coarsened exact matching were performed in addition to multivariable regression models. RESULTS Among 406 consecutive patients, 139 (34.2%) were treated with IVADs. Logistic regression analyses of the unmatched and matched cohorts revealed increased odds for death and unfavorable outcome in survivors who had received IVADs (unmatched: ORdeath = 3.13, 95% confidence interval [CI] 1.47-6.60 and ORGOS1-3 = 2.51, 95% CI 1.37-4.60; propensity score matched: ORdeath = 3.29, 95% CI 1.35-8.05 and ORGOS1-3 = 2.27, 95% CI 1.02-5.06; coarsened exact matched: ORdeath = 2.19, 95% CI 1.27-3.78 and ORGOS1-3 = 3.94, 95% CI 2.12-7.32). CONCLUSION The use of IVADs in SE is associated with death and unfavorable outcome in survivors independent of known confounders and using different statistical approaches. Randomized trials are needed to determine if these associations are biased by outcome predictors not yet identified and hence not accounted for in this study.
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Affiliation(s)
- Raoul Sutter
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA. .,Division of Neurosciences Critical Care, Department of Anesthesiology, Critical Care Medicine and Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA. .,Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland. .,Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland.
| | - Gian Marco De Marchis
- Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Saskia Semmlack
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Peter Fuhr
- Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Stephan Rüegg
- Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Stephan Marsch
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Wendy C Ziai
- Division of Neurosciences Critical Care, Department of Anesthesiology, Critical Care Medicine and Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Abstract
Nonconvulsive status epilepticus (NCSE) is a state of continuous or repetitive seizures without convulsions. Owing to the nonspecific symptoms and considerable morbidity and mortality associated with NCSE, clinical research has focused on early diagnosis, risk stratification and seizure termination. The subtle symptoms and the necessity for electroencephalographic confirmation of seizures result in under-diagnosis with deleterious consequences. The introduction of continuous EEG to clinical practice, and the characterization of electrographic criteria have delineated a number of NCSE types that are associated with different prognoses in several clinical settings. Epidemiological studies have uncovered risk factors for NCSE; knowledge of these factors, together with particular clinical characteristics and EEG observations, enables tailored treatment. Despite these advances, NCSE can be refractory to antiepileptic drugs, necessitating further escalation of treatment. The presumptive escalation to anaesthetics, however, has recently been questioned owing to an association with increased mortality. This Review compiles epidemiological, clinical and diagnostic aspects of NCSE, and considers current treatment options and prognosis.
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Are Newer AEDs Better Than the Classic Ones in the Treatment of Status Epilepticus? J Clin Neurophysiol 2016; 33:18-21. [PMID: 26840872 DOI: 10.1097/wnp.0000000000000211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Several newer antiepileptic drugs have been increasingly used in patients with status epilepticus, especially levetiracetam and lacosamide, because of their intravenous availability. They may offer advantages in terms of tolerability; however, to date, no clear evidence suggests any advantage regarding efficacy after the use of newer antiepileptic drugs in this specific clinical setting. However, there has been a considerable revival of interest regarding some classic compounds, such as midazolam (MDZ), valproate (VPA), ketamine, or ketogenic diet. Awaiting comparative studies, which in part are ongoing, it seems reasonable, for the first choice, to rely on those agents that are best known and less expensive.
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Buttram SDW, Au AK, Koch J, Lidsky K, McBain K, O'Brien N, Zielinski BA, Bell MJ. Feasibility Study Evaluating Therapeutic Hypothermia for Refractory Status Epilepticus in Children. Ther Hypothermia Temp Manag 2015; 5:198-202. [PMID: 26562493 DOI: 10.1089/ther.2015.0016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Pediatric refractory status epilepticus (RSE) is a neurological emergency with significant morbidity and mortality, which lacks consensus regarding diagnosis and treatment(s). Therapeutic hypothermia (TH) is an effective treatment for RSE in preclinical models and small series. In addition, TH is a standard care for adults after cardiac arrest and neonates with hypoxic-ischemic encephalopathy. The purpose of this study was to identify the feasibility of a study of pediatric RSE within a research group (Pediatric Neurocritical Care Research Group [PNCRG]). Pediatric intensive care unit (PICU) admissions at seven centers were prospectively screened from October 2012 to July 2013 for RSE. Experts within the PNCRG estimated that clinicians would be unwilling to enroll a child, unless the child required at least two different antiepileptic medications and a continuous infusion of another antiepileptic medication with ongoing electrographic seizure activity for ≥2 hours after continuous infusion initiation. Data for children meeting the above inclusion criteria were collected, including the etiology of RSE, history of epilepsy, and maximum dose of continuous antiepileptic infusions. There were 8113 PICU admissions over a cumulative 52 months (October 2012-July 2013) at seven centers. Of these, 69 (0.85%) children met inclusion criteria. Twenty children were excluded due to acute diagnoses affected by TH, contraindications to TH, or lack of commitment to aggressive therapies. Sixteen patients had seizure cessation within 2 hours, resulting in 33 patients who had inadequate seizure control after 2 hours and a continuous antiepileptic infusion. Midazolam (21/33, 64%) and pentobarbital (5/33, 15%) were the most common infusions with a wide maximum dose range. More than one infusion was required for seizure control in four patients. There are substantial numbers of subjects at clinical sites within the PNCRG with RSE that would meet the proposed inclusion criteria for a study of TH. The true feasibility of such a study depends on the sample size necessary to achieve therapeutic effects on justifiable clinical outcomes.
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Affiliation(s)
- Sandra D W Buttram
- 1 Division of Critical Care Medicine, Department of Child Health, Phoenix Children's Hospital, University of Arizona College of Medicine Phoenix , Phoenix, Arizona
| | - Alicia K Au
- 2 Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Joshua Koch
- 3 Division of Critical Care Medicine, Children's Medical Center of Dallas, University of Texas Southwestern , Dallas, Texas
| | - Karen Lidsky
- 4 Rainbow Babies and Children's Hospital, Case Western Reserve University , Cleveland, Ohio
| | - Kristin McBain
- 5 Department of Neurology, The Hospital for Sick Children , Toronto, Canada
| | - Nicole O'Brien
- 6 Division of Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University , Columbus, Ohio
| | - Brandon A Zielinski
- 7 Division of Child Neurology, Departments of Pediatrics and Neurology, Primary Children's Medical Center, University of Utah , Salt Lake City, Utah
| | - Michael J Bell
- 2 Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh , Pittsburgh, Pennsylvania
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Admissions to paediatric intensive care units (PICU) with refractory convulsive status epilepticus (RCSE): A two-year multi-centre study. Seizure 2015; 29:153-61. [DOI: 10.1016/j.seizure.2015.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 04/03/2015] [Accepted: 04/04/2015] [Indexed: 11/18/2022] Open
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Lai A, Outin HD, Jabot J, Mégarbane B, Gaudry S, Coudroy R, Louis G, Schneider F, Barbarot N, Roch A, Lerolle N, Luis D, Fourrier F, Renault A, Argaud L, Sharshar T, Gibot S, Bollaert PE. Functional outcome of prolonged refractory status epilepticus. Crit Care 2015; 19:199. [PMID: 25925042 PMCID: PMC4426536 DOI: 10.1186/s13054-015-0914-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 04/09/2015] [Indexed: 11/25/2022] Open
Abstract
Introduction To characterize etiology, clinical course and outcomes of patients in prolonged refractory status epilepticus (PRSE) and looking for prognostic factors. Methods Retrospective study conducted in patients hospitalized from January 1, 2001 to December 31, 2011 in 19 polyvalent intensive care units in French university and general hospitals. Patients were adults with a generalized convulsive refractory status epilepticus that lasted more than seven days, despite treatment including an anesthetic drug and mechanical ventilation. Patients with anoxic encephalopathy were excluded. Follow-up phone call was used to determine functional outcome using modified Rankin Scale (mRS) with mRS 0–3 defining good and mRS 4–6 poor outcome. Results 78 patients (35 female) were included. Median age was 57 years. Causes of status epilepticus were various, mainly including prior epilepsy (14.1%), CNS infection (12.8%), and stroke (12.8%). No etiology was found in 27 (34.6%) patients. PRSE was considered controlled in only 53 (67.9%) patients after a median duration of 17 (IQR 12–26) days. The median length of ICU stay was 28 (19–48) days. Forty-one (52.5%) patients died in the ICU, 26 from multiple organ failure, 8 from care withdrawal, 2 from sudden cardiac arrest, 1 from brain death and 4 from unknown causes. PRSE was previously resolved in 20 patients who died in the ICU. At one-year follow-up, there were 12 patients with good outcome and 58 with poor outcome and 8 lost of follow-up. On multivariate analysis, only vasopressor use was a predictor of poor outcome (OR 6.54; 95%CI 1.09-39.29; p = 0.04). Conclusion Poor outcome was observed in about 80% of this population of PRSE. Most patients died from systemic complications linked to their ICU stay. Some patients can recover satisfactorily over time though we did not identify any robust factor of good outcome.
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Affiliation(s)
- Alexandre Lai
- Service de Réanimation médicale, Hôpital Central, CHU de Nancy, Nancy, France.
| | - Hervé D Outin
- Service de Réanimation médico-chirurgicale, CHI de Poissy-Saint Germain en Laye, Poissy, France.
| | - Julien Jabot
- Service de Réanimation Polyvalente, CHU Réunion, Saint Denis de la Réunion, France.
| | - Bruno Mégarbane
- Service de Réanimation et de Toxicologie, CHU Lariboisière, Université Paris VI, Paris, France.
| | - Stéphane Gaudry
- Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Colombes, France. .,Univ Paris Diderot, UMRS 1123, Paris, France.
| | - Rémi Coudroy
- Service de Réanimation Médicale, CHU de Poitiers, Poitiers, France.
| | - Guillaume Louis
- Service de Réanimation Polyvalente, CHR de Metz-Thionville, Metz, France.
| | - Francis Schneider
- Service de Réanimation Médicale, Hôpital de Strasbourg-Hautepierre, Université Louis Pasteur, Strasbourg, France.
| | - Nicolas Barbarot
- Service de Réanimation Polyvalente, CH de St Brieuc, St Brieuc, France.
| | - Antoine Roch
- Service de Réanimation, Hôpital Nord, CHU de Marseille, Marseille, France.
| | - Nicolas Lerolle
- Service de Réanimation Médicale et de Médecine Hyperbare, CHU et Université d'Angers, Angers, France.
| | - David Luis
- Service de Réanimation Médico-chirurgicale, Garches, France.
| | - François Fourrier
- Service de Réanimation Polyvalente, Hôpital Roger Salengro, CHU de Lille, Lille, France.
| | - Anne Renault
- Service de Réanimation Médicale, CHU de Brest, Brest, France.
| | - Laurent Argaud
- Service de Réanimation Médicale, Hôpital Edouard Herriot, Lyon, France.
| | - Tarek Sharshar
- Service de Réanimation Médico-chirurgicale, Hôpital Raymond Poincaré, Garches and Université de Versailles St Quentin en Yvelines, Garches, France.
| | - Sébastien Gibot
- Service de Réanimation médicale, Hôpital Central, CHU de Nancy, Nancy, France.
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Intensive care treatment of uncontrolled status epilepticus in children: systematic literature search of midazolam and anesthetic therapies*. Pediatr Crit Care Med 2014; 15:632-9. [PMID: 24901802 DOI: 10.1097/pcc.0000000000000173] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE A systematic literature search and review of the best evidence for intensive care treatment of refractory status epilepticus in children using continuous infusion of midazolam or anesthetic agents. DESIGN MEDLINE and EMBASE search before December 2013 using key words and/or Medical Subject Headings identified English-language citations that were screened for eligibility and used if 1) the study was about high-dose benzodiazepine or anesthetic agent for children; 2) the treatment protocol was described and used for refractory status epilepticus; 3) the outcomes included seizure control; and 4) the series included at least five children. MAIN RESULTS Sixteen studies (645 patients) were identified, including midazolam (nine studies), barbiturate (four studies), and other anesthetic approaches (three studies). When midazolam was used as the initial agent for refractory status epilepticus, the rate of clinical seizure control was 76%, which was achieved on average 41 minutes after starting the infusion. When midazolam was used in conjunction with continuous electroencephalography, the time to seizure control was much longer and the mean dose required for seizure control was 10.7 μg/kg/min compared with a lower dose (2.8 μg/kg/min) in the studies not using this form of monitoring, suggesting that continuous electroencephalography provided additional targets for treatment. Barbiturates were usually used after midazolam failed and treatment was started, on average, 66 hours after refractory status epilepticus onset with the goal of electroencephalography burst suppression, which was achieved, on average, 22.6 hours later. Among patients failing midazolam, barbiturate infusion was effective in 65%. Inhaled anesthetics, ketamine, and hypothermia were generally used after prior therapy with midazolam and barbiturates had failed, usually several days after seizure onset. CONCLUSIONS The data on intensive care treatment of pediatric refractory status epilepticus are of poor quality, yet they show a hierarchy in strategies: early midazolam, then barbiturates, and then trial of other anesthetic strategies. In addition, using a solely clinical endpoint for seizure control may be missing significant seizure burden in pediatric refractory status epilepticus.
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Rossetti AO, Bleck TP. What's new in status epilepticus? Intensive Care Med 2014; 40:1359-62. [PMID: 24923581 DOI: 10.1007/s00134-014-3363-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 06/04/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Andrea O Rossetti
- Department of Clinical Neurosciences, Service de Neurologie, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland,
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Fernandez A, Lantigua H, Lesch C, Shao B, Foreman B, Schmidt JM, Hirsch LJ, Mayer SA, Claassen J. High-dose midazolam infusion for refractory status epilepticus. Neurology 2013; 82:359-65. [PMID: 24363133 DOI: 10.1212/wnl.0000000000000054] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This study compares 2 treatment protocols allowing low vs high continuous IV midazolam (cIV-MDZ) doses. METHODS We compared adults with refractory status epilepticus treated with a protocol allowing for high-dose cIV-MDZ (n = 100; 2002-2011) with those treated with the previous lower-dose cIV-MDZ (n = 29; 1996-2000). We collected data on baseline characteristics, cIV-MDZ doses, seizure control, hospital course, and outcome. RESULTS Median maximum cIV-MDZ dose was 0.4 mg/kg/h (interquartile range [IQR] 0.2, 1.0) for the high-dose group and 0.2 mg/kg/h (IQR 0.1, 0.3) for the low-dose group (p < 0.001) with similar duration of infusion. Median time from status epilepticus onset to cIV-MDZ start was 1 day (IQR 1, 3) for the high-dose group and 2 days (IQR 1, 5) for the low-dose group (p = 0.016). "Withdrawal seizures" (occurring within 48 hours of discontinuation of cIV-MDZ) were less frequent in the high-dose group (15% vs 64%, odds ratio 0.10, 95% confidence interval 0.03-0.27). "Ultimate cIV-MDZ failure" (patients requiring change to a different cIV antiepileptic medication) and hospital complications were not different between groups. Hypotension was more frequent with higher cIV-MDZ doses but was not associated with worse outcome. Discharge mortality was lower in the high-dose group (40% vs 62%, odds ratio 0.34, 95% confidence interval 0.13-0.92 in multivariate analysis). CONCLUSIONS High-dose cIV-MDZ treatment of refractory status epilepticus can be performed safely, is associated with a lower seizure rate after cIV-MDZ discontinuation, and may be associated with lower mortality than traditional lower-dose protocols. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that midazolam at higher infusion rates is associated with a reduction in seizure recurrence within 48 hours after discontinuation and may be associated with lower mortality.
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Affiliation(s)
- Andres Fernandez
- From the Department of Neurology (A.F., H.L., B.S., B.F., J.M.S., L.J.H., S.A.M., J.C.), Columbia University Medical Center; and Department of Pharmacy (C.L.), New York-Presbyterian Hospital, NY
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Sutter R, Marsch S, Fuhr P, Kaplan PW, Rüegg S. Anesthetic drugs in status epilepticus: risk or rescue? A 6-year cohort study. Neurology 2013; 82:656-64. [PMID: 24319039 DOI: 10.1212/wnl.0000000000000009] [Citation(s) in RCA: 206] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the risks of continuously administered IV anesthetic drugs (IVADs) on the outcome of adult patients with status epilepticus (SE). METHODS All intensive care unit patients with SE from 2005 to 2011 at a tertiary academic medical care center were included. Relative risks were calculated for the primary outcome measures of seizure control, Glasgow Outcome Scale score at discharge, and death. Poisson regression models were used to control for possible confounders and to assess effect modification. RESULTS Of 171 patients, 37% were treated with IVADs. Mortality was 18%. Patients with anesthetic drugs had more infections during SE (43% vs 11%; p < 0.0001) and a 2.9-fold relative risk for death (2.88; 95% confidence interval 1.45-5.73), independent of possible confounders (i.e., duration and severity of SE, nonanesthetic third-line antiepileptic drugs, and critical medical conditions) and without significant effect modification by different grades of SE severity and etiologies. As IVADs were used after first- and second-line drugs failed, there was a correlation between treatment-refractory SE and the use of IVADs, leading to insignificant results regarding the risk of IVADs and outcome after additional adjustment for refractory SE. CONCLUSION Our findings heighten awareness regarding adverse effects of IVADs. Randomized controlled trials are needed to further clarify the association of IVADs with outcome in patients with SE. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that patients with SE receiving IVADs have a higher proportion of infection and an increased risk of death as compared to patients not receiving IVADs.
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Affiliation(s)
- Raoul Sutter
- From the Clinic for Intensive Care Medicine (R.S., S.M.) and the Division of Clinical Neurophysiology, Department of Neurology (R.S., P.F., S.R.), University Hospital Basel, Switzerland; the Division of Neurosciences Critical Care (R.S.), Department of Anesthesiology, Critical Care Medicine and Neurology, Johns Hopkins University School of Medicine, Baltimore; and the Department of Neurology (R.S., P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
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Rogawski MA, Loya CM, Reddy K, Zolkowska D, Lossin C. Neuroactive steroids for the treatment of status epilepticus. Epilepsia 2013; 54 Suppl 6:93-8. [PMID: 24001085 DOI: 10.1111/epi.12289] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Benzodiazepines are the current first-line standard-of-care treatment for status epilepticus but fail to terminate seizures in about one third of cases. Synaptic GABAA receptors, which mediate phasic inhibition in central circuits, are the molecular target of benzodiazepines. As status epilepticus progresses, these receptors are internalized and become functionally inactivated, conferring benzodiazepine resistance, which is believed to be a major cause of treatment failure. GABAA receptor positive allosteric modulator neuroactive steroids, such as allopregnanolone, also potentiate synaptic GABAA receptors, but in addition they enhance extrasynaptic GABAA receptors that mediate tonic inhibition. Extrasynaptic GABAA receptors are not internalized, and desensitization of these receptors does not occur during continuous seizures in status epilepticus models. Here we review the broad-spectrum antiseizure activity of allopregnanolone in animal seizure models and the evidence for its activity in models of status epilepticus. We also demonstrate that allopregnanolone inhibits ongoing behavioral and electrographic seizures in a model of status epilepticus, even when there is benzodiazepine resistance. Parenteral allopregnanolone may provide an improved treatment for refractory status epilepticus.
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Affiliation(s)
- Michael A Rogawski
- Department of Neurology, School of Medicine, University of California-Davis, 4860 Y Street, Sacramento, CA 95817, U.S.A.
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Riviello JJ, Claassen J, LaRoche SM, Sperling MR, Alldredge B, Bleck TP, Glauser T, Shutter L, Treiman DM, Vespa PM, Bell R, Brophy GM. Treatment of status epilepticus: an international survey of experts. Neurocrit Care 2013; 18:193-200. [PMID: 23097138 DOI: 10.1007/s12028-012-9790-1] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND As part of the development of the Neurocritical Care Society (NCS) Status Epilepticus (SE) Guidelines, the NCS SE Writing Committee conducted an international survey of SE experts. METHODS The survey consisted of three patient vignettes (case 1, an adult; case 2, an adolescent; case 3, a child) and questions regarding treatment. The questions for each case focused on initial and sequential therapy as well as when to use continuous intravenous (cIV) therapy and for what duration. Responses were obtained from 60/120 (50%) of those surveyed. RESULTS This survey reveals that there is expert consensus for using intravenous lorazepam for the emergent (first-line) therapy of SE in children and adults. For urgent (second-line) therapy, the most common agents chosen were phenytoin/fosphenytoin, valproate sodium, and levetiracetam; these choices varied by the patient age in the case scenarios. Physicians who care for adult patients chose cIV therapy for RSE, especially midazolam and propofol, rather than a standard AED sooner than those who care for children; and in children, there is a reluctance to choose propofol. Pentobarbital was chosen later in the therapy for all ages. CONCLUSION There is close agreement between the recently published NCS guideline for SE and this survey of experts in the treatment of SE.
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Affiliation(s)
- James J Riviello
- NYU Comprehensive Epilepsy Center, NYU Langone Medical Center, Division of Pediatric Neurology, Department of Neurology, New York University School of Medicine, 223 East 34th Street, New York, NY 10016, USA.
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Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ, Shutter L, Sperling MR, Treiman DM, Vespa PM. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17:3-23. [PMID: 22528274 DOI: 10.1007/s12028-012-9695-z] [Citation(s) in RCA: 973] [Impact Index Per Article: 81.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Status epilepticus (SE) treatment strategies vary substantially from one institution to another due to the lack of data to support one treatment over another. To provide guidance for the acute treatment of SE in critically ill patients, the Neurocritical Care Society organized a writing committee to evaluate the literature and develop an evidence-based and expert consensus practice guideline. Literature searches were conducted using PubMed and studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using standardized assessment methods from the American Heart Association and Grading of Recommendations Assessment, Development, and Evaluation systems, as well as expert opinion when sufficient data were lacking.
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Affiliation(s)
- Gretchen M Brophy
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Medical College of Virginia Campus, 410 N. 12th Street, P.O. Box 980533, Richmond, VA 23298-0533, USA.
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Pouliot W, Bialer M, Hen N, Shekh-Ahmad T, Kaufmann D, Yagen B, Ricks K, Roach B, Nelson C, Dudek FE. A comparative electrographic analysis of the effect of sec-butyl-propylacetamide on pharmacoresistant status epilepticus. Neuroscience 2012; 231:145-56. [PMID: 23159312 DOI: 10.1016/j.neuroscience.2012.11.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Accepted: 11/03/2012] [Indexed: 01/10/2023]
Abstract
Better treatment of status epilepticus (SE), which typically becomes refractory after about 30 min, will require new pharmacotherapies. The effect of sec-butyl-propylacetamide (SPD), an amide derivative of valproic acid (VPA), on electrographic status epilepticus (ESE) was compared quantitatively to other standard-of-care compounds. Cortical electroencephalograms (EEGs) were recorded from rats during ESE induced with lithium-pilocarpine. Using a previously-published algorithm, the effects of SPD on ESE were compared quantitatively to other relevant compounds. To confirm benzodiazepine resistance, diazepam (DZP) was shown to suppress ESE when administered 15 min after the first motor seizure, but not after 30 min (100mg/kg). VPA (300 mg/kg) also lacked efficacy at 30 min. SPD (130 mg/kg) strongly suppressed ESE at 30 min, less after 45 min, and not at 60 min. At a higher dose (180 mg/kg), SPD profoundly suppressed ESE at 60 min, similar to propofol (100mg/kg) and pentobarbital (30 mg/kg). After 4-6h of SPD-induced suppression, EEG activity often overshot control levels at 7-12h. Valnoctamide (VCD, 180 mg/kg), an SPD homolog, was also efficacious at 30 min. SPD blocks pilocarpine-induced electrographic seizures when administered at 1h after the first motor seizure. SPD has a faster onset and greater efficacy than DZP and VPA, and is similar to propofol and pentobarbital. SPD and structurally similar compounds may be useful for the treatment of refractory ESE. Further development and use of automated analyses of ESE may facilitate drug discovery for refractory SE.
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Affiliation(s)
- W Pouliot
- Department of Physiology, University of Utah School of Medicine, Salt Lake City, UT, USA
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Kramer AH, Bleck TP. Neurocritical care of patients with central nervous system infections. Curr Treat Options Neurol 2012; 10:201-11. [PMID: 18579024 DOI: 10.1007/s11940-008-0022-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Bacterial meningitis and viral encephalitis are life-threatening infections with high mortality rates. Patients who survive these infections often remain permanently disabled. Potential neurologic complications requiring careful attention include impaired consciousness, elevated intracranial pressure (ICP), hydrocephalus, stroke, and seizures. Systemic complications are also common and are frequently the immediate cause of death. The importance of emergent administration of appropriate antimicrobial therapy cannot be overstated, but critical care of these patients should focus not only on treatment of the underlying infection and its immediate complications but also on minimizing secondary brain injury. Given the increasing complexity of the diagnostic and therapeutic modalities available to manage central nervous system (CNS) infections, the involvement of neurocritical care units and neurointensivists may be particularly helpful in improving outcomes. It is our opinion that ICP measurement should be strongly considered in selected patients with CNS infections, particularly those who are comatose. Treatments for intracranial hypertension, specifically in the setting of CNS infection, are described in this paper. For bacterial meningitis, intravenous dexamethasone should be administered, beginning concomitantly with the initial dose of antibiotics, at least until Streptococcus pneumoniae can be excluded as a pathogen. Clinicians should maintain a high index of suspicion for nonconvulsive seizures. Deterioration in neurologic status should also prompt early use of CT or magnetic resonance angiography and venography to exclude cerebrovascular complications.
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Affiliation(s)
- Andreas H Kramer
- Andreas H. Kramer, MD, MSc, FRCPC Department of Critical Care Medicine, Foothills Medical Center, Room EG 23 J, 1403 29th Street NW, Calgary, Alberta T2N 2T9, Canada.
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Abstract
PURPOSE OF REVIEW Refractory status epilepticus (RSE) has a high morbidity and mortality. There are currently no definitive data to guide both the optimal choice of therapy and treatment goals. This review focuses on RSE diagnosis and outcome and discusses both commonly used and anecdotal therapies for RSE. RECENT FINDINGS The challenges in performing randomized controlled trials (RCTs) in neurocritical care and more specifically for the treatment of RSE are illustrated by the early termination of the first RCT of RSE due to low recruitment that compared propofol to barbiturates. Recent case series include the successful treatment of recurrent RSE with ketamine, intravenous lacosamide as an add-on treatment, the use of combination antiepileptics (phenytoin, levetiracetam, and pregabalin), and surgical treatments (vagal nerve and deep brain stimulation) for the control of RSE. SUMMARY A number of different therapeutic options are available for the treatment of RSE but none have been shown to be superior to others at this point.
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Rossetti AO, Lowenstein DH. Management of refractory status epilepticus in adults: still more questions than answers. Lancet Neurol 2011; 10:922-30. [PMID: 21939901 DOI: 10.1016/s1474-4422(11)70187-9] [Citation(s) in RCA: 217] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Refractory status epilepticus (RSE) is defined as status epilepticus that continues despite treatment with benzodiazepines and one antiepileptic drug. RSE should be treated promptly to prevent morbidity and mortality; however, scarce evidence is available to support the choice of specific treatments. Major independent outcome predictors are age (not modifiable) and cause (which should be actively targeted). Recent recommendations for adults suggest that the aggressiveness of treatment for RSE should be tailored to the clinical situation. To minimise intensive care unit-related complications, focal RSE without impairment of consciousness might initially be approached conservatively; conversely, early induction of pharmacological coma is advisable in generalised convulsive forms of the disorder. At this stage, midazolam, propofol, or barbiturates are the most commonly used drugs. Several other treatments, such as additional anaesthetics, other antiepileptic or immunomodulatory compounds, or non-pharmacological approaches (eg, electroconvulsive treatment or hypothermia), have been used in protracted RSE. Treatment lasting weeks or months can sometimes result in a good outcome, as in selected patients after encephalitis or autoimmune disorders. Well designed prospective studies of RSE are urgently needed.
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Affiliation(s)
- Andrea O Rossetti
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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Rosenow F, Knake S. Recent and future advances in the treatment of status epilepticus. Ther Adv Neurol Disord 2011; 1:33-42. [PMID: 21180563 DOI: 10.1177/1756285608094263] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Status epilepticus (SE) is one of the most frequent neurological emergencies with an incidence of 20/100,000 per year and a mortality between 3% and 40% depending on etiology, age, SE type and duration. Generalized convulsive forms of SE (GTCSE), in particular, require aggressive treatment. Presently, only 55-80% of cases of GTCSE are controlled by initial therapy. Therefore, there is a need for new options for the treatment of SE. Here we review the current standard treatment including recent advances and provide a summary of preclinical and clinical data regarding treatment options which may become available in the near future. The initial treatment of SE usually consists of a benzodiazepine (preferably lorazepam 0.1 mg/kg) followed by phenytoin or fosphenytoin or valproic acid (where approved for SE therapy). With intravenous formulations of levetiracetam, available since 2006, and lacosamide, which is expected for autumn of 2008, new treatment options have become available, that should be evaluated in prospective controlled trials. If SE remains refractory, the induction of general anaesthesia using propofol, midazolam, thiopental, or pentobarbital is warranted in GTCSE.
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Affiliation(s)
- Felix Rosenow
- Interdisciplinary Epilepsy Center Marburg Department of Neurology Philipps-University Marburg, Rudolf-Bultmann-Str. 8, 35033 Marburg, Germany
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Rossetti AO, Milligan TA, Vulliémoz S, Michaelides C, Bertschi M, Lee JW. A randomized trial for the treatment of refractory status epilepticus. Neurocrit Care 2011; 14:4-10. [PMID: 20878265 DOI: 10.1007/s12028-010-9445-z] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Refractory status epilepticus (RSE) has a mortality of 16-39%; coma induction is advocated for its management, but no comparative study has been performed. We aimed to assess the effectiveness (RSE control, adverse events) of the first course of propofol versus barbiturates in the treatment of RSE. METHODS In this randomized, single blind, multi-center trial studying adults with RSE not due to cerebral anoxia, medications were titrated toward EEG burst-suppression for 36-48 h and then progressively weaned. The primary endpoint was the proportion of patients with RSE controlled after a first course of study medication; secondary endpoints included tolerability measures. RESULTS The trial was terminated after 3 years, with only 24 patients recruited of the 150 needed; 14 subjects received propofol, 9 barbiturates. The primary endpoint was reached in 43% in the propofol versus 22% in the barbiturates arm (P = 0.40). Mortality (43 vs. 34%; P = 1.00) and return to baseline clinical conditions at 3 months (36 vs. 44%; P = 1.00) were similar. While infections and arterial hypotension did not differ between groups, barbiturate use was associated with a significantly longer mechanical ventilation (P = 0.03). A non-fatal propofol infusion syndrome was detected in one patient, while one subject died of bowel ischemia after barbiturates. DISCUSSION Although undersampled, this trial shows significantly longer mechanical ventilation with barbiturates and the occurrence of severe treatment-related complications in both arms. We describe practical issues necessary for the success of future studies needed to improve the current unsatisfactory state of evidence.
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Affiliation(s)
- Andrea O Rossetti
- Department of Neurology, CHUV et Université de Lausanne, Lausanne, Switzerland.
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Power KN, Flaatten H, Gilhus NE, Engelsen BA. Propofol treatment in adult refractory status epilepticus. Mortality risk and outcome. Epilepsy Res 2011; 94:53-60. [PMID: 21300522 DOI: 10.1016/j.eplepsyres.2011.01.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Revised: 01/07/2011] [Accepted: 01/08/2011] [Indexed: 10/18/2022]
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Abstract
Status epilepticus is a common neurological emergency in childhood and associated with significant morbidity and mortality. Status epilepticus (SE) has been defined as continuous seizure activity lasting more than 30 min or 2 or more seizures in this duration without gaining consciousness between them. However, the operational definition has brought the time down to 5 min. Management can be broadly divided into initial stabilization, seizure termination, and evaluation and treatment of the underlying cause. Diagnostic evaluation and seizure control should be achieved simultaneously to improve outcome. Seizure termination is achieved by pharmacotherapy. Benzodiazepines are the first line drugs for SE. Commonly used drugs include lorazepam, diazepam, and midazolam. In children without an IV access, buccal or nasal midazolam or rectal diazepam can be used. Phenytoin as a second line agent is usually indicated when seizure is not controlled after one or more doses of benzodiazepines. If the seizures continue to persist, valproate, phenobarbitone or levetiracetam is indicated. Midazolam infusion is useful in refractory status epilepticus. Thiopentone, propofol or high dose phenobarbitone are considered for treatment of refractory status epilepticus. Prolonged SE is associated with higher morbidity and mortality. Long term neurological sequelae include epilepsy, behavioural problems, cognitive decline, and focal neurologic deficits.
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Abstract
This review discusses the medical management of pediatric refractory status epilepticus, defined here as persistent seizures of any type after the administration of 2 appropriate anticonvulsants. The use of both nonanesthetic and anesthetic anticonvulsants is discussed along with the relative strengths and weaknesses of each agent. Appropriate treatment goals and the use of electroencephalographic monitoring are described as are reasonable treatment algorithms. Finally, ethical considerations are briefly discussed in the context of available outcome data.
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Affiliation(s)
- James Owens
- Department of Pediatrics and Neurology, Baylor College of Medicine, Houston, TX, USA.
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Tesoro EP, Brophy GM. Pharmacological management of seizures and status epilepticus in critically ill patients. J Pharm Pract 2010; 23:441-54. [PMID: 21507848 DOI: 10.1177/0897190010372321] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Seizures are serious complications seen in critically ill patients and can lead to significant morbidity and mortality if the cause is not identified and treated quickly. Uncontrolled seizures can lead to status epilepticus (SE), which is considered a medical emergency. The first-line treatment of seizures is an intravenous (IV) benzodiazepine followed by anticonvulsant therapy. Refractory SE can evolve into a nonconvulsive state requiring IV anesthetics or induction of pharmacological coma. To prevent seizures and further complications in critically ill patients with acute neurological disease or injury, short-term seizure prophylaxis should be considered in certain patients.
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Affiliation(s)
- Eljim P Tesoro
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Kramer AH, Bleck TP. Neurocritical care of patients with central nervous system infections. Curr Infect Dis Rep 2010; 9:308-14. [PMID: 17618551 DOI: 10.1007/s11908-007-0048-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Bacterial meningitis and viral encephalitis are life-threatening infections with high mortality rates. Patients who survive these infections often remain permanently disabled. Potential neurologic complications requiring careful attention include impaired consciousness, elevated intracranial pressure, hydrocephalus, stroke, and seizures. Systemic complications are also common and are frequently the immediate cause of death. Critical care of these patients should focus not only on treatment of the underlying infection and its immediate complications but also on minimizing secondary brain injury. Given the increasing complexity of the diagnostic and therapeutic modalities available in managing central nervous system infections, the involvement of neurocritical care units and neurointensivists may be particularly helpful in improving outcomes.
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Affiliation(s)
- Andreas H Kramer
- Department of Neurology, University of Virginia, P.O. Box 800394, Charlottesville, VA 22908, USA.
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Al-Mefty O, Wrubel D, Haddad N. Postoperative nonconvulsive encephalopathic status: identification of a syndrome responsible for delayed progressive deterioration of neurological status after skull base surgery. J Neurosurg 2009; 111:1062-8. [DOI: 10.3171/2008.12.jns08418] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Over a 10-year period, the authors have observed a rare but recurring syndrome manifested by a delayed, postoperative, progressive decline in the level of consciousness to deep coma that is time-limited to several days with abrupt awakening. Extensive evaluation and workup demonstrated an abnormality on continuous electroencephalographic monitoring that implied nonconvulsive status epilepticus after the exclusion of structural, perfusion, infectious, or metabolic causes. This state has been very refractory to treatment with antiepileptic medication. In this article, the authors raise the awareness of this syndrome and its diagnosis, management, and outcome.
Methods
The authors reviewed the medical records of a cohort of 7 patients who exemplified this syndrome who were treated during the last 5 years.
Results
All 7 patients were women with a mean (± SD) age of 55 ± 15 years. The mean duration of surgery was 8.9 ± 1.8 hours. All patients had a stereotypical course of delayed progressive decline in their level of consciousness after surgery (average 3.3 ± 4.3 days) leading to deep coma. The unconscious state was time-limited, lasting on average 17.3 ± 13.7 days. Continuous electroencephalographic monitoring demonstrated a generalized abnormality with periodic discharges and abundant slow delta activity. A rather abrupt awakening occurred a few days after cessation of electrographic seizure activity. Structural, vascular, infectious, or metabolic causes were excluded based on an extensive workup.
Conclusions
In this study, the authors delineate and raise the awareness of an unusual syndrome. Recognition of this syndrome is important as a cause for delayed coma after surgery. The authors stress the need for respiratory, hemodynamic, and nutritional support for these patients until recovery. The origin of this syndrome remains enigmatic and is likely to be multifactorial with a prominent pharmacological role related to anesthetic agent or medication in a setting of craniotomy that is associated with alteration of the blood-brain barrier.
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Knake S, Hamer HM, Rosenow F. Status epilepticus: a critical review. Epilepsy Behav 2009; 15:10-4. [PMID: 19236943 DOI: 10.1016/j.yebeh.2009.02.027] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Accepted: 02/19/2009] [Indexed: 10/21/2022]
Abstract
Status epilepticus (SE) is a major neurological emergency with an incidence of about 20/100,000 and a mortality between 3 and 40% depending on etiology, age, status type, and status duration. Generalized tonic-clonic SE, in particular, requires immediate, aggressive, and effective treatment to stop seizure activity, and to prevent neuronal damage and systemic complications and death. Benzodiazepines and phenytoin/fosphenytoin are traditionally used as first-line drugs and are effective in about 60% of all episodes. However, a notable portion of patients remain in SE. For those, narcotics and induction of general anesthesia are used as second-line treatment. Therefore, there is a need for more effective first-line treatment options. Recently, valproic acid was approved for the treatment of status epilepticus in some European countries, and two of the newer antiepileptic drugs have become available for intravenous use: Levetiracetam (LEV) and lacosamide (LCM) should be evaluated in prospective controlled trials as possible treatment options. Standardized protocols for the management of SE are useful to improve immediate care.
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Affiliation(s)
- Susanne Knake
- Interdisciplinary Epilepsy Center Marburg, Department of Neurology, Philipps University Marburg, Rudolf-Bultmann-Strasse 8, 35033 Marburg, Germany.
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Rossetti A, Santoli F. Traitement pharmacologique de l’état de mal réfractaire. Rev Neurol (Paris) 2009; 165:373-9. [DOI: 10.1016/j.neurol.2008.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 12/05/2008] [Indexed: 10/21/2022]
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Lehmkuhle MJ, Thomson KE, Scheerlinck P, Pouliot W, Greger B, Dudek FE. A simple quantitative method for analyzing electrographic status epilepticus in rats. J Neurophysiol 2009; 101:1660-70. [PMID: 19129295 DOI: 10.1152/jn.91062.2008] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Electrographic status epilepticus (ESE) is a medical emergency consisting of repetitive seizures and may result in death or severe brain damage. Epilepsy can develop following ESE. The properties of ESE (e.g., duration and intensity) are variable, as are the effects of putative therapeutic treatments. Therefore a straightforward method to quantify different components of ESE would be beneficial for both researchers and clinicians. A frequency range close to the gamma band was selected for extraction of seizure-related activity from the EEG. This filtering strategy reduced motion artifacts and other noise sources in the electrophysiological recordings, thus increasing the signal-to-noise ratio of the EEG spike activity. EEG spiking was quantified using an energy operator and modeled by an eighth-order polynomial. In a benzodiazepine-resistant rat model of pilocarpine-induced ESE, the efficacy of various pharmaceutical agents at suppressing ESE was analyzed with this and other methods on data collected for < or =24 h after ESE induction. This approach allows for the objective, quantitative, and rapid assessment of the effects of both short- and long-lasting pharmacological manipulations on ESE and other forms of prolonged repetitive electrical activity.
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Affiliation(s)
- M J Lehmkuhle
- Department of Physiology, University of Utah School of Medicine, 420 Chipeta Way, Suite 1700, Salt Lake City, UT 84108, USA
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Cereda C, Berger MM, Rossetti AO. Bowel Ischemia: A Rare Complication of Thiopental Treatment for Status Epilepticus. Neurocrit Care 2008; 10:355-8. [DOI: 10.1007/s12028-008-9168-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2008] [Accepted: 10/29/2008] [Indexed: 10/21/2022]
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Abstract
Status epilepticus still remains a formidable adversary to neurointensivists. Although the majority of cases admitted to the Neuro-ICU are easily controlled with one or two antiepileptic drug defense lines, several cases become refractory and end up receiving general anesthetics for days or weeks with significant morbidity. Treatment algorithms have been published and should be followed, but in many cases they are inadequate because, especially in the distal branches of the treatment tree, are based on anecdotal data or small series of patients. In addition, a double-blind, randomized-controlled study in status has not been done for many years and solid data are lacking for the newer antiepileptics. Therefore, in the moderately to severely refractory cases, status treatment is based on personal previous experience and becomes an art more than a science. In this review of a difficult case, we discuss some fine details of the treatment provided and emphasize the multidisciplinary approach that should be followed including involvement of neurointensivists, epileptologists, electroencephalographers, and neurosurgeons.
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Affiliation(s)
- Panayiotis N Varelas
- Department of Neurology, Henry Ford Hospital, K-11, 2799 West Grand Blvd, Detroit, MI 48202, USA.
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47
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Abstract
It is proposed that a reduced surface expression of GABA(A) receptors (GABARs) contributes to the pathogenesis of status epilepticus (SE), a condition characterized by prolonged seizures. This hypothesis was based on the finding that prolonged epileptiform bursting (repetitive bursts of prolonged depolarizations with superimposed action potentials) in cultures of dissociated hippocampal pyramidal neurons (dissociated cultures) results in the increased intracellular accumulation of GABARs. However, it is not known whether this rapid modification in the surface-expressed GABAR pool results from selective, subunit-dependent or nonselective, subunit-independent internalization of GABARs. In hippocampal slices obtained from animals undergoing prolonged SE (SE-treated slices), we found that the surface expression of the GABAR beta2/3 and gamma2 subunits was reduced, whereas that of the delta subunit was not. Complementary electrophysiological recordings from dentate granule cells in SE-treated slices demonstrated a reduction in GABAR-mediated synaptic inhibition, but not tonic inhibition. A reduction in the surface expression of the gamma2 subunit, but not the delta subunit was also observed in dissociated cultures and organotypic hippocampal slice cultures when incubated in an elevated KCl external medium or an elevated KCl external medium supplemented with NMDA, respectively. Additional studies demonstrated that the reduction in the surface expression of the gamma2 subunit was independent of direct ligand binding of the GABAR. These findings demonstrate that the regulation of surface-expressed GABAR pool during SE is subunit-specific and occurs independent of ligand binding. The differential modulation of the surface expression of GABARs during SE has potential implications for the treatment of this neurological emergency.
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48
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Ferro JM, Canhão P. Acute treatment of cerebral venous and dural sinus thrombosis. Curr Treat Options Neurol 2008; 10:126-37. [DOI: 10.1007/s11940-008-0014-0] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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49
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Cortico-thalamic activation in generalized status epilepticus, a PET study. Clin Neurol Neurosurg 2008; 110:182-5. [DOI: 10.1016/j.clineuro.2007.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2007] [Revised: 08/31/2007] [Accepted: 09/14/2007] [Indexed: 11/18/2022]
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50
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Martin BS, Kapur J. A combination of ketamine and diazepam synergistically controls refractory status epilepticus induced by cholinergic stimulation. Epilepsia 2007; 49:248-55. [PMID: 17941842 DOI: 10.1111/j.1528-1167.2007.01384.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE New treatments are needed for status epilepticus (SE) that is refractory to drugs modulating GABA(A) receptors, and NMDA receptor antagonists are candidate drugs. METHODS Clinically available NMDA receptor antagonist ketamine was tested for effectiveness in terminating prolonged SE induced by a combination of lithium and pilocarpine. Animals were treated 10 min after first grade 5 behavioral seizure (Racine scoring scale) by intraperitoneal administration of ketamine, diazepam, or saline. Seizure termination was determined by electroencephalogram (EEG) recordings from the hippocampus and the cortex. RESULTS Animals treated with normal saline or either 20 mg/kg diazepam, or 50 mg/kg ketamine continued in SE for the next 300 min. However, combined treatment with diazepam and ketamine rapidly terminated prolonged cholinergic stimulation-induced SE. Detailed study of dose response relationships demonstrated that diazepam enhanced efficacy and potency of ketamine in terminating SE. DISCUSSION This study demonstrated synergistic action of diazepam and ketamine in terminating SE. It suggests that a ketamine-diazepam combination might be a clinically useful therapeutic option for the treatment of refractory SE.
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Affiliation(s)
- Brandon S Martin
- Department of Neurology, University of Virginia Health Sciences Center, Charlottesville, Virginia 22908-800394, U.S.A
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