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Kraus KL, Nawreen N, Godale CM, Chordia AP, Packard B, LaSarge CL, Herman JP, Danzer SC. Hippocampal glucocorticoid receptors modulate status epilepticus severity. Neurobiol Dis 2023; 178:106014. [PMID: 36702319 PMCID: PMC10055427 DOI: 10.1016/j.nbd.2023.106014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 01/04/2023] [Accepted: 01/22/2023] [Indexed: 01/24/2023] Open
Abstract
Status epilepticus (SE) is a life-threatening medical emergency with significant morbidity and mortality. SE is associated with a robust and sustained increase in serum glucocorticoids, reaching concentrations sufficient to activate the dense population of glucocorticoid receptors (GRs) expressed among hippocampal excitatory neurons. Glucocorticoid exposure can increase hippocampal neuron excitability; however, whether activation of hippocampal GRs during SE exacerbates seizure severity remains unknown. To test this, a viral strategy was used to delete GRs from a subset of hippocampal excitatory neurons in adult male and female mice, producing hippocampal GR knockdown mice. Two weeks after GR knockdown, mice were challenged with the convulsant drug pilocarpine to induce SE. GR knockdown had opposing effects on early vs late seizure behaviors, with sex influencing responses. For both male and female mice, the onset of mild behavioral seizures was accelerated by GR knockdown. In contrast, GR knockdown delayed the onset of more severe convulsive seizures and death in male mice. Concordantly, GR knockdown also blunted the SE-induced rise in serum corticosterone in male mice. GR knockdown did not alter survival times or serum corticosterone in females. To assess whether loss of GR affected susceptibility to SE-induced cell death, within-animal analyses were conducted comparing local GR knockdown rates to local cell loss. GR knockdown did not affect the degree of localized neuronal loss, suggesting cell-intrinsic GR signaling neither protects nor sensitizes neurons to acute SE-induced death. Overall, the findings reveal that hippocampal GRs exert an anti-convulsant role in both males and females in the early stages of SE, followed by a switch to a pro-convulsive role for males only. Findings reveal an unexpected complexity in the interaction between hippocampal GR activation and the progression of SE.
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Affiliation(s)
- Kimberly L Kraus
- Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America; Neuroscience Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America; Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America.
| | - Nawshaba Nawreen
- Neuroscience Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America; Department of Pharmacology and Systems Physiology, University of Cincinnati School of Medicine, Cincinnati, OH, United States of America.
| | - Christin M Godale
- Neuroscience Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America; Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America.
| | - Arihant P Chordia
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America.
| | - Ben Packard
- Department of Pharmacology and Systems Physiology, University of Cincinnati School of Medicine, Cincinnati, OH, United States of America.
| | - Candi L LaSarge
- Neuroscience Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America; Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America; Department of Anesthesiology, University of Cincinnati School of Medicine, Cincinnati, OH, United States of America
| | - James P Herman
- Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America; Department of Anesthesiology, University of Cincinnati School of Medicine, Cincinnati, OH, United States of America.
| | - Steve C Danzer
- Medical Scientist Training Program, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America; Neuroscience Graduate Program, University of Cincinnati College of Medicine, Cincinnati, OH, United States of America; Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America; Department of Anesthesiology, University of Cincinnati School of Medicine, Cincinnati, OH, United States of America.
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Trinka E, Rainer LJ, Granbichler CA, Zimmermann G, Leitinger M. Mortality, and life expectancy in Epilepsy and Status epilepticus-current trends and future aspects. FRONTIERS IN EPIDEMIOLOGY 2023; 3:1081757. [PMID: 38455899 PMCID: PMC10910932 DOI: 10.3389/fepid.2023.1081757] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/31/2023] [Indexed: 03/09/2024]
Abstract
Patients with epilepsy carry a risk of premature death which is on average two to three times higher than in the general population. The risk of death is not homogenously distributed over all ages, etiologies, and epilepsy syndromes. People with drug resistant seizures carry the highest risk of death compared to those who are seizure free, whose risk is similar as in the general population. Most of the increased risk is directly related to the cause of epilepsy itself. Sudden unexplained death in epilepsy patients (SUDEP) is the most important cause of epilepsy-related deaths especially in the young and middle-aged groups. Population based studies with long-term follow up demonstrated that the first years after diagnosis carry the highest risk of death, while in the later years the mortality decreases. Improved seizure control and being exposed to a specialized comprehensive care centre may help to reduce the risk of death in patients with epilepsy. The mortality of status epilepticus is substantially increased with case fatality rates between 4.6% and 39%, depending on its cause and duration, and the age of the population studied. The epidemiological data on overall and cause specific mortality as well as their determinants and risk factors are critically reviewed and methodological issues pertinent to the studies on mortality of epilepsy and Status epilepticus are discussed.
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Member of EpiCARE, Salzburg, Austria
- Neuroscience Institute, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Salzburg, Austria
- Institute of Public Health, Medical Decision-Making and HTA, UMIT – Private University for Health Sciences, Medical Informatics and Technology, Hall In Tyrol, Austria
| | - Lucas J. Rainer
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Member of EpiCARE, Salzburg, Austria
- Neuroscience Institute, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Salzburg, Austria
| | | | - Georg Zimmermann
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Member of EpiCARE, Salzburg, Austria
- Team Biostatistics and Big Medical Data, IDA Lab Salzburg, Paracelsus Medical University, Salzburg, Austria
- Research and Innovation Management, Paracelsus Medical University, Salzburg, Austria
| | - Markus Leitinger
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Member of EpiCARE, Salzburg, Austria
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Benaiteau M, Valton L, Gardy L, Denuelle M, Debs R, Wucher V, Rulquin F, Barbeau EJ, Bonneville F, Pariente J, Curot J. Specific profiles of new-onset vs. non-inaugural status epilepticus: From diagnosis to 1-year outcome. Front Neurol 2023; 14:1101370. [PMID: 36860570 PMCID: PMC9969963 DOI: 10.3389/fneur.2023.1101370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
While new-onset status epilepticus (NOSE) is a harbinger of chronic epilepsy, prospective medical data are sparse in terms of specifying whether the evolution of status epilepticus (SE) and seizure expression in NOSE resembles what occurs in patients who have already been diagnosed with epilepsy [non-inaugural SE (NISE)] in all aspects apart from its inaugural nature. The aim of this study was to compare the clinical, MRI, and EEG features that could distinguish NOSE from NISE. We conducted a prospective monocentric study in which all patients ≥18 years admitted for SE over a 6-month period were included. A total of 109 patients (63 NISE and 46 NOSE cases) were included. Despite similar modified Rankin scores before SE, several aspects of the clinical history distinguished NOSE from NISE patients. NOSE patients were older and frequently had neurological comorbidity and preexisting cognitive decline, but they had a similar prevalence of alcohol consumption to NISE patients. NOSE and NISE evolve in the same proportions as refractory SE (62.5% NOSE, 61% NISE) and share common features such as the same incidence (33% NOSE, 42% NISE, and p = 0.53) and volumes of peri-ictal abnormalities on MRI. However, in NOSE patients, we observed greater non-convulsive semiology (21.7% NOSE, 6% NISE, and p = 0.02), more periodic lateral discharges on EEG (p = 0.004), later diagnosis, and higher severity according to the STESS and EMSE scales (p < 0.0001). Mortality occurred in 32.6% of NOSE patients and 21% of NISE patients at 1 year (p = 0.19), but with different causes of death occurring at different time points: more early deaths directly linked to SE at 1 month occurred in the NOSE group, while there were more remote deaths linked to causal brain lesions in the NISE group at final follow-up. In survivors, 43.6% of the NOSE cases developed into epilepsy. Despite acute causal brain lesions, the novelty related to its inaugural nature is still too often associated with a delay in diagnosing SE and a poorer outcome, which justifies the need to more clearly specify the various types of SE to constantly raise awareness among clinicians. These results highlight the relevance of including novelty-related criteria, clinical history, and temporality of occurrence in the nosology of SE.
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Affiliation(s)
- Marie Benaiteau
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, University Hospital of Lyon HCL, Lyon, France,Neurology Department, Toulouse University Hospital, Toulouse, France,*Correspondence: Marie Benaiteau ✉
| | - Luc Valton
- Neurology Department, Toulouse University Hospital, Toulouse, France,Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France,Luc Valton ✉
| | - Ludovic Gardy
- Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France
| | - Marie Denuelle
- Neurology Department, Toulouse University Hospital, Toulouse, France,Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France
| | - Rachel Debs
- Neurology Department, Toulouse University Hospital, Toulouse, France
| | - Valentin Wucher
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, University Hospital of Lyon HCL, Lyon, France,Synaptopathies and Autoantibodies (SynatAc) Team, NeuroMyoGene-MeLis Institute, INSERM U1314/CNRS UMR 5284, University of Lyon, Lyon, France
| | - Florence Rulquin
- Neurology Department, Toulouse University Hospital, Toulouse, France
| | - Emmanuel J. Barbeau
- Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France,Faculty of Health, University of Toulouse-Paul Sabatier, Toulouse, France
| | - Fabrice Bonneville
- Faculty of Health, University of Toulouse-Paul Sabatier, Toulouse, France,INSERM, U1214, Toulouse Neuro Imaging Center (ToNIC), Toulouse, France,Neuroradiology Department, Toulouse University Hospital, Toulouse, France
| | - Jérémie Pariente
- Neurology Department, Toulouse University Hospital, Toulouse, France,Faculty of Health, University of Toulouse-Paul Sabatier, Toulouse, France,INSERM, U1214, Toulouse Neuro Imaging Center (ToNIC), Toulouse, France
| | - Jonathan Curot
- Neurology Department, Toulouse University Hospital, Toulouse, France,Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France,Faculty of Health, University of Toulouse-Paul Sabatier, Toulouse, France,Jonathan Curot ✉
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Hidalgo de la Cruz M, Miranda Acuña JA, Luque Buzo E, Chavarria Cano B, Esteban de Antonio E, Prieto Montalvo J, Galiano Fragua ML, Massot-Tarrús A. Status epilepticus management and mortality risk factors: A retrospective study. Neurologia 2022; 37:532-542. [PMID: 31771778 DOI: 10.1016/j.nrl.2019.06.004] [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: 02/14/2019] [Revised: 05/28/2019] [Accepted: 06/20/2019] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Status epilepticus (SE) is a neurological emergency with relatively high mortality rates. In this study, we analysed the management of SE and identified mortality risk factors that may be addressed with educational interventions or modifications to hospital protocols. METHODS In this retrospective study, we analysed demographic, treatment, and outcome data from 65 patients (mean age, 59 years [range, 44.5-77]; 53.8% women) who were admitted to our tertiary hospital during an 18-month period and met the 2015 International League Against Epilepsy criteria for SE. RESULTS Thirty patients (46.2%) had history of epilepsy. The most frequent causes of SE were cerebrovascular disease (27.7%) and systemic infection (16.9%). The following deviations were observed in the administration of the antiepileptic drugs: benzodiazepines were used as first option in only 33 (50.8%) patients; the combination of 2 benzodiazepines was recorded in 7 cases (10.8%); and lacosamide was used as an off-label drug in 5 patients (7.7%). Electroencephalography studies were performed in only 26 patients (40%); and only 5 studies (7.7% of patients) were performed within 12 hours of seizure onset. The mortality rate was 21.5%. Acute stroke and cerebrovascular complications were associated with higher mortality rates, while previous history of epilepsy and admission to intensive care were related to better prognosis (P <.05). CONCLUSIONS To improve SE management and reduce mortality rates, training activities targeting emergency department physicians should be implemented, together with elective intensive care admission for patients with multiple mortality risk factors (eg, absence of history of epilepsy, acute stroke, or cardiovascular complications).
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Affiliation(s)
- M Hidalgo de la Cruz
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - J A Miranda Acuña
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - E Luque Buzo
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - B Chavarria Cano
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - E Esteban de Antonio
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J Prieto Montalvo
- Servicio de Neurofisiología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - M L Galiano Fragua
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - A Massot-Tarrús
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
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Hidalgo de la Cruz M, Miranda Acuña J, Luque Buzo E, Chavarria Cano B, Esteban de Antonio E, Prieto Montalvo J, Galiano Fragua M, Massot-Tarrús A. Status epilepticus management and mortality risk factors: a retrospective study. NEUROLOGÍA (ENGLISH EDITION) 2022; 37:532-542. [DOI: 10.1016/j.nrleng.2019.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/20/2019] [Indexed: 10/20/2022] Open
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Trinka E, Leitinger M. Management of Status Epilepticus, Refractory Status Epilepticus, and Super-refractory Status Epilepticus. Continuum (Minneap Minn) 2022; 28:559-602. [PMID: 35393970 DOI: 10.1212/con.0000000000001103] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW Status epilepticus is a serious condition caused by disorders and diseases that affect the central nervous system. In status epilepticus, hypersynchronous epileptic activity lasts longer than the usual duration of isolated self-limited seizures (time t1), which causes neuronal damage or alteration of neuronal networks at a certain time point (time t2), depending on the type of and duration of status epilepticus. The successful management of status epilepticus includes both the early termination of seizure activity and the earliest possible identification of a causative etiology, which may require independent acute treatment. In nonconvulsive status epilepticus, patients present only with subtle clinical signs or even without any visible clinical manifestations. In these cases, EEG allows for the assessment of cerebral function and identification of patterns in need of urgent treatment. RECENT FINDINGS In 2015, the International League Against Epilepsy proposed a new definition and classification of status epilepticus, encompassing four axes: symptomatology, etiology, EEG, and age. Various validation studies determined the practical usefulness of EEG criteria to identify nonconvulsive status epilepticus. The American Clinical Neurophysiology Society has incorporated these criteria into their most recent critical care EEG terminology in 2021. Etiology, age, symptomatology, and the metabolic demand associated with an increasing duration of status epilepticus are the most important determinants of prognosis. The consequences of status epilepticus can be visualized in vivo by MRI studies. SUMMARY The current knowledge about status epilepticus allows for a more reliable diagnosis, earlier treatment, and improved cerebral imaging of its consequences. Outcome prediction is a soft tool for estimating the need for intensive care resources.
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Machado RA, Patel J, Elsayed MS. The role of ketamine-induced beta activity in the treatment of refractory status epilepticus. Is the EEG useful to determine responder's rate? A retrospective study. Epilepsy Behav 2022; 127:108512. [PMID: 34974373 DOI: 10.1016/j.yebeh.2021.108512] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Multiple investigations have been done to evaluate the possible effect of ketamine in the treatment of status epilepticus (SE). OBJECTIVES To evaluate the electrographic effect of ketamine on EEG, and its clinical utility following-up refractory and super refractory status epilepticus (SRSE). METHODS Retrospective review of 24 patients with SE. Clinical record and Video-electroencephalogram (video-EEG) of all included patients were reviewed. The patients' EEGs were then monitored for any immediate changes after administration of the first dose of ketamine as well as at the time patients would be predicted to have peak serum concentration of ketamine. Patients with cessation of electrographic seizures and no SE recurrence within the same admissions were categorized as "Responders". Statistical differences between qualitative variables were analyzed using chi square test. Differences between median were analyzed by Mann-Whitney U test. Difference between groups were considered significant when p < 0.05. RESULTS We identified 24 patients with SE. Twelve out of 24 (50%) had SRSE and 12 out of 24 (50%) had refractory status epilepticus (RSE). The appearance of superimposed beta activity after ketamine was initiated was associated with a higher responder rate (100% versus 33.3% in the responder group versus the non-responder group respectively). Notably, the presence of a burst suppression pattern had no significant association with one group compared to the other (41.6% versus 33.3%, in the responder group vs the non-responder group respectively). CONCLUSIONS Background superimposed beta activity induced by ketamine is an early and reliable EEG finding associated with status epilepticus termination.
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Affiliation(s)
| | - Janaki Patel
- Wayne State University/Detroit Medical Center, United States
| | - Mona S Elsayed
- Adult Comprehensive Epilepsy Program, Wayne State University/Detroit Medical Center, United States
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Ng MC, Pavlova M. Status epilepticus in the Canadian Arctic: A public health imperative hidden in plain sight. Epilepsia Open 2021; 6:703-713. [PMID: 34510825 PMCID: PMC8633482 DOI: 10.1002/epi4.12538] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/18/2021] [Accepted: 09/04/2021] [Indexed: 02/02/2023] Open
Abstract
Objective The World Health Organization, International League Against Epilepsy (ILAE), and International Bureau for Epilepsy have called epilepsy a public health imperative, with appropriate emphasis on low‐to‐middle‐income countries (LMIC). Although Canada is a high‐income country (HIC), income is not distributed uniformly. Furthermore, epilepsy data from the national statistical agency explicitly overlook the Arctic by excluding these territories. A common neurologic emergency, status epilepticus (SE) is a life‐threatening manifestation of epilepsy that demands prompt treatment to avoid death and long‐term sequelae. Therefore, we examined the rate of SE in a well‐defined Canadian Arctic region. Methods This study takes epidemiologic advantage of the Kivalliq Region's geographical isolation, which is accessible only by air. All SE patients requiring emergency care are consistently flown 1200‐1900 kilometers to a single designated hospital in a distinct southern part of Canada for further management and electroencephalography (EEG). We conducted a retrospective database and chart review at this “bottleneck” hospital to identify patients with seizure(s) severe enough to justify emergency airborne medical evacuation over a 11.25‐year period from 2009 to 2020. Results We screened 40 392 EEGs to yield 117 distinct medical evacuations for “operational SE” from 99 patients to derive estimated SE incidences of 99.9 evacuations per 100 000/year and 84.5 patients per 100 000/year. The average time from seizure onset to EEG was 3.2 days. Only 16.2% of SE patients had known epilepsy. For “confirmed SE” cases meeting ILAE criteria, or cases with persistently epileptiform EEG despite days of empiric treatment, estimated incidence was 77.7 evacuations per 100 000/year and 64.9 patients per 100 000/year. Significance High SE and epilepsy rates in the Canadian Arctic are consistent with LMIC rather than HIC. Our findings demonstrate the paradox of LMIC‐equivalent epilepsy populations camouflaged within HIC. Our findings also highlight the long‐standing plight of these under‐served and overlooked populations hidden in plain sight.
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Affiliation(s)
- Marcus C Ng
- Section of Neurology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Milena Pavlova
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Epidemiology, management and outcome of status epilepticus in adults: single-center Italian survey. Neurol Sci 2021; 43:2003-2013. [PMID: 34490535 DOI: 10.1007/s10072-021-05572-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 08/17/2021] [Indexed: 10/20/2022]
Abstract
The official variations of status epilepticus (SE) International League Against Epilepsy (ILAE, 2015) diagnostic criteria and the non-convulsive SE (NCSE) Salzburg Consensus Criteria (2013), impose the collection of updated population-based epidemiological Italian data. In this study, we aimed at evaluating (a) the frequency of SE in our hospital adopting the new ILAE 2015 SE diagnostic criteria and NCSE Salzburg Consensus Criteria, (b) the frequency of adherence to current treatment guidelines for SE and their relationship with patients' outcome, and (c) reliability of standardized prognostic scales (Status Epilepticus Severity Score-STESS-and modified STESS) for short-term outcome prediction in the setting of the newest diagnostic criteria for SE and NCSE. Detailed clinical and electrophysiological data collected in a 1-year retrospective hospital-based single-center survey on SE at Parma Hospital, Northern Italy are provided. Non-adherence to current treatment guidelines was recorded in around 50% cases, but no relation to outcome was appreciated. Mortality in our cohort increased from 30 to 50% when follow-up was extended to 30 days. STESS score was strongly correlated with short-term mortality risk (OR 18.9, 2.2-163.5, CI), and we confirm its role as easy-to-use tool for outcome evaluation also when the new ILAE diagnostic SE criteria are applied.
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Gasparini S, Ferlazzo E, Gigli G, Pauletto G, Nilo A, Lettieri C, Bilo L, Labate A, Fortunato F, Varrasi C, Cantello R, D'Aniello A, Gennaro GD, d'Orsi G, Sabetta A, Claudio MTD, Avolio C, Dono F, Evangelista G, Cavalli SM, Cianci V, Ascoli M, Mastroianni G, Lobianco C, Neri S, Mercuri S, Mammì A, Gambardella A, Beghi E, Torino C, Tripepi G, Aguglia U. Predictive factors of Status Epilepticus and its recurrence in patients with adult-onset seizures: A multicenter, long follow-up cohort study. Seizure 2021; 91:397-401. [PMID: 34298459 DOI: 10.1016/j.seizure.2021.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Status epilepticus (SE) is associated with high morbidity and mortality. This multicenter retrospective cohort study aims to identify the factors associated with the occurrence of SE and the predictors of its recurrence in patients with adult-onset seizures. METHODS We retrospectively analyzed data of 1115 patients with seizure onset>18 years, observed from 1983 to 2020 in 7 Italian Centers (median follow-up 2.1 years). Data were collected from the databases of the Centers. Patients with SE were consecutively recruited, and patients without SE history were randomly selected in a 2:1 ratio. To assess determinants of SE, different clinical-demographic variables were evaluated and included in univariate and multivariate logistic regression model. RESULTS Three hundred forty-seven patients had a SE history, whereas the remaining 768 patients had either isolated seizures or epilepsy without SE history. The occurrence of SE was independently associated with increasing age at onset of disease (OR 1.02, 95% CI 1.01--1.03, p<0.001), female sex (OR 1.39, 95% CI 1.05--1.83, p=0.02) and known etiology (OR 3.58, 95% CI 2.61--4.93, p<0.001). SE recurred in 21% of patients with adult-onset SE and recurrence was associated with increasing number of anti-seizure medications taken at last follow-up (OR 1.88, 95% CI 1.31--2.71, p<0.001). CONCLUSIONS In patients with adult-onset seizures, SE occurrence is associated with known etiologies, advanced age and female sex. Patients with recurrent SE are likely to have a refractory epilepsy, deserving careful treatment to prevent potentially fatal events.
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Affiliation(s)
- Sara Gasparini
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan Hospital, Bianchi-Melacrino Morelli, Reggio Calabria, Italy
| | - Edoardo Ferlazzo
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan Hospital, Bianchi-Melacrino Morelli, Reggio Calabria, Italy
| | - Gianluigi Gigli
- Department of Medicine (DAME), University of Udine Medical School, Udine, Italy and Clinical Neurology, Department of Neurosciences, S. Maria della Misericordia University Hospital, Udine, Italy; Clinical Neurology, Department of Neurosciences, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Giada Pauletto
- Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Annacarmen Nilo
- Clinical Neurology, Department of Neurosciences, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Christian Lettieri
- Neurology Unit, Department of Neurosciences, S. Maria della Misericordia University Hospital, Udine, Italy
| | - Leonilda Bilo
- Department of Neuroscience and Reproductive and Odontostomatological Sciences, University "Federico II", Napoli, Italy
| | - Angelo Labate
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Italy
| | - Francesco Fortunato
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Italy
| | - Claudia Varrasi
- Neurology Unit, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Roberto Cantello
- Neurology Unit, Department of Health Sciences, University of Piemonte Orientale, Novara, Italy
| | - Alfredo D'Aniello
- Centre for epilepsy study and treatment, IRCCS "Neuromed", Pozzilli (IS), Italy
| | | | - Giuseppe d'Orsi
- Epilepsy Centre-S.C. Neurologia Universitaria, Policlinico Riuniti, Foggia, Italy
| | - Annarita Sabetta
- Epilepsy Centre-S.C. Neurologia Universitaria, Policlinico Riuniti, Foggia, Italy
| | - Maria T Di Claudio
- Epilepsy Centre-S.C. Neurologia Universitaria, Policlinico Riuniti, Foggia, Italy
| | - Carlo Avolio
- Epilepsy Centre-S.C. Neurologia Universitaria, Policlinico Riuniti, Foggia, Italy
| | - Fedele Dono
- Department of Neuroscience, Imaging and Clinical Sciences, "D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Giacomo Evangelista
- Department of Neuroscience, Imaging and Clinical Sciences, "D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Salvatore M Cavalli
- Regional Epilepsy Centre, Great Metropolitan Hospital, Bianchi-Melacrino Morelli, Reggio Calabria, Italy
| | - Vittoria Cianci
- Regional Epilepsy Centre, Great Metropolitan Hospital, Bianchi-Melacrino Morelli, Reggio Calabria, Italy
| | - Michele Ascoli
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan Hospital, Bianchi-Melacrino Morelli, Reggio Calabria, Italy
| | - Giovanni Mastroianni
- Regional Epilepsy Centre, Great Metropolitan Hospital, Bianchi-Melacrino Morelli, Reggio Calabria, Italy
| | - Concetta Lobianco
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan Hospital, Bianchi-Melacrino Morelli, Reggio Calabria, Italy
| | - Sabrina Neri
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan Hospital, Bianchi-Melacrino Morelli, Reggio Calabria, Italy
| | - Sergio Mercuri
- Regional Epilepsy Centre, Great Metropolitan Hospital, Bianchi-Melacrino Morelli, Reggio Calabria, Italy
| | - Anna Mammì
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Italy
| | - Antonio Gambardella
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Italy
| | - Ettore Beghi
- Laboratory of Neurological Disorders IRCCS "Mario Negri", Milan, Italy
| | - Claudia Torino
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension of Reggio Calabria, National Council of Research, Institute of Clinical Physiology, Reggio Calabria, Italy
| | - Giovanni Tripepi
- Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension of Reggio Calabria, National Council of Research, Institute of Clinical Physiology, Reggio Calabria, Italy
| | - Umberto Aguglia
- Department of Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Italy; Regional Epilepsy Centre, Great Metropolitan Hospital, Bianchi-Melacrino Morelli, Reggio Calabria, Italy.
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11
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Ascoli M, Ferlazzo E, Gasparini S, Mastroianni G, Citraro R, Roberti R, Russo E. Epidemiology and Outcomes of Status Epilepticus. Int J Gen Med 2021; 14:2965-2973. [PMID: 34234526 PMCID: PMC8254099 DOI: 10.2147/ijgm.s295855] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 06/15/2021] [Indexed: 12/25/2022] Open
Abstract
Status epilepticus (SE) is a neurological and medical emergency, defined as a condition resulting either from the failure of the mechanisms responsible of seizure self-limitation or from the initiation of mechanisms which lead to atypically prolonged seizures. Further than death, SE can have long-term consequences, including neuronal injury, depending on the type, cause and duration of seizures with severe associated disabilities. In Europe, SE shows an incidence rate ranging about 9 to 40/100,000/y. In adults, mortality of patients with SE is ~30%, and even higher (up to 40%) in refractory status epilepticus. To date, etiology, duration, presence of comorbidity, level of consciousness, semiology and age are the main clinical predictors of SE outcome.
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Affiliation(s)
- Michele Ascoli
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Regional Epilepsy Centre, Great Metropolitan Hospital, Reggio, Calabria, Italy
| | - Edoardo Ferlazzo
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Regional Epilepsy Centre, Great Metropolitan Hospital, Reggio, Calabria, Italy
| | - Sara Gasparini
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Regional Epilepsy Centre, Great Metropolitan Hospital, Reggio, Calabria, Italy
| | | | - Rita Citraro
- Science of Health Department, Magna Græcia University, Catanzaro, Italy
| | - Roberta Roberti
- Science of Health Department, Magna Græcia University, Catanzaro, Italy
| | - Emilio Russo
- Science of Health Department, Magna Græcia University, Catanzaro, Italy
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12
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Langenbruch L, Strippel C, Görlich D, Elger CE, Möddel G, Meuth SG, Kellinghaus C, Wiendl H, Kovac S. Occurrence of status epilepticus in persons with epilepsy is determined by sex, epilepsy classification, and etiology: a single center cohort study. J Neurol 2021; 268:4816-4823. [PMID: 34021409 PMCID: PMC8563665 DOI: 10.1007/s00415-021-10600-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 11/28/2022]
Abstract
Background Status epilepticus (SE) can occur in persons with or without epilepsy and is associated with high morbidity and mortality. Methods This survey aimed to record self-reported frequency of SE in persons with epilepsy, its association with clinical characteristics and patient level of information on SE and rescue medication. 251 persons with epilepsy at a tertiary epilepsy center were included in the study. Results 87 (35%) had a history of SE defined as seizure duration of more than 5 min. These patients were less likely to be seizure-free, and had a higher number of present and past anti-seizure medication. Female sex, cognitive disability, younger age at epilepsy onset, defined epilepsy etiology, and focal epilepsy were associated with a history of SE. On Cox regression analysis, female sex, defined etiology and focal classification remained significant. 67% stated that they had information about prolonged seizures, and 75% knew about rescue medication. 85% found it desirable to receive information about SE at the time of initial diagnosis of epilepsy, but only 16% had been offered such information at the time. Conclusion SE is frequent among persons with epilepsy and there remain unmet needs regarding patient education.
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Affiliation(s)
- Lisa Langenbruch
- Department of Neurology with Institute of Translational Neurology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Christine Strippel
- Department of Neurology with Institute of Translational Neurology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Christian E Elger
- Department of Neurology with Institute of Translational Neurology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Gabriel Möddel
- Department of Neurology with Institute of Translational Neurology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Sven G Meuth
- Department of Neurology, University of Düsseldorf, Düsseldorf, Germany
| | | | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany
| | - Stjepana Kovac
- Department of Neurology with Institute of Translational Neurology, University of Münster, University Hospital Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Germany.
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13
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Vijiala S, Alvarez V. Epidemiology of status epilepticus in a non-urban area in Switzerland. Acta Neurol Scand 2021; 143:413-420. [PMID: 33251617 DOI: 10.1111/ane.13383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/18/2020] [Accepted: 11/23/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The aim of this study is to provide a precise population-based data on incidence, types, and causes of SE according to the 2015 ILAE definition and classification using a prospectively cohort in an adult population of a non-urban area. MATERIALS & METHODS Prospective observational SE cohort in a single large community hospital. The center is the only one in the region (French-speaking Valais canton), with all available resources to treat SE (including neurologist available 24/7, EEG monitoring and ICU). Every adult patient with SE is included (except post-anoxic SE). All variables are collected prospectively using the 2015 ILAE status epilepticus classification. RESULTS We identified 103 patients with SE in the study period between 1st of May 2015 and 30th of June 2019 for a population of 260,855 people. The incidence is 8.6 per 100,000 adults per year with an overall case-fatality rate of 7.8%. SE was generalized convulsive in 52% of cases and nonconvulsive SE in coma in 34%. CONCLUSIONS Using a prospective reliable data collection with strict inclusion criteria, we found an incidence of 8.6 per 100,000 persons per year, in line with previous report using similar methods. The most severe forms-generalized convulsive and nonconvulsive SE in coma-represent the majority of cases. These data might be important for resources allocation in non-urban area with non-university healthcare system.
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Affiliation(s)
- Sergiu Vijiala
- Neurology Department Hopital du Valais Sion Switzerland
- Department of Clinical Neurosciences Service of Neurology Lausanne University Hospital (CHUVUniversity of Lausanne Lausanne Switzerland
| | - Vincent Alvarez
- Neurology Department Hopital du Valais Sion Switzerland
- Department of Clinical Neurosciences Service of Neurology Lausanne University Hospital (CHUVUniversity of Lausanne Lausanne Switzerland
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14
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Christian CA, Reddy DS, Maguire J, Forcelli PA. Sex Differences in the Epilepsies and Associated Comorbidities: Implications for Use and Development of Pharmacotherapies. Pharmacol Rev 2021; 72:767-800. [PMID: 32817274 DOI: 10.1124/pr.119.017392] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The epilepsies are common neurologic disorders characterized by spontaneous recurrent seizures. Boys, girls, men, and women of all ages are affected by epilepsy and, in many cases, by associated comorbidities as well. The primary courses of treatment are pharmacological, dietary, and/or surgical, depending on several factors, including the areas of the brain affected and the severity of the epilepsy. There is a growing appreciation that sex differences in underlying brain function and in the neurobiology of epilepsy are important factors that should be accounted for in the design and development of new therapies. In this review, we discuss the current knowledge on sex differences in epilepsy and associated comorbidities, with emphasis on those aspects most informative for the development of new pharmacotherapies. Particular focus is placed on sex differences in the prevalence and presentation of various focal and generalized epilepsies; psychiatric, cognitive, and physiologic comorbidities; catamenial epilepsy in women; sex differences in brain development; the neural actions of sex and stress hormones and their metabolites; and cellular mechanisms, including brain-derived neurotrophic factor signaling and neuronal-glial interactions. Further attention placed on potential sex differences in epilepsies, comorbidities, and drug effects will enhance therapeutic options and efficacy for all patients with epilepsy. SIGNIFICANCE STATEMENT: Epilepsy is a common neurological disorder that often presents together with various comorbidities. The features of epilepsy and seizure activity as well as comorbid afflictions can vary between men and women. In this review, we discuss sex differences in types of epilepsies, associated comorbidities, pathophysiological mechanisms, and antiepileptic drug efficacy in both clinical patient populations and preclinical animal models.
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Affiliation(s)
- Catherine A Christian
- Department of Molecular and Integrative Physiology, Neuroscience Program, and Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, Illinois (C.A.C.); Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas (D.S.R.); Neuroscience Department, Tufts University School of Medicine, Boston, Massachusetts (J.M.); and Departments of Pharmacology and Physiology and Neuroscience, Georgetown University, Washington, D.C. (P.A.F.)
| | - Doodipala Samba Reddy
- Department of Molecular and Integrative Physiology, Neuroscience Program, and Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, Illinois (C.A.C.); Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas (D.S.R.); Neuroscience Department, Tufts University School of Medicine, Boston, Massachusetts (J.M.); and Departments of Pharmacology and Physiology and Neuroscience, Georgetown University, Washington, D.C. (P.A.F.)
| | - Jamie Maguire
- Department of Molecular and Integrative Physiology, Neuroscience Program, and Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, Illinois (C.A.C.); Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas (D.S.R.); Neuroscience Department, Tufts University School of Medicine, Boston, Massachusetts (J.M.); and Departments of Pharmacology and Physiology and Neuroscience, Georgetown University, Washington, D.C. (P.A.F.)
| | - Patrick A Forcelli
- Department of Molecular and Integrative Physiology, Neuroscience Program, and Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign, Urbana, Illinois (C.A.C.); Department of Neuroscience and Experimental Therapeutics, College of Medicine, Texas A&M University Health Science Center, Bryan, Texas (D.S.R.); Neuroscience Department, Tufts University School of Medicine, Boston, Massachusetts (J.M.); and Departments of Pharmacology and Physiology and Neuroscience, Georgetown University, Washington, D.C. (P.A.F.)
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15
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Alkhachroum A, Der-Nigoghossian CA, Rubinos C, Claassen J. Markers in Status Epilepticus Prognosis. J Clin Neurophysiol 2020; 37:422-428. [PMID: 32890064 PMCID: PMC7864547 DOI: 10.1097/wnp.0000000000000761] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Status epilepticus (SE) is a neurologic emergency with high morbidity and mortality. The assessment of a patient's prognosis is crucial in making treatment decisions. In this review, we discuss various markers that have been used to prognosticate SE in terms of recurrence, mortality, and functional outcome. These markers include demographic, clinical, electrophysiological, biochemical, and structural data. The heterogeneity of SE etiology and semiology renders development of prognostic markers challenging. Currently, prognostication in SE is limited to a few clinical scores. Future research should integrate clinical, genetic and epigenetic, metabolic, inflammatory, and structural biomarkers into prognostication models to approach "personalized medicine" in prognostication of outcomes after SE.
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Affiliation(s)
- Ayham Alkhachroum
- Department of Neurology, Columbia University, New York, NY, USA
- Department of Neurology, University of Miami, Miami, FL, USA
| | | | - Clio Rubinos
- Department of Neurology, Columbia University, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY, USA
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16
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Błaszczyk B, Walczak A, Ścirka N, Konarzewska A, Miziak B, Czuczwar SJ. Pharmacological and non-pharmacological approaches to life threatening conditions in epilepsy. JOURNAL OF EPILEPTOLOGY 2020. [DOI: 10.21307/jepil-2020-002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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17
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Liampas I, Siokas V, Brotis A, Zintzaras E, Stefanidis I, Dardiotis E. Intravenous sodium valproate in status epilepticus: review and Meta-analysis. Int J Neurosci 2020; 131:70-84. [DOI: 10.1080/00207454.2020.1732967] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Ioannis Liampas
- Department of Neurology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Vasileios Siokas
- Department of Neurology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Alexandros Brotis
- Department of Neurosurgery, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Elias Zintzaras
- Department of Biomathematics, School of Medicine, University of Thessaly, Larissa, Greece
- Center for Clinical Evidence Synthesis, the Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ioannis Stefanidis
- Department of Nephrology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital of Larissa, School of Medicine, University of Thessaly, Larissa, Greece
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18
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What is status epilepticus and what do we know about its epidemiology? Seizure 2020; 75:131-136. [DOI: 10.1016/j.seizure.2019.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 11/16/2022] Open
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19
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Leitinger M, Trinka E, Zimmermann G, Granbichler CA, Kobulashvili T, Siebert U. Epidemiology of status epilepticus in adults: Apples, pears, and oranges - A critical review. Epilepsy Behav 2020; 103:106720. [PMID: 31902646 DOI: 10.1016/j.yebeh.2019.106720] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 11/02/2019] [Accepted: 11/13/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Status epilepticus (SE) is a severe neurologic condition associated with high morbidity and mortality. Population-based studies in adults have found a wide range of incidences in various regions in the world. Although the incidence of SE increases almost exponentially in the elderly, data on census-based population statistics in these studies are scarce. This study provides a critical review with an emphasis on census-based population statistics and study characteristics in adults. METHODS We performed a systematic search of population-based studies on SE in adults in PubMed using "status epilepticus" in combination with "epidemiology", "population", and "incidence" as search terms, and also screened references. For each identified study, we assessed and extracted the respective population pyramids of study and reference population, and study characteristics. RESULTS We identified 22 population-based studies (eleven from Europe, six from North America, three from Asia, one from Africa, and one from Australasia). Incidence rates of patients with SE ranged from 1.29 to 73.7/100,000 adults (95% confidence interval (CI): 76.6-80.3) and of SE episodes up to 81.1/100,000 adults (95% CI: 75.8-87.0). The proportions of elderly and very old patients varied by a factor of 2.6 and 8.5, respectively, depending on study period and place. Further major reasons for heterogeneity were retrospective or prospective study design, definition of time to diagnose SE, variable detection of nonconvulsive SE (NCSE), different etiologies, inclusion of children, recurrent episodes, postanoxic patients, exclusion of patients with preexisting epilepsy or patients identified outside the emergency department, and choice of reference population for age- and gender adjustment. The most recent definition and classification of SE by the International League Against Epilepsy (ILAE) 2015 was used in two studies. Four studies (18.2%) reported incidences per ten-year age strata necessary for age adjustment to various reference populations. CONCLUSIONS This critical review reveals a marked heterogeneity among population-based studies on SE in adults. It provides comprehensive details on census-based population statistics in study and reference populations and various study designs and characteristics essential for direct comparisons between studies. Reporting on these essential key features should be improved in population-based studies on SE.
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Affiliation(s)
- Markus Leitinger
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University Salzburg, Austria; Centre of Neuroscience, Christian Doppler University Hospital, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University Salzburg, Austria; Centre of Neuroscience, Christian Doppler University Hospital, Salzburg, Austria; Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics nd Technology, Hall in Tirol, Austria
| | - Georg Zimmermann
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University Salzburg, Austria; Department of Mathematics, Paris-Lodron-University of Salzburg, Salzburg, Austria
| | - Claudia A Granbichler
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University Salzburg, Austria; Sheba Medical Center, Department of Neurology, Tel Hashomer, Israel
| | - Teia Kobulashvili
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University Salzburg, Austria; Centre of Neuroscience, Christian Doppler University Hospital, Salzburg, Austria
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics nd Technology, Hall in Tirol, Austria; Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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20
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21
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Bergin PS, Brockington A, Jayabal J, Scott S, Litchfield R, Roberts L, Timog J, Beilharz E, Dalziel SR, Jones P, Yates K, Thornton V, Walker EB, Davis S, Te Ao B, Parmar P, Beghi E, Rossetti AO, Feigin V. Status epilepticus in Auckland, New Zealand: Incidence, etiology, and outcomes. Epilepsia 2019; 60:1552-1564. [PMID: 31260104 DOI: 10.1111/epi.16277] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 05/18/2019] [Accepted: 06/12/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To determine the incidence, etiology, and outcome of status epilepticus (SE) in Auckland, New Zealand, using the latest International League Against Epilepsy (ILAE) SE semiological classification. METHODS We prospectively identified patients presenting to the public or major private hospitals in Auckland (population = 1.61 million) between April 6, 2015 and April 5, 2016 with a seizure lasting 10 minutes or longer, with retrospective review to confirm completeness of data capture. Information was recorded in the EpiNet database. RESULTS A total of 477 episodes of SE occurred in 367 patients. Fifty-one percent of patients were aged <15 years. SE with prominent motor symptoms comprised 81% of episodes (387/477). Eighty-four episodes (18%) were nonconvulsive SE. Four hundred fifty episodes occurred in 345 patients who were resident in Auckland. The age-adjusted incidence of 10-minute SE episodes and patients was 29.25 (95% confidence interval [CI] = 27.34-31.27) and 22.22 (95% CI = 20.57-23.99)/100 000/year, respectively. SE lasted 30 minutes or longer in 250 (56%) episodes; age-adjusted incidence was 15.95 (95% CI = 14.56-17.45) SE episodes/100 000/year and 12.92 (95% CI = 11.67-14.27) patients/100 000/year. Age-adjusted incidence (10-minute SE) was 25.54 (95% CI = 23.06-28.24) patients/100 000/year for males and 19.07 (95% CI = 16.91-21.46) patients/100 000/year for females. The age-adjusted incidence of 10-minute SE was higher in Māori (29.31 [95% CI = 23.52-37.14]/100 000/year) and Pacific Islanders (26.55 [95% CI = 22.05-31.99]/100 000/year) than in patients of European (19.13 [95% CI = 17.09-21.37]/100 000/year) or Asian/other descent (17.76 [95% CI = 14.73-21.38]/100 000/year). Seventeen of 367 patients in the study died within 30 days of the episode of SE; 30-day mortality was 4.6%. SIGNIFICANCE In this population-based study, incidence and mortality of SE in Auckland lie in the lower range when compared to North America and Europe. For pragmatic reasons, we only included convulsive SE if episodes lasted 10 minutes or longer, although the 2015 ILAE SE classification was otherwise practical and easy to use.
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Affiliation(s)
- Peter S Bergin
- Auckland District Health Board, Grafton, Auckland, New Zealand.,Centre for Brain Research, University of Auckland, Auckland, New Zealand
| | - Alice Brockington
- Auckland District Health Board, Grafton, Auckland, New Zealand.,Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Jayaganth Jayabal
- Auckland District Health Board, Grafton, Auckland, New Zealand.,Pantai-Gleneagles Hospital, Penang and Sungai Petani, Malaysia
| | - Shona Scott
- Auckland District Health Board, Grafton, Auckland, New Zealand.,Western General Hospital, Edinburgh, UK
| | | | - Lynair Roberts
- Auckland District Health Board, Grafton, Auckland, New Zealand
| | - Jerelyn Timog
- Auckland District Health Board, Grafton, Auckland, New Zealand
| | - Erica Beilharz
- Auckland District Health Board, Grafton, Auckland, New Zealand
| | - Stuart R Dalziel
- Auckland District Health Board, Grafton, Auckland, New Zealand.,Department of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand
| | - Peter Jones
- Auckland District Health Board, Grafton, Auckland, New Zealand
| | - Kim Yates
- Waitematā District Health Board, Auckland, New Zealand
| | | | | | - Suzanne Davis
- Auckland District Health Board, Grafton, Auckland, New Zealand
| | - Braden Te Ao
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
| | - Priya Parmar
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
| | - Ettore Beghi
- Mario Negri Institute of Pharmacological Research, Scientific Institute for Research and Health Care, Milan, Italy
| | - Andrea O Rossetti
- Department of Clinical Neurosciences, Vaud University Hospital Center and University of Lausanne, Lausanne, Switzerland
| | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, Auckland University of Technology, Auckland, New Zealand
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22
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Chakraborty T, Hocker S. Weaning from antiseizure drugs after new onset status epilepticus. Epilepsia 2019; 60:979-985. [PMID: 30963565 DOI: 10.1111/epi.14730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 03/04/2019] [Accepted: 03/21/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE In patients with status epilepticus (SE) without prior epilepsy, there are limited data on the safety of discontinuing antiseizure drugs (ASDs) after seizure control. We aimed to describe seizure recurrence when weaning from ASDs following new onset SE (NOSE). METHODS Retrospective review of adult patients with NOSE admitted to Mayo Clinic, Rochester, Minnesota between January 1, 1990 and December 31, 2015 was performed. Weaning was defined as a discontinuation of ASDs following discharge. Patient demographics, SE characteristics, timing of ASD withdrawal, and seizure recurrence were collected. RESULTS One hundred seventy-seven patients with mean age 63 ± 18 years were identified; 96 (54.2%) patients had refractory SE (RSE), and 81 (45.8%) had nonrefractory SE. Mean follow-up was 3.8 ± 3.2 years for those successfully weaned off ASDs. One hundred thirty (73.4%) with outpatient follow-up were included in the analysis; 128 (98.5%) patients were discharged on an ASD; 44 of 128 (34.4%) patients underwent weaning from at least 1 ASD following discharge, including 27 of 128 (21.1%) who were completely weaned off of all ASDs. Younger patients (P = 0.009) and those with RSE (P = 0.048, odds ratio = 2.12, 95% confidence interval = 1.00-4.48) tended to undergo weaning. Six of 44 (13.6%) patients had seizure recurrence when weaned off of any ASD, and two of 27 (7.4%) patients completely weaned off all ASDs had seizure recurrence. Two of seven (28.6%) patients who underwent attempted barbiturate weaning experienced seizure recurrence. SIGNIFICANCE We found a rate of 13.6% for late seizure recurrence after weaning from at least one ASD in patients with NOSE; seizure recurrence was more likely in patients with RSE treated with barbiturates. Systematic collection of longitudinal data in patients requiring multiple ASDs for NOSE control will provide more conclusive guidance on weaning from ASDs.
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Affiliation(s)
| | - Sara Hocker
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
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Leitinger M, Trinka E, Giovannini G, Zimmermann G, Florea C, Rohracher A, Kalss G, Neuray C, Kreidenhuber R, Höfler J, Kuchukhidze G, Granbichler C, Dobesberger J, Novak HF, Pilz G, Meletti S, Siebert U. Epidemiology of status epilepticus in adults: A population-based study on incidence, causes, and outcomes. Epilepsia 2018; 60:53-62. [PMID: 30478910 PMCID: PMC7380005 DOI: 10.1111/epi.14607] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/24/2018] [Accepted: 10/24/2018] [Indexed: 11/28/2022]
Abstract
Objective In 2015, the International League Against Epilepsy (ILAE) proposed a new definition of status epilepticus (SE): 5 minutes of ongoing seizure activity to diagnose convulsive SE (CSE, ie, bilateral tonic–clonic SE) and 10 minutes for focal SE and absence SE, rather than the earlier criterion of 30 minutes. Based on semiology, several types of SE with prominent motor phenomena at any time (including CSE) were distinguished from those without (ie, nonconvulsive SE, NCSE). We present the first population‐based incidence study applying the new 2015 ILAE definition and classification of SE and report the impact of the evolution of semiology and level of consciousness (LOC) on outcome. Methods We conducted a retrospective population‐based incidence study of all adult patients with SE residing in the city of Salzburg between January 2011 and December 2015. Patients with hypoxic encephalopathy were excluded. SE was defined and classified according to the ILAE 2015. Results We identified 221 patients with a median age of 69 years (range 20‐99 years). The age‐ and sex‐adjusted incidence of a first episode of SE, NCSE, and SE with prominent motor phenomena (including CSE) was 36.1 (95% confidence interval [CI] 26.2‐48.5), 12.1 (95% CI 6.8‐20.0), and 24.0 (95% CI 16.0‐34.5; including CSE 15.8 [95% CI 9.4‐24.8]) per 100 000 adults per year, respectively. None of the patients whose SE ended with or consisted of only bilateral tonic–clonic activity died. In all other clinical presentations, case fatality was lower in awake patients (8.2%) compared with patients with impaired consciousness (33%). Significance This first population‐based study using the ILAE 2015 definition and classification of SE found an increase of incidence of 10% compared to previous definitions. We also provide epidemiologic evidence that different patterns of status evolution and LOCs have strong prognostic implications.
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Affiliation(s)
- Markus Leitinger
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Center for Neuroscience, Christian Doppler Medical Center, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Center for Neuroscience, Christian Doppler Medical Center, Salzburg, Austria.,Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Giada Giovannini
- Unit of Neurology, OCSAE Hospital, Azienda Ospedaliera Universitaria, Modena, Italy
| | - Georg Zimmermann
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Center for Neuroscience, Christian Doppler Medical Center, Salzburg, Austria.,Department of Mathematics, Paris Lodron University, Salzburg, Austria
| | - Cristina Florea
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Center for Neuroscience, Christian Doppler Medical Center, Salzburg, Austria
| | - Alexandra Rohracher
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Center for Neuroscience, Christian Doppler Medical Center, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Center for Neuroscience, Christian Doppler Medical Center, Salzburg, Austria
| | - Caroline Neuray
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Center for Neuroscience, Christian Doppler Medical Center, Salzburg, Austria
| | - Rudolf Kreidenhuber
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Center for Neuroscience, Christian Doppler Medical Center, Salzburg, Austria
| | - Julia Höfler
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Center for Neuroscience, Christian Doppler Medical Center, Salzburg, Austria
| | - Giorgi Kuchukhidze
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Center for Neuroscience, Christian Doppler Medical Center, Salzburg, Austria
| | - Claudia Granbichler
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Judith Dobesberger
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Center for Neuroscience, Christian Doppler Medical Center, Salzburg, Austria
| | - Helmut F Novak
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Center for Neuroscience, Christian Doppler Medical Center, Salzburg, Austria
| | - Georg Pilz
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria.,Center for Neuroscience, Christian Doppler Medical Center, Salzburg, Austria
| | - Stefano Meletti
- Unit of Neurology, OCSAE Hospital, Azienda Ospedaliera Universitaria, Modena, Italy.,Department of Biomedical, Metabolic, and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria.,Center for Health Decision Science, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.,Institute for Technology Assessment and Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
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Lv RJ, Wang Q, Cui T, Zhu F, Shao XQ. Status epilepticus-related etiology, incidence and mortality: A meta-analysis. Epilepsy Res 2017; 136:12-17. [PMID: 28734267 DOI: 10.1016/j.eplepsyres.2017.07.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/11/2017] [Accepted: 07/02/2017] [Indexed: 10/19/2022]
Abstract
Status epilepticus (SE) is a severe medical condition. To determine its epidemiology and outcome of SE, we performed a meta-analysis to investigate the etiology, incidence and mortality of SE. We searched PubMed and Embase between Jan 1, 2000, and Oct 31, 2016, with no regional restrictions, for observational studies of the etiology, incidence and mortality of SE. Forty-three studies were included in the meta-analysis. The pooled crude annual incidence rate, the pooled case fatality rate and the pooled crude annual mortality rate of SE were 12.6/100,000 (95% CI: 10.0-15.3), 14.9% (95% CI: 11.7-118.7) and 0.98/100,000 (95% CI: 0.74-1.22), respectively. Elderly subjects with SE had a higher case fatality rate (28.4% (95% CI: 17.7-42.3)) and crude annual incidence rate (27.1% (95% CI: 15.8-38.2)). The most important etiology-specific attributable fraction of patients with SE was acute symptomatic etiology (OR 0.411, 95% CI: 0.315-0.507). Age and economic income contributed to differences in SE incidence and short-term case fatality rate.
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Affiliation(s)
- Rui-Juan Lv
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China; China National Clinical Research Center for Neurological Diseases, Beijing, PR. China, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China
| | - Qun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China; China National Clinical Research Center for Neurological Diseases, Beijing, PR. China, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China
| | - Tao Cui
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China; China National Clinical Research Center for Neurological Diseases, Beijing, PR. China, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China
| | - Fei Zhu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China; China National Clinical Research Center for Neurological Diseases, Beijing, PR. China, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China
| | - Xiao-Qiu Shao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China; China National Clinical Research Center for Neurological Diseases, Beijing, PR. China, 6 Tiantanxili, Dongcheng District, Beijing, 100050, China.
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Mortality, morbidity and refractoriness prediction in status epilepticus: Comparison of STESS and EMSE scores. Seizure 2017; 46:31-37. [DOI: 10.1016/j.seizure.2017.01.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/29/2017] [Accepted: 01/30/2017] [Indexed: 11/23/2022] Open
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Abstract
Status epilepticus is a neurologic and medical emergency manifested by prolonged seizure activity or multiple seizures without return to baseline. It is associated with substantial medical cost, morbidity, and mortality. There is a spectrum of severity dependent on the type of seizure, underlying pathology, comorbidities, and appropriate and timely medical management. This chapter discusses the evolving definitions of status epilepticus and multiple patient and clinical factors which influence outcome. The pathophysiology of status epilepticus is reviewed to provide a better understanding of the mechanisms which contribute to status epilepticus, as well as the potential long-term effects. The clinical presentations of different types of status epilepticus in adults are discussed, with emphasis on the hospital course and management of the most dangerous type, generalized convulsive status epilepticus. Strategies for the evaluation and management of status epilepticus are provided based on available evidence from clinical trials and recommendations from the Neurocritical Care Society and the European Federation of Neurological Societies.
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Affiliation(s)
- M Pichler
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - S Hocker
- Division of Critical Care Neurology, Mayo Clinic, Rochester, MN, USA.
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Alvarez V, Lee JW, Westover MB, Drislane FW, Novy J, Faouzi M, Marchi NA, Dworetzky BA, Rossetti AO. Therapeutic coma for status epilepticus: Differing practices in a prospective multicenter study. Neurology 2016; 87:1650-1659. [PMID: 27664985 DOI: 10.1212/wnl.0000000000003224] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 05/20/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Our aim was to analyze and compare the use of therapeutic coma (TC) for refractory status epilepticus (SE) across different centers and its effect on outcome. METHODS Clinical data for all consecutive adults (>16 years) with SE of all etiologies (except postanoxic) admitted to 4 tertiary care centers belonging to Harvard Affiliated Hospitals (HAH) and the Centre Hospitalier Universitaire Vaudois (CHUV) were prospectively collected and analyzed for TC details, mortality, and duration of hospitalization. RESULTS Two hundred thirty-six SE episodes in the CHUV and 126 in the HAH were identified. Both groups were homogeneous in demographics, comorbidities, SE characteristics, and Status Epilepticus Severity Score (STESS); TC was used in 25.4% of cases in HAH vs 9.75% in CHUV. After adjustment, TC use was associated with younger age, lower Charlson Comorbidity Index, increasing SE severity, refractory SE, and center (odds ratio 11.3 for HAH vs CHUV, 95% confidence interval 2.47-51.7). Mortality was associated with increasing Charlson Comorbidity Index and STESS, etiology, and refractory SE. Length of stay correlated with STESS, etiology, refractory SE, and use of TC (incidence rate ratio 1.6, 95% confidence interval 1.22-2.11). CONCLUSIONS Use of TC for SE treatment seems markedly different between centers from the United States and Europe, and did not affect mortality considering the whole cohort. However, TC may increase length of hospital stay and related costs. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for patients with SE, TC does not significantly affect mortality. The study lacked the precision to exclude an important effect of TC on mortality.
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Affiliation(s)
- Vincent Alvarez
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland.
| | - Jong Woo Lee
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - M Brandon Westover
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - Frank W Drislane
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - Jan Novy
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - Mohamed Faouzi
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - Nicola A Marchi
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - Barbara A Dworetzky
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - Andrea O Rossetti
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
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Status Epilepticus: Epidemiology and Public Health Needs. J Clin Med 2016; 5:jcm5080071. [PMID: 27537921 PMCID: PMC4999791 DOI: 10.3390/jcm5080071] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 08/08/2016] [Accepted: 08/10/2016] [Indexed: 11/17/2022] Open
Abstract
Status epilepticus (SE) is defined as a continuous clinical and/or electrographic seizure activity lasting five minutes or more or recurrent seizure activity without return to baseline. There is a paucity of epidemiological studies of SE, as most research is derived from small population studies. The overall incidence of SE is 9.9 to 41 per 100,000/year, with peaks in children and the elderly and with febrile seizures and strokes as its main etiologies. The etiology is the major determinant of mortality. Governments and the academic community should predominantly focus on the primary prevention of etiologies linked to SE, as these are the most important risk factors for its development. This review describes the incidence, prevalence, etiology, risk factors, outcomes and costs of SE and aims to identify future research and public health needs.
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Lui HKK, Hui KF, Fong WC, Ip CT, Lui HTC. De novo status epilepticus is associated with adverse outcome: An 11-year retrospective study in Hong Kong. Seizure 2016; 40:42-5. [DOI: 10.1016/j.seizure.2016.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/19/2016] [Accepted: 06/07/2016] [Indexed: 10/21/2022] Open
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Rossetti AO, Trinka E, Stähli C, Novy J. New ILAE versus previous clinical status epilepticus semiologic classification: Analysis of a hospital-based cohort. Epilepsia 2016; 57:1036-41. [DOI: 10.1111/epi.13403] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Andrea O. Rossetti
- Department of Clinical Neurosciences; Lausanne University Hospital (CHUV); Lausanne University; Lausanne Switzerland
| | - Eugen Trinka
- Department of Neurology; Paracelsus Medical University; Christian Doppler Klinik; Center for Cognitive Neuroscience; Salzburg Austria
| | - Christine Stähli
- Department of Clinical Neurosciences; Lausanne University Hospital (CHUV); Lausanne University; Lausanne Switzerland
| | - Jan Novy
- Department of Clinical Neurosciences; Lausanne University Hospital (CHUV); Lausanne University; Lausanne Switzerland
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Abstract
Status epilepticus (SE) represents the most severe form of epilepsy. It is one of the most common neurologic emergencies, with an incidence of up to 61 per 100,000 per year and an estimated mortality of 20 %. Clinically, tonic-clonic convulsive SE is divided into four subsequent stages: early, established, refractory, and super-refractory. Pharmacotherapy of status epilepticus, especially of its later stages, represents an "evidence-free zone," due to a lack of high-quality, controlled trials to inform clinical decisions. This comprehensive narrative review focuses on the pharmacotherapy of SE, presented according to the four-staged approach outlined above, and providing pharmacological properties and efficacy/safety data for each antiepileptic drug according to the strength of scientific evidence from the available literature. Data sources included MEDLINE and back-tracking of references in pertinent studies. Intravenous lorazepam or intramuscular midazolam effectively control early SE in approximately 63-73 % of patients. Despite a suboptimal safety profile, intravenous phenytoin or phenobarbital are widely used treatments for established SE; alternatives include valproate, levetiracetam, and lacosamide. Anesthetics are widely used in refractory and super-refractory SE, despite the current lack of trials in this field. Data on alternative treatments in the later stages are limited. Valproate and levetiracetam represent safe and effective alternatives to phenobarbital and phenytoin for treatment of established SE persisting despite first-line treatment with benzodiazepines. To date there are no class I data to support recommendations for most antiepileptic drugs for established, refractory, and super-refractory SE. Limiting the methodologic heterogeneity across studies is required and high-class randomized, controlled trials to inform clinicians about the best treatment in established and refractory status are needed.
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University Salzburg, Ignaz Harrerstrasse 79, 5020, Salzburg, Austria,
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Giovannini G, Monti G, Polisi MM, Mirandola L, Marudi A, Pinelli G, Valzania F, Girardis M, Nichelli PF, Meletti S. A one-year prospective study of refractory status epilepticus in Modena, Italy. Epilepsy Behav 2015; 49:141-5. [PMID: 26074182 DOI: 10.1016/j.yebeh.2015.05.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 05/09/2015] [Accepted: 05/12/2015] [Indexed: 11/29/2022]
Abstract
Refractory status epilepticus (RSE) is a particular critical condition characterized by seizures that continue despite the use of first- and second-line therapies and by high mortality. To date, only one prospective study investigated clinical features and prognostic factors in RSE. In this study, we performed a one-year prospective survey to identify clinical features, outcomes, and variables associated with the development of RSE in the adolescent and adult population of Modena, northern Italy. We observed 83 episodes of SE in 83 patients. In 31% of the cases, third-line therapy (anesthetic drug) was needed. Among this group, 14% resolved and were classified as RSE, while, in 17%, seizures recurred at withdrawal of anesthetics and were classified as super-RSE. The development of RSE/super-RSE was associated with a stuporous/comatose state at presentation and with the absence of a previous history of epilepsy. Refractory status epilepticus/super-refractory status epilepticus showed a worse outcome compared with responsive SE: 54% versus 21% for 30-day mortality; 19% versus 56% for a return to baseline condition. This prospective study confirms stupor/coma at onset as a relevant clinical factor associated with SE refractoriness. We observed a rate of RSE comparable with previous reports, with high mortality and morbidity. Mortality in the observed RSE was higher than in previous studies; this result is probably related to the low rate of a previous epilepsy history in our population that reflects a high incidence of acute symptomatic etiologies, especially the inclusion of patients with postanoxic SE who have a bad prognosis per se. This article is part of a Special Issue entitled "Status Epilepticus".
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Affiliation(s)
- Giada Giovannini
- Department of Biomedical, Metabolic, and Neural Science, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, NOCSAE Hospital, ASL Modena, Italy.
| | - Giulia Monti
- Department of Biomedical, Metabolic, and Neural Science, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, NOCSAE Hospital, ASL Modena, Italy
| | - Michela M Polisi
- Department of Biomedical, Metabolic, and Neural Science, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, NOCSAE Hospital, ASL Modena, Italy
| | - Laura Mirandola
- Department of Biomedical, Metabolic, and Neural Science, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, NOCSAE Hospital, ASL Modena, Italy
| | - Andrea Marudi
- Intensive Care Unit, NOCSAE Hospital, ASL Modena, Italy
| | | | | | | | - Paolo F Nichelli
- Department of Biomedical, Metabolic, and Neural Science, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, NOCSAE Hospital, ASL Modena, Italy
| | - Stefano Meletti
- Department of Biomedical, Metabolic, and Neural Science, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, NOCSAE Hospital, ASL Modena, Italy
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Spatola M, Novy J, Du Pasquier R, Dalmau J, Rossetti AO. Status epilepticus of inflammatory etiology: a cohort study. Neurology 2015; 85:464-70. [PMID: 26092915 DOI: 10.1212/wnl.0000000000001717] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 04/01/2015] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE Inflammation-related epilepsy is increasingly recognized; however, studies on status epilepticus (SE) are very infrequent. We therefore aimed to determine the frequency of inflammatory etiologies in adult SE, and to assess related demographic features and outcomes. METHODS This was a retrospective analysis of a prospective registry of adult patients with SE treated in our center, from January 2008 to June 2014, excluding postanoxic causes. We classified SE episodes into 3 etiologic categories: infectious, autoimmune, and noninflammatory. Demographic and clinical variables were analyzed regarding their relationship to etiologies and functional outcome. RESULTS Among the 570 SE consecutive episodes, 33 (6%) were inflammatory (2.5% autoimmune; 3.3% infectious), without any change in frequency over the study period. Inflammatory SE episodes involved younger patients (mean age 53 vs 61 years, p = 0.015) and were more often refractory to initial antiepileptic treatment (58% vs 38%, odds ratio = 2.19, 95% confidence interval = 1.07-4.47, p = 0.041), despite similar clinical outcome. Subgroup analysis showed that, compared with infectious SE episodes, autoimmune SE involved younger adults (mean age 44 vs 60 years, p = 0.017) and was associated with lower morbidity (return to baseline conditions in 71% vs 32%, odds ratio = 5.41, 95% confidence interval = 1.19-24.52, p = 0.043) without any difference in mortality. CONCLUSIONS Despite increasing awareness, inflammatory SE etiologies were relatively rare; their occurrence in younger individuals and higher refractoriness to treatment did not have any effect on outcome. Autoimmune SE episodes also occurred in younger patients, but tended to have better outcomes in survivors than infectious SE.
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Affiliation(s)
- Marianna Spatola
- From the Service of Neurology (M.S., J.N., R.D.P., A.O.R.), Department of Clinical Neurosciences, CHUV and University of Lausanne, Switzerland; IDIBAPS and Service of Neurology (J.D.), Hospital Clinic, University of Barcelona, Spain; and Department of Neurology (J.D.), University of Pennsylvania, Philadelphia
| | - Jan Novy
- From the Service of Neurology (M.S., J.N., R.D.P., A.O.R.), Department of Clinical Neurosciences, CHUV and University of Lausanne, Switzerland; IDIBAPS and Service of Neurology (J.D.), Hospital Clinic, University of Barcelona, Spain; and Department of Neurology (J.D.), University of Pennsylvania, Philadelphia
| | - Renaud Du Pasquier
- From the Service of Neurology (M.S., J.N., R.D.P., A.O.R.), Department of Clinical Neurosciences, CHUV and University of Lausanne, Switzerland; IDIBAPS and Service of Neurology (J.D.), Hospital Clinic, University of Barcelona, Spain; and Department of Neurology (J.D.), University of Pennsylvania, Philadelphia
| | - Josep Dalmau
- From the Service of Neurology (M.S., J.N., R.D.P., A.O.R.), Department of Clinical Neurosciences, CHUV and University of Lausanne, Switzerland; IDIBAPS and Service of Neurology (J.D.), Hospital Clinic, University of Barcelona, Spain; and Department of Neurology (J.D.), University of Pennsylvania, Philadelphia
| | - Andrea O Rossetti
- From the Service of Neurology (M.S., J.N., R.D.P., A.O.R.), Department of Clinical Neurosciences, CHUV and University of Lausanne, Switzerland; IDIBAPS and Service of Neurology (J.D.), Hospital Clinic, University of Barcelona, Spain; and Department of Neurology (J.D.), University of Pennsylvania, Philadelphia.
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Ong CT, Sheu SM, Tsai CF, Wong YS, Chen SCC. Age-dependent sex difference of the incidence and mortality of status epilepticus: a twelve year nationwide population-based cohort study in Taiwan. PLoS One 2015; 10:e0122350. [PMID: 25826701 PMCID: PMC4380468 DOI: 10.1371/journal.pone.0122350] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 02/15/2015] [Indexed: 11/19/2022] Open
Abstract
Status epilepticus (SE) is a serious neurologic emergency associated with a significant mortality. The objective of this study is to investigate its epidemiology in terms of age- and sex-specific incidences and mortality. By using the Taiwan National Health Insurance Research Database during 2000 to 2011, we identified hospitalized patients with a discharged diagnosis of SE and calculated the incidence and in-hospital mortality of SE with respect to age and sex. The overall incidence of SE was 4.61 per 100,000 person-years, which displayed a "J-shaped" distribution by age with a little higher under the age of 5 and highest over 60 years. The male-to-female rate ratio was 1.57 and it demonstrated a "mountain-shape" across ages with the peak at 45 to 49 years old. The in-hospital mortality was significantly lower in males (7.38%) than in females (11.12%) with an odds ratio of 0.64 (95% CI 0.56-0.72). Notably, the in-hospital mortality for females increased rapidly after the age of 40 to 45 years. The multivariate analysis found males had a significantly lower risk of mortality than females after, but not before, 45 years of age with an odds ratio of 0.56 (95% CI 0.49-0.65). Sex and age are crucial factors associated with the incidence and in-hospital mortality of SE. The females over 45 years of age have a higher risk of occurrence and mortality from SE. The underlying mechanism deserves further study.
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Affiliation(s)
- Cheung-Ter Ong
- Department of Neurology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi city, Taiwan
- Department of Nursing, Chung Jen Junior College of Nursing, Health Science and Management, Chia-Yi, Taiwan
| | - Shew-Meei Sheu
- Department of Medical Research, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi city, Taiwan
| | - Ching-Fang Tsai
- Department of Medical Research, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi city, Taiwan
| | - Yi-Sin Wong
- Department of Family Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi city, Taiwan
| | - Solomon Chih-Cheng Chen
- Department of Medical Research, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi city, Taiwan
- Department of Pediatrics, School of Medicine, Taipei Medical University, Taipei, Taiwan
- * E-mail: (SCC)
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Trinka E, Höfler J, Zerbs A, Brigo F. Efficacy and safety of intravenous valproate for status epilepticus: a systematic review. CNS Drugs 2014; 28:623-39. [PMID: 24806973 PMCID: PMC4078236 DOI: 10.1007/s40263-014-0167-1] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The effectiveness of valproate (VPA) in the treatment of focal and generalized epilepsies is well established. The drug has a wide spectrum of action, good tolerability, and has been available as an injectable formulation since 1993. Despite the lack of class A evidence, it has been used extensively in various forms of status epilepticus (SE). AIM Our aim was to present a systematic review of data from randomized and non-randomized controlled trials to evaluate the efficacy and safety of intravenous VPA for the treatment of SE. METHODS Data sources included MEDLINE, back tracing of references in pertinent studies, and contact with the manufacturer of VPA (Sanofi-Aventis). RESULTS Overall, the search strategy yielded 433 results (425 MEDLINE, seven congress abstracts, one unpublished study); after excluding duplicate publications and case reports, 30 studies were identified (the earliest was published in 1993, the most recent in 2012); ten were controlled (six randomized controlled trials, four non-randomized controlled studies), and 20 uncontrolled trials (eight prospective observational studies, 12 retrospective case series). The cumulative literature describes the experiences of 860 patients with various forms of SE treated with intravenous VPA. The overall response rate to abrogate SE was 70.9% (601/848; 95% confidence interval [CI] 67.8-73.9). Response rates to intravenous VPA were better in children than in adults and did not differ between the SE types. The most commonly reported effective doses were between 15 and 45 mg/kg in bolus (6 mg/kg/min) followed by 1-3 mg/kg/h infusion. Safety studies of intravenous VPA administration in patients with SE showed a low incidence of adverse events overall (<10%), mainly dizziness, thrombocytopenia, and mild hypotension, which was independent of infusion rates. Of note, good cardiovascular and respiratory tolerability was observed in these studies, even at high doses and fast infusion rates (up to 30 mg/kg at 10 mg/kg/min), despite multiple morbidities or other antiepileptic drugs. The most serious concern relates to the possibility of acute encephalopathy, sometimes related to hepatic abnormalities or hyperammonemia. CONCLUSIONS The published experience is consistent with VPA being a safe and effective therapeutic option for patients with established SE who have previously failed conventional first-line treatment with benzodiazepines, but high-quality randomized controlled trials are needed to inform clinicians on its comparative effectiveness in SE.
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Centre for Cognitive Neuroscience Salzburg, Paracelsus Medical University Salzburg, Ignaz Harrerstrasse 79, 5020, Salzburg, Austria,
| | - Julia Höfler
- Department of Neurology, Christian Doppler Klinik, Centre for Cognitive Neuroscience Salzburg, Paracelsus Medical University Salzburg, Ignaz Harrerstrasse 79, 5020 Salzburg, Austria ,Christian Doppler Medical Centre, Salzburg, Austria
| | - Alexander Zerbs
- Department of Neurology, Christian Doppler Klinik, Centre for Cognitive Neuroscience Salzburg, Paracelsus Medical University Salzburg, Ignaz Harrerstrasse 79, 5020 Salzburg, Austria ,Christian Doppler Medical Centre, Salzburg, Austria
| | - Francesco Brigo
- Department of Neurological and Movement Sciences, University of Verona, Verona, Italy
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Seif-Eddeine H, Treiman DM. Problems and controversies in status epilepticus: a review and recommendations. Expert Rev Neurother 2012; 11:1747-58. [PMID: 22091598 DOI: 10.1586/ern.11.160] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Status epilepticus (SE) is a neurologic emergency that require immediate vigorous treatment in order to prevent serious morbidity or even death. Several investigators have suggested that the underlying etiology is the primary determinant of outcome. We believe that this may be true in aggressively treated SE, but not when the treatment is less than optimal. In this article, we will discuss the factors that have been implicated in affecting SE outcomes, and argue, on the basis of both human and experimental animal data, that aggressive treatment is necessary and appropriate for all presentations of SE in order to maximize the probability of a successful outcome even when the etiology suggests a poor prognosis.
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Affiliation(s)
- Hussam Seif-Eddeine
- Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
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Affiliation(s)
- Felix Rosenow
- Department of Neurology, Philipps-University Marburg, Marburg, Germany.
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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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Aranda A, Foucart G, Ducassé JL, Grolleau S, McGonigal A, Valton L. Generalized convulsive status epilepticus management in adults: a cohort study with evaluation of professional practice. Epilepsia 2010; 51:2159-67. [PMID: 20738380 DOI: 10.1111/j.1528-1167.2010.02688.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Generalized convulsive status epilepticus (GCSE) needs immediate management. Despite guidelines, adherence to management protocols is often poor, this contributing to poor outcome. We aimed to evaluate the usefulness of a management protocol in GCSE. METHODS This is a prospective population-based study of consecutive adults with GCSE in Haute-Garonne district, France. Demographics and treatment procedures were documented. Factors associated with seizure termination and refractoriness were analyzed using logistic regression. RESULTS One hundred eighteen episodes in 111 adults (mean age 55 years) between October 2006 and February 2008 were included. SE was convulsive in 101 episodes. Incidence was 6.6 per 100,000 and case fatality was 9%. Adequate initial treatment according to protocol was observed in 38%; 64% were treated out-of-hospital, and SE was refractory in 27% [no response after two antiepileptic drugs (AED)]. Patients who received adequate first-line treatment were 6.8 times [95% confidence interval (CI) 2.8-16.9] more likely to have seizure termination, with 74% versus 29% efficacy rate (p < 0.0001). Inadequate initial management was 4.7 times (1.9-11.1) more likely to need several benzodiazepine doses (p = 0.0004) and 9.1 times (3.7-20) more likely to require a long-acting AED as next treatment (p < 0.0001). Seizure termination after initial treatment was associated with decreased intensive care unit stay [1 (1-2) versus 2 (1-5.5) days, p < 0.0001] and hospital stay [3 (2-11) versus 7 (3-18) days, p = 0.009]. DISCUSSION GCSE termination and outcome seem clearly associated with adherence to treatment protocol. Results add to the debate on appropriate allocation of resources for out-of-hospital treatment, licensed drugs, and achievement of guideline implementation to improve SE outcome.
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Neligan A, Shorvon SD. Prognostic factors, morbidity and mortality in tonic-clonic status epilepticus: a review. Epilepsy Res 2010; 93:1-10. [PMID: 20947300 DOI: 10.1016/j.eplepsyres.2010.09.003] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 09/01/2010] [Accepted: 09/13/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVES to determine how the duration of SE, the EEG findings during/after SE, the depth of coma at presentation and age impact on the prognosis of convulsive status epilepticus indepedent of aetiology and to analyse the outcome of status epilepticus with respect to mortality and morbidity (the latter measured in terms of functional decline, cognitive/intellectual decline and the prospective risk of epilepsy). DESIGN a systematic review of all studies of status epilepticus (SE) with greater then 30 patients published from the 01/01/1990 up until 31/12/2009. RESULTS oveall the longer the duration of SE the worse the prognosis particularly after 1-2h of continuous seizures although this affect may be lost after 10h. The depth of coma correlates well with outcome. Only periodic epileptiform discharges (PEDs) have been shown to be associated with a poorer outcome in most (but not all) studies although this is probably related to the underlying aetiology. Age is an important prognostic factor with children having a better prognosis then adults. CONCLUSIONS age and depth of coma at presentation appear to be the strongest predictors of outcome of SE independent of aetiology with the duration of SE and the EEG findings less important.
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Affiliation(s)
- A Neligan
- UCL Institute of Neurology, Queen Square, London WC1N 3BG, United Kingdom
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Abstract
Status epilepticus (SE) is one of the most commonly occurring neurologic emergencies. About 40% of SE cases occur in people with epilepsy. Convulsive SE is easily recognized, but nonconvulsive SE is not and requires both a high index of suspicion and EEG confirmation. SE has a high mortality risk and requires rapid effective treatment for optimal response to therapy and outcome. The goal of treatment is to stop all clinical and electrographic seizures while maintaining vital functions. If seizures continue after initial treatment with a benzodiazepine, additional antiepileptic therapy should be administered. When SE is refractory to these treatments, continuous IV infusion with midazolam, propofol, or a barbiturate suppresses seizure activity. Standard treatment protocols are useful in promoting rapid intervention with appropriate medications.
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Kalita J, Nair PP, Misra UK. A clinical, radiological and outcome study of status epilepticus from India. J Neurol 2010; 257:224-9. [PMID: 19730928 DOI: 10.1007/s00415-009-5298-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Revised: 07/29/2009] [Accepted: 08/14/2009] [Indexed: 10/20/2022]
Abstract
The objective of this study is to evaluate the clinical and radiological characteristics and the outcome of status epilepticus (SE). 117 consecutive patients with SE were evaluated including their demographics, history of epilepsy, antiepileptic drug (AED) default, comorbidities, SE type and duration. The study included 22 children, 77 adults and 18 elderly patients with SE. Blood counts, serum chemistry, ECG, cranial MRI, cerebrospinal fluid and EEG were done. Patients were treated with IV phenytoin, valproate, lorazepam or diazepam as per a fixed protocol and responses to first and second drugs were noted. Death during hospital was recorded. The etiology of SE was infection in 53.8%, drug default in 7.9%, metabolic in 14.5%, stroke in 12.8% and miscellaneous in 11% of patients. 92.3% of patients had convulsive and 7.7% nonconvulsive SE. Cranial MRI was abnormal in 62%. Infection as an etiology was more common in children, drug default and metabolic causes in adults and stroke in adults and elderly. Following first AED, SE was controlled in 50%. 30% of patients remained refractory to second AED which was related to duration of SE and mortality. 29% patients died and death was higher in elderly (44%) compared to children (14%). Acute symptomatic SE is more common in developing countries. Refractory SE is associated with SE duration and mortality.
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Affiliation(s)
- J Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareily Road, Lucknow 226014, India.
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Tilz C, Resch R, Hofer T, Eggers C. Successful treatment for refractory convulsive status epilepticus by non-parenteral lacosamide. Epilepsia 2010; 51:316-7. [DOI: 10.1111/j.1528-1167.2009.02256.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chen L, Zhou B, Li JM, Zhu Y, Wang JH, Sander JW, Stefan H, Zhou D. Clinical features of convulsive status epilepticus: a study of 220 cases in western China. Eur J Neurol 2009; 16:444-9. [PMID: 19170743 DOI: 10.1111/j.1468-1331.2008.02404.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE Convulsive status epilepticus (CSE) is the most common and life-threatening form of status epilepticus (SE). The aim of this study was to describe the clinical features of CSE in western China. METHODS Convulsive status epilepticus patients hospitalized from January 1996 to October 2007 were prospectively observed. Logistic regression was used to identify predictors of prognosis. RESULTS The average age of CSE patients (n = 220) was 37.5 years (SD 20.31), 50% of the patients had a history of epilepsy. The primary cause of CSE was central nervous system infection (32.7%), followed by discontinuation or reduction of antiepileptic drugs (AEDs; 15.5%). The median duration of CSE was 5 h and median duration of seizures before treatment was 2 h; both were longer in rural patients than in urban patients (P < 0.05). The fatality rate on discharge was 15.9%. Logistic regression analysis showed the duration of CSE [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.03-1.07], a history of epilepsy (OR 0.35, 95% CI 0.14-0.89), and respiratory depression (OR 5.96, 95% CI 2.49-14.24) were independent predictors of CSE prognosis. DISCUSSION Central nervous system infection and AEDs withdrawal in epilepsy patients were the most important causes of CSE. There is a large gap between antiepileptic therapy in China and European Status Epilepticus guidelines.
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Affiliation(s)
- L Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Berning S, Boesebeck F, van Baalen A, Kellinghaus C. Intravenous levetiracetam as treatment for status epilepticus. J Neurol 2009; 256:1634-42. [PMID: 19458986 DOI: 10.1007/s00415-009-5166-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Revised: 04/05/2009] [Accepted: 04/27/2009] [Indexed: 11/28/2022]
Abstract
There are established drugs for the treatment of status epilepticus (SE) but their potentially hazardous side-effects are well known. Levetiracetam (LEV) is a novel anticonvulsant available for intravenous (i.v.) application. It could be an alternative when standard drugs fail or should be avoided. We retrospectively identified patients from two German teaching hospitals who were treated with LEV i.v. for SE. Their charts were reviewed regarding sociodemographic data, type, etiology, onset and duration of SE, dose of LEV, concurrent antiepileptic drugs (AED) treatment, tolerability, and outcome. Thirty-two patients (15 female) were found who were treated with i.v. LEV for SE (median age 71 years). Two patients were exclusively treated with LEV. Eight received a low and further 20 patients a high dose of benzodiazepines before LEV. Two patients were treated with LEV to enable discontinuation of narcosis. SE was generalized convulsive in five, nonconvulsive in 20, and simple focal in seven patients. Etiology was acute 13 times and remote symptomatic 16 times; three SE were of unknown etiology. Therapy was initiated within a median time of 3 h and LEV i.v. was applied within a median time of 6 h. Median LEV bolus was 2,000 mg; median total dose on day 1 was 3,500 mg. Benzodiazepines plus i.v. LEV terminated SE in 23 patients without application of additional anticonvulsants, 10 within 30 min. LEV could not terminate SE in seven patients. We documented nausea and emesis in one and elevation of liver enzymes in another patient that were likely to be attributed to LEV. LEV i.v. seems to be safe with relevant efficiency for the treatment of SE in elderly and multimorbid patients when comorbidity and respiratory insufficiency precludes high doses of benzodiazepines or phenytoin.
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Affiliation(s)
- Sascha Berning
- Department of Neurology, Klinikum Osnabrück, Am Finkenhügel 1, 49076 Osnabrück, Germany.
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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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Pronostic de l’état de mal chez l’adulte. Rev Neurol (Paris) 2009; 165:344-7. [DOI: 10.1016/j.neurol.2008.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2008] [Accepted: 12/04/2008] [Indexed: 11/24/2022]
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Agan K, Afsar N, Midi I, Us O, Aktan S, Aykut-Bingol C. Predictors of refractoriness in a Turkish status epilepticus data bank. Epilepsy Behav 2009; 14:651-4. [PMID: 19435569 DOI: 10.1016/j.yebeh.2009.02.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2008] [Revised: 02/04/2009] [Accepted: 02/07/2009] [Indexed: 11/19/2022]
Abstract
Refractory status epilepticus (RSE) is known to constitute approximately 10-50% of all cases of status epilepticus (SE) and is associated with significant morbidity and mortality. In the present study, data from a prospectively collected SE database were analyzed. Patients with RSE (defined as a SE episode requiring a second line of intravenous treatment following intravenous phenytoin) were compared with patients with nonrefractory SE (NRSE); 290 episodes of SE were identified, of which 108 (38%) were defined as RSE. Univariate analysis revealed that age, female gender, SE type, SE duration, and acute etiology were associated with refractoriness, whereas electroencephalographic patterns were not. Nonconvulsive SE, which is probably associated with delays in treatment initiation, was a predictor of RSE, although it was not retained as a predictor in multivariate analysis. In the latter analysis, female gender (odds ratio: 1.815, 95% CI: 1.053-3.126) and acute etiology (odds ratio: 0.619, 95% CI: 0.429-0.894) were shown to be the only significant independent predictors of refractoriness.
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Affiliation(s)
- Kadriye Agan
- Department of Neurology, Marmara University Hospital, Istanbul, Turkey
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Rossetti AO, Logroscino G, Milligan TA, Michaelides C, Ruffieux C, Bromfield EB. Status Epilepticus Severity Score (STESS): a tool to orient early treatment strategy. J Neurol 2008; 255:1561-6. [PMID: 18769858 DOI: 10.1007/s00415-008-0989-1] [Citation(s) in RCA: 287] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Revised: 03/30/2008] [Accepted: 04/28/2008] [Indexed: 11/25/2022]
Abstract
BACKGROUND Status epilepticus (SE) treatment ranges from small benzodiazepine doses to coma induction. For some SE subgroups, it is unclear how the risk of an aggressive therapeutic approach balances with outcome improvement. We recently developed a prognostic score (Status Epilepticus Severity Score, STESS), relying on four outcome predictors (age, history of seizures, seizure type and extent of consciousness impairment), determined before treatment institution. Our aim was to assess whether the score might have a role in the treatment strategy choice. METHODS This cohort study involved adult patients in three centers. For each patient, the STESS was calculated before primary outcome assessment: survival vs. death at discharge. Its ability to predict survival was estimated through the negative predictive value for mortality (NPV). Stratified odds ratios (OR) for mortality were calculated considering coma induction as exposure; strata were defined by the STESS level. RESULTS In the observed 154 patients, the STESS had an excellent negative predictive value (0.97). A favorable STESS was highly related to survival (P < 0.001), and to return to baseline clinical condition in survivors (P < 0.001). The combined Mantel-Haenszel OR for mortality in patients stratified after coma induction and their STESS was 1.5 (95 % CI: 0.59-3.83). CONCLUSION The STESS reliably identifies SE patients who will survive. Early aggressive treatment could not be routinely warranted in patients with a favorable STESS, who will almost certainly survive their SE episode. A randomized trial using this score would be needed to confirm this hypothesis.
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