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Syed MJ, Zutshi D, Muzammil SM, Mohamed W. Ketamine to Prevent Endotracheal Intubation in Adults with Refractory Non-convulsive Status Epilepticus: A Case Series. Neurocrit Care 2024; 40:976-983. [PMID: 37783825 DOI: 10.1007/s12028-023-01853-8] [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: 05/09/2023] [Accepted: 09/01/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Non-convulsive status epilepticus (NCSE) is defined as status epilepticus (SE) with no obvious motor phenomenon and is diagnosed based on electroencephalogram (EEG). Refractory SE (RSE) is the persistence of seizures despite treatment with an adequately dosed first-line and second-line agents. Although guidelines for convulsive RSE include third-line agents such as intravenous anesthetic drugs (midazolam, propofol, or barbiturates), the therapeutic approach to NCSE is not well outlined. Treatment with traditional anesthetics invariably includes endotracheal intubation, which is associated with significant adverse events. Comparatively, ketamine, a non-competitive N-methyl-D-aspartate receptor antagonist is not associated with significant cardiorespiratory depression and may help in avoiding intubation. OBJECTIVE In this case series, we describe our experience with the early use of intravenous ketamine as the first anesthetic agent in patients with refractory NCSE to avoid endotracheal intubation. METHODS We present a case series of nine patients managed in the Neurointensive Care Unit at a university-affiliated tertiary care hospital. The study was approved by the hospital and university institutional review boards and the requirement for informed consent was waived for retrospective analysis of existing data, per institutional policy. All cases of SE were identified from a prospective database, and a subsequent retrospective chart review identified all patients with a diagnosis of refractory NCSE in whom ketamine was used as the first anesthetic agent. The primary endpoint was the avoidance of endotracheal intubation while on ketamine infusion. The secondary endpoint was defined as cessation of both clinical and electrographic seizures recorded on continuous EEG within 24 h of ketamine administration. RESULTS A total of nine patients experiencing refractory NCSE were included in this case series, with a median age of 61 (range 26-72) years and seven patients were male. The primary endpoint, avoiding intubation, was achieved in five out of nine (55%) cases. Six patients experienced resolution of refractory NCSE with ketamine administration as the sole anesthetic agent. Four patients required endotracheal intubation and three patients had a failure of seizure cessation with ketamine. Hypersalivation and pneumonia were the most common ketamine associated adverse events. In non-intubated patients, no deaths occurred. One patient was discharged home, four to subacute rehabilitation, one to a long term acute care hospital, and one patient to hospice. CONCLUSION The use of ketamine as the primary anesthetic agent may be a reasonable option to avoid endotracheal intubation in a subset of patients with refractory NCSE. This study is limited by its small sample size, retrospective design, and reliance on information obtained from chart review.
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Affiliation(s)
- Maryam J Syed
- Wayne State University School of Medicine, Detroit Medical Center, 4201 St Antoine, Detroit, MI, 48201, USA
| | - Deepti Zutshi
- Wayne State University School of Medicine, Detroit Medical Center, 4201 St Antoine, Detroit, MI, 48201, USA
| | - Syeda Maria Muzammil
- Wayne State University School of Medicine, Detroit Medical Center, 4201 St Antoine, Detroit, MI, 48201, USA
| | - Wazim Mohamed
- Wayne State University School of Medicine, Detroit Medical Center, 4201 St Antoine, Detroit, MI, 48201, USA.
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Benghanem S, Robieux EP, Neligan A, Walker MC. Status epilepticus: what's new for the intensivist. Curr Opin Crit Care 2024; 30:131-141. [PMID: 38441162 DOI: 10.1097/mcc.0000000000001137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Status epilepticus (SE) is a common neurologic emergency affecting about 36.1/100 000 person-years that frequently requires intensive care unit (ICU) admission. There have been advances in our understanding of epidemiology, pathophysiology, and EEG monitoring of SE, and there have been large-scale treatment trials, discussed in this review. RECENT FINDINGS Recent changes in the definitions of SE have helped guide management protocols and we have much better predictors of outcome. Observational studies have confirmed the efficacy of benzodiazepines and large treatment trials indicate that all routinely used second line treatments (i.e., levetiracetam, valproate and fosphenytoin) are equally effective. Better understanding of the pathophysiology has indicated that nonanti-seizure medications aimed at underlying pathological processes should perhaps be considered in the treatment of SE; already immunosuppressant treatments are being more widely used in particular for new onset refractory status epilepticus (NORSE) and Febrile infection-related epilepsy syndrome (FIRES) that sometimes revealed autoimmune or paraneoplastic encephalitis. Growing evidence for ICU EEG monitoring and major advances in automated analysis of the EEG could help intensivist to assess the control of electrographic seizures. SUMMARY Research into the morbi-mortality of SE has highlighted the potential devastating effects of this condition, emphasizing the need for rapid and aggressive treatment, with particular attention to cardiorespiratory and neurological complications. Although we now have a good evidence-base for the initial status epilepticus management, the best treatments for the later stages are still unclear and clinical trials of potentially disease-modifying therapies are long overdue.
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Affiliation(s)
- Sarah Benghanem
- Medical Intensive Care Unit, Cochin hospital, APHP.Centre
- University of Paris cite - Medical School
- INSERM 1266, psychiatry and neurosciences institute of Paris (IPNP)
| | - Estelle Pruvost Robieux
- University of Paris cite - Medical School
- INSERM 1266, psychiatry and neurosciences institute of Paris (IPNP)
- Neurophysiology and epileptology department, Sainte Anne hospital, Paris, France
| | - Aidan Neligan
- Homerton University Hospital NHS Foundation Trust, Homerton Row
- UCL Queen Square Institute of Neurology, Queen Square, London
- Centre for Preventive Neurology, Wolfson Institute of Population Health, QMUL, UK
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Beuchat I, Novy J, Rosenow F, Kellinghaus C, Rüegg S, Tilz C, Trinka E, Unterberger I, Uzelac Z, Strzelczyk A, Rossetti AO. Staged treatment response in status epilepticus: Lessons from the SENSE registry. Epilepsia 2024; 65:338-349. [PMID: 37914525 DOI: 10.1111/epi.17817] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/20/2023] [Accepted: 10/31/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Although in epilepsy patients the likelihood of becoming seizure-free decreases substantially with each unsuccessful treatment, to our knowledge this has been poorly investigated in status epilepticus (SE). We aimed to evaluate the proportion of SE cessation and functional outcome after successive treatment steps. METHODS We conducted a post hoc analysis of a prospective, observational, multicenter cohort (Sustained Effort Network for treatment of Status Epilepticus [SENSE]), in which 1049 incident adult SE episodes were prospectively recorded at nine European centers. We analyzed 996 SE episodes without coma induction before the third treatment step. Rates of SE cessation, mortality (in ongoing SE or after SE control), and favorable functional outcome (assessed with modified Rankin scale) were evaluated after each step. RESULTS SE was treated successfully in 838 patients (84.1%), 147 (14.8%) had a fatal outcome (36% of them died while still in SE), and 11 patients were transferred to palliative care while still in SE. Patients were treated with a median of three treatment steps (range 1-13), with 540 (54.2%) receiving more than two steps (refractory SE [RSE]) and 95 (9.5%) more than five steps. SE was controlled after the first two steps in 45%, with an additional 21% treated after the third, and 14% after the fourth step. Likelihood of SE cessation (p < 0.001), survival (p = 0.003), and reaching good functional outcome (p < 0.001) decreased significantly between the first two treatment lines and the third, especially in patients not experiencing generalized convulsive SE, but remained relatively stable afterwards. SIGNIFICANCE The significant worsening of SE prognosis after the second step clinically supports the concept of RSE. However, and differing from findings in human epilepsy, RSE remains treatable in about one third of patients, even after several failed treatment steps. Clinical judgment remains essential to determine the aggressiveness and duration of SE treatment, and to avoid premature treatment cessation in patients with SE.
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Affiliation(s)
- Isabelle Beuchat
- Department of Neurology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Jan Novy
- Department of Neurology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University, Frankfurt am Main, Germany
| | - Christoph Kellinghaus
- Department of Neurology, Klinikum Osnabrück, Osnabrück, Germany
- Epilepsy Center, Münster-Osnabrück, Campus Osnabrück, Osnabrück, Germany
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel, and University of Basel, Basel, Switzerland
| | - Christian Tilz
- Department of Neurology, Krankenhaus Barmherzige Brüder, Regensburg, Germany
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Member of the European Reference Network EpiCARE, Salzburg, Austria
- Neuroscience Institute, Christian Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, 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
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Salzburg, Austria
| | - Iris Unterberger
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Zeljko Uzelac
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University, Frankfurt am Main, Germany
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Andrea O Rossetti
- Department of Neurology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
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Liu G, Wang Y, Tian F, Jiang M, Huang H, Chen W, Zhang Y, Su Y. Long-term follow-up of phenobarbital versus valproate for generalized convulsive status epilepticus in adults: A randomized clinical trial. Epilepsy Res 2023; 195:107187. [PMID: 37467704 DOI: 10.1016/j.eplepsyres.2023.107187] [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: 03/09/2023] [Revised: 06/16/2023] [Accepted: 07/03/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Intravenous phenobarbital is frequently offered to patients with generalized convulsive status epilepticus (GCSE) in China, but its long-term benefits are unclear. We aimed to evaluate the long-term effects of intravenous phenobarbital on adult patients with GCSE. METHODS This randomized clinical trial with a 12-month follow-up was performed in Xuanwu Hospital, Capital Medical University (Beijing, China) between February 2011 and December 2021. After the failure of intravenous diazepam treatment, adult patients with GCSE were randomized to receive either intravenous phenobarbital or valproate. Neurological outcome within 12-month was dichotomized as good (modified Rankin scale, mRS 0-2) or poor (mRS 3-6). Cognitive function was measured by mini-mental state examination (MMSE) and Montreal cognitive assessment (MoCA). Hamilton anxiety scale (HAMA) and Hamilton depression scale (HAMD) were tested for mood disorders. RESULTS We consecutively recruited 166 patients with GCSE. After excluding individuals with termination after intravenous diazepam (n = 61), and with other exclusion criteria (n = 7), 98 patients were included and 88.0% (66/75) of survivors achieved seizure freedom at 12-month. Forty-five patients (45.92%) had good outcomes at 3-month and 57 patients (58.16%) had good outcomes at 12-month. And 46.67% (35/75) of survivors showed mRS improvement at 12-month (phenobarbital group, n = 17 vs. valproate group, n = 18, P = 0.321). Despite there was no significant difference with respect to good outcomes at 3-month (54.0% vs. 37.5%, P = 0.101), the rate of good outcomes in phenobarbital group was higher than valproate group at 12-month (68.0% vs. 47.92%, P = 0.044). A total of 43 patients successfully participated cognitive and emotional tests. Mild cognitive impairment was found in 7.14% of phenobarbital group and 50.0% in valproate group (P = 0.026). In addition, there were no significant differences with respect to anxiety (36.36% vs. 38.10%) and depression (31.82% vs. 47.62%) between the phenobarbital and valproate groups. CONCLUSIONS Combined with long term conventional therapy, intravenous phenobarbital group had more good outcomes than intravenous valproate group in Chinese adult patients with GCSE up to 12-month follow-up. This finding may prompt the option of intravenous phenobarbital especially in patients with limited access to new antiseizure drugs.
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Affiliation(s)
- Gang Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Yuan Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Fei Tian
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Mengdi Jiang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Huijin Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China.
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China.
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Raičević B, Janković S, Gojak R, Dabanović V, Janković S. Long-term outcomes in refractory status epilepticus. Expert Rev Neurother 2023; 23:1063-1068. [PMID: 38058207 DOI: 10.1080/14737175.2023.2292143] [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: 08/29/2023] [Accepted: 12/04/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Refractory status epilepticus (RSE) is a diagnosis that can be made when tonic-clonic status epilepticus (SE) and focal SE cannot be stopped by at least two anti-seizure medications after 30 and 60 minutes, respectively, from the time of commencement. It could result in mortality, loss of functionality, neurological deficiency, and other serious short- and long-term effects. AREAS COVERED This narrative review covers original clinical studies of any design and case series investigating long-term outcomes of RSE recorded after at least a year from the SE onset. EXPERT OPINION The future of a patient with RSE rests mostly on the long-term effects of this severe pathological condition, which may be accompanied with systemic complications like hyperthermia, hyperkalemia, acidosis, and/or stress cardiomyopathy. Younger patients with less severe RSE of shorter duration, particularly of the convulsive kind, are reported to have better long-term outcomes. Previous studies on the factors influencing the long-term outcomes of RSE, however, did not link the outcomes to treatment options for the condition. Such circumstances currently prevent making any definitive recommendations on the treatment of RSE until future research with adequate statistical power is completed.
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Affiliation(s)
| | - Snežana Janković
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Refet Gojak
- Medical Faculty, University of Sarajevo, Sarajevo, Bosnia & Herzegovina
| | | | - Slobodan Janković
- Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
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Vaitkevicius H, Ramsay RE, Swisher CB, Husain AM, Aimetti A, Gasior M. Intravenous ganaxolone for the treatment of refractory status epilepticus: Results from an open-label, dose-finding, phase 2 trial. Epilepsia 2022; 63:2381-2391. [PMID: 35748707 PMCID: PMC9796093 DOI: 10.1111/epi.17343] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Patients with refractory status epilepticus (RSE) have failed treatment with benzodiazepines and ≥1 second-line intravenous (IV) antiseizure medication (ASM). Guidelines recommend IV anesthesia when second-line ASMs have failed, but potential harms can outweigh the benefits. Novel treatments are needed to stop and durably control RSE without escalation to IV anesthetics. Ganaxolone is an investigational neuroactive steroid in development for RSE treatment. This study's objective was to determine the appropriate dosing for IV ganaxolone in RSE and obtain a preliminary assessment of efficacy and safety. METHODS This was an open-label, phase 2 trial conducted from February 19, 2018 to September 18, 2019, at three sites in the United States. Patients were aged ≥12 years, had convulsive or nonconvulsive SE, and failed to respond to ≥1 second-line IV ASM. Twenty-one patients were screened; 17 were enrolled. Patients received IV ganaxolone added to standard-of-care ASMs. Ganaxolone infusion was initiated as an IV bolus (over 3 min) with continuous infusion of decreasing infusion rates for 48-96 h followed by an 18-h taper. There were three ganaxolone dosing cohorts: low, 500 mg/day; medium, 650 mg/day; and high, 713 mg/day. The primary end point was the number of patients not requiring escalation to IV anesthetic treatment within 24 h of ganaxolone initiation. RESULTS Most of the 17 enrolled patients (65%) had nonconvulsive SE, and had failed a median of three prior ASMs, including first-line benzodiazepine and second-line IV ASM therapy. Median time to SE cessation following ganaxolone initiation was 5 min. No patient required escalation to third-line IV anesthetics during the 24-h period following ganaxolone initiation. Two treatment-related serious adverse events (sedation) were reported. Of the three deaths, none was considered related to ganaxolone; all occurred 9-22 days after completing ganaxolone. SIGNIFICANCE IV ganaxolone achieved rapid and durable seizure control in patients with RSE, and showed acceptable safety and tolerability.
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Affiliation(s)
- Henrikas Vaitkevicius
- Department of NeurologyBrigham and Women's HospitalBostonMassachusettsUSA,Marinus PharmaceuticalsRadnorPennsylvaniaUSA
| | - R. Eugene Ramsay
- International Center for EpilepsySt. Bernard HospitalNew OrleansLouisianaUSA
| | | | - Aatif M. Husain
- Department of NeurologyDuke UniversityDurhamNorth CarolinaUSA,Neurodiagnostic CenterVeterans Affairs Medical CenterDurhamNorth CarolinaUSA
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Migdady I, Rosenthal ES, Cock HR. Management of status epilepticus: a narrative review. Anaesthesia 2022; 77 Suppl 1:78-91. [PMID: 35001380 DOI: 10.1111/anae.15606] [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] [Accepted: 10/01/2021] [Indexed: 11/26/2022]
Abstract
Status epilepticus causes prolonged or repetitive seizures that, if left untreated, can lead to neuronal injury, severe disability, coma and death in paediatric and adult populations. While convulsive status epilepticus can be diagnosed using clinical features alone, non-convulsive status epilepticus requires confirmation by electroencephalogram. Early seizure control remains key in preventing the complications of status epilepticus. This is especially true for convulsive status epilepticus, which has stronger evidence supporting the benefit of treatment on outcomes. When status epilepticus becomes refractory, often due to gamma-aminobutyric acid and N-methyl-D-aspartate receptor modulation, anaesthetic drugs are needed to suppress seizure activity, of which there is limited evidence regarding the selection, dose or duration of their use. Seizure monitoring with electroencephalogram is often needed when patients do not return to baseline or during anaesthetic wean; however, it is resource-intensive, costly, only available in highly specialised centres and has not been shown to improve functional outcomes. Thus, the treatment goals and aggressiveness of therapy remain under debate, especially for non-convulsive status epilepticus, where prolonged therapeutic coma can lead to severe complications. This review presents an evidence-based, clinically-oriented and comprehensive review of status epilepticus and its definitions, aetiologies, treatments, outcomes and prognosis at different stages of the patient's journey.
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Affiliation(s)
- I Migdady
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - E S Rosenthal
- Department of Neurology, Divisions of Clinical Neurophysiology and Neurocritical Care Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - H R Cock
- Clinical Neurosciences Academic Group, Institute of Molecular and Clinical Sciences, St. George's University of London, London, UK
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Dericioglu N, Ayvacioglu Cagan C, Sokmen O, Arsava EM, Topcuoglu MA. Frequency and Types of Complications Encountered in Patients With Nonconvulsive Status Epilepticus in the Neurological ICU: Impact on Outcome. Clin EEG Neurosci 2021; 54:265-272. [PMID: 34714180 DOI: 10.1177/15500594211046722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives. The frequency and types of complications in patients with nonconvulsive status epilepticus (NCSE) who are followed up in the intensive care unit (ICU), and the impact of these complications on outcome are not well-known. We investigated the complications and their effects on prognosis in NCSE patients. Methods. After reviewing the video-EEG monitoring (VEEGM) reports of all the consecutive patients who were followed up in our ICU between 2009 and 2019, we identified two groups of patients: 1-patients with NCSE (study group) and 2-patients who underwent VEEGM for possible NCSE but did not have ictal recordings (no-NCSE group). Electronic health records were reviewed to identify demographic and clinical data, duration of ICU care, medical and surgical complications, pharmacologic treatment, and outcome. These parameters were compared statistically between the groups. We also investigated the parameters affecting prognosis at discharge. Results. Thirty-two patients with NCSE comprised the study group. Infection developed in 84%. More than half were intubated, had tracheostomy or percutaneous endoscopic gastrostomy application. Refractory NCSE was associated with significantly more frequent complications and worse outcome. There was a higher tendency of infections in the study group (P = .059). Higher organ failure scores and prolonged stay in ICU predicted worse outcome (P < .05). Conclusion. The frequency of complications in patients with NCSE who are cared for in the ICU is considerable. Most of the complications are similar to the other patients in ICU, except for the higher frequency of infections. Increased physician awareness about modifiable parameters and timely interventions might help improve prognosis.
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Welling LC, Rabelo NN, Yoshikawa MH, Telles JPM, Teixeira MJ, Figueiredo EG. Efficacy of topiramate as an add-on therapy in patients with refractory status epilepticus: a short systematic review. Rev Bras Ter Intensiva 2021; 33:440-444. [PMID: 35107556 PMCID: PMC8555390 DOI: 10.5935/0103-507x.20210054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/19/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To identify current evidence on the use of topiramate for refractory status epilepticus. METHODS We reviewed the literature to investigate the efficacy of topiramate in the treatment of refractory status epilepticus. The search terms used were "status epilepticus", "refractory", "treatment" and "topiramate". No restrictions were used. RESULTS The search yielded 487 articles that reported using topiramate as a treatment for refractory status epilepticus and its outcomes. Case reports, review articles, and animal experiments were excluded. After excluding duplicates and applying inclusion and exclusion criteria, nine studies were included for analyses. Descriptive and qualitative analyses were performed, and the results were as follows: response rates (defined as termination in-hospital until 72 hours after the administration of topiramate) varied from 27% to 100%. The mortality rate varied from 5.9% to 68%. Positive functional long-term outcomes, defined as discharge, back to baseline or rehabilitation, were documented by seven studies, and the rates ranged between 4% and 55%. Most studies reported no or mild adverse effects. CONCLUSION Topiramate was effective in terminating refractory status epilepticus, presented relatively low mortality and was well tolerated. Therefore, topiramate could be a good option as a third-line therapy for refractory status epilepticus, but further studies are necessary.
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Yu Z, Ling L. Determinants of nutritional status and outcome in adults with RCSE: a retrospective cohort study. BMC Neurol 2021; 21:344. [PMID: 34496796 PMCID: PMC8424937 DOI: 10.1186/s12883-021-02373-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 08/30/2021] [Indexed: 02/08/2023] Open
Abstract
Background This study aimed to investigate the association between nutritional characteristics in patients with refractory convulsive status epilepticus. Methods We retrospectively enrolled 73 patients with refractory convulsive status epilepticus over 18 years of age at the West China Hospital between January 2017 and May 2019. All patients met the 2016 International League Against Epilepsy diagnostic criteria for refractory convulsive status epilepticus. A logistic regression model was used to evaluate the association between malnutrition and refractory convulsive status epilepticus. Results Of the 73 patients with refractory convulsive status epilepticus, 33 (45.21 %) suffered from malnutrition during hospitalization, and duration of hospitalization in days (OR = 1.251; 95 % CI,–1.067–1.384; P = 0.007), nasal feeding (OR = 22.623; 95 % CI: 1.091-286.899; P = 0.013), and malnutrition on admission (OR = 30.760; 95 % CI: 1.064–89.797; P = 0.046) were significantly associated with malnutrition in patients with refractory convulsive status epilepticus. Conclusions Malnutrition is a common complication during hospitalization in patients with refractory convulsive status epilepticus. The duration of hospitalization (days), nasal feeding, and malnutrition at admission are associated with malnutrition in patients with refractory convulsive status epilepticus. Further longitudinal studies are needed to identify the relationship between refractory convulsive status epilepticus and adverse outcomes.
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Affiliation(s)
- Zhang Yu
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #, 610041, Chengdu, Sichuan, China.,Department of Neurology, Chengdu Shangjin Nanfu Hospital, Shang Jin Road 253#, 610000, Chengdu, Sichuan, China
| | - Liu Ling
- Department of Neurology, West China Hospital, Sichuan University, Wai Nan Guo Xue Lane 37 #, 610041, Chengdu, Sichuan, China.
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Jose J, Keni RR, Hassan H, Menon R, Sukumaran S, Cherian A, Radhakrishnan A. Predictors of outcome in super refractory status epilepticus. Epilepsy Behav 2021; 118:107929. [PMID: 33775578 DOI: 10.1016/j.yebeh.2021.107929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/06/2021] [Accepted: 03/07/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE We conducted this study to determine the clinical, electrophysiological and radiological predictors of outcome in Super Refractory Status Epilepticus (SRSE). METHODS Data of patients treated for SRSE between January 2000 and November 2019, archived prospectively in our SE registry were analyzed. Functional outcome was measured by Glasgow outcome score (GOS) at the time of hospital discharge and was divided into: good i.e. GOS ≥ 3 and bad outcome i.e. GOS < 3. The predictors of outcome were determined using appropriate statistical tests by univariate and multivariate analysis, p < 0.05 was considered as statistically significant. RESULTS Of the 384 patients with status epilepticus (SE) identified during the study, 28 (8%) were diagnosed as SRSE and were included in the final analysis. Acute symptomatic SE comprising 15 (53.6%) patients was the most common etiology of SRSE. Thirteen patients (three patients with viral encephalitis and 10 patients with clinically possible autoimmune encephalitis) had New Onset Refractory Status Epilepticus (NORSE) like clinical presentation.12 patients (42.9%) had good outcome and 16 patients (57.1%) had bad outcome. Multivariate logistic regression analysis showed that independent predictors of poor outcome were: duration of ICU stay (p < 0.001); EEG findings such as non-convulsive SE in coma (0.032), spontaneous burst suppression (0.001) and postictal diffuse attenuation (<0.001); delay in starting anesthesia (0.002); and delay in starting immunotherapy in NORSE due to autoimmune encephalitis (0.002). CONCLUSION We could determine independent therapeutic and electrophysiological prognostic factors for SRSE. Early initiation of treatment and stringent management of these factors especially in an younger age-group, aided by continuous EEG monitoring and a thorough etiological work-up can result in good outcomes in more than one-third of cases.
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Affiliation(s)
- Jithu Jose
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ravish R Keni
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Haseeb Hassan
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ramshekhar Menon
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sajith Sukumaran
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ajith Cherian
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ashalatha Radhakrishnan
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.
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Zeidan S, Rohaut B, Outin H, Bolgert F, Houot M, Demoule A, Chemouni F, Combes A, Navarro V, Demeret S. Not all patients with convulsive status epilepticus intubated in pre-hospital settings meet the criteria for refractory status epilepticus. Seizure 2021; 88:29-35. [PMID: 33799137 DOI: 10.1016/j.seizure.2021.03.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Mechanically ventilated patients admitted to the intensive care unit (ICU) for generalized convulsive status epilepticus (GCSE) are a heterogeneous population. Our objective was to evaluate the number of patients who fulfilled the diagnostic criteria for refractory GCSE and describe their initial management and prognosis. METHODS This multicenter retrospective study was conducted in four French ICUs in Pitié-Salpêtrière University Hospital in Paris and in the Hospital of Jossigny. Mechanically ventilated patients admitted to the ICU for GCSE between, January 1, 2014, and, December 31, 2016, were included. Patients with anoxia and traumatic brain injury were excluded. Their pre-hospital and ICU medical records were reviewed. The collected data included pre-hospital clinical status, pre-hospital antiepileptic treatment, reason for mechanical ventilation, duration of general anesthesia, and prognosis in the ICU. A retrospective initial diagnosis based on the findings of the analysis of the clinical records was attributed to each patient. RESULTS Among the 98 patients included, 88.8% (n = 87/98) fulfilled the diagnostic criteria for GCSE; of these cases, 16.1% (n = 14/87) were refractory. Eleven percent of the patients did not fulfill the criteria for GCSE at the time of initial management (retrospective diagnosis of single convulsive seizure, repetitive convulsive seizures, or psychogenic non-epileptic seizures). Most patients were intubated for coma (58.9%, n = 56/95, missing data: n = 3). In the ICU, the median [Q1-Q3] duration of general anesthesia before weaning was 12.3 h (5.0-18.0 h); 7% of the patients had a relapse of status epilepticus, and 2% died in the ICU. CONCLUSION Among the cases of confirmed GCSE in the mechanically ventilated patients admitted to the ICU, 16.1% were refractory, with an overall good prognosis. A significant proportion of patients did not fulfill the diagnostic criteria for refractory GCSE.
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Affiliation(s)
- Sinead Zeidan
- Department of Neurology, Neuro Intensive Care Unit, Hôpital Pitié-Salpêtrière, APHP.Sorbonne, Paris, France
| | - Benjamin Rohaut
- Department of Neurology, Neuro Intensive Care Unit, Hôpital Pitié-Salpêtrière, APHP.Sorbonne, Paris, France; Department of Neurology, Critical Care Neurology, Columbia University, New York, NY, USA
| | - Hervé Outin
- Medical Intensive Care Unit, CHI de Poissy-Saint Germain en Laye, Poissy, France
| | - Francis Bolgert
- Department of Neurology, Neuro Intensive Care Unit, Hôpital Pitié-Salpêtrière, APHP.Sorbonne, Paris, France
| | - Marion Houot
- Institute of Memory and Alzheimer's Disease (IM2A), Centre of Excellence of Neurodegenerative Disease (CoEN), ICM, CIC Neurosciences, APHP Department of Neurology, Hopital Pitié-Salpêtrière, APHP.Sorbonne, Paris, France
| | - Alexandre Demoule
- Medical Intensive Care Unit, Hôpital Pitié-Salpêtrière, APHP.Sorbonne, Paris, France
| | - Frank Chemouni
- Medical and Surgical Intensive Care Unit, Grand Hôpital de l'Est Francilien, Marne-La-Vallée, France
| | - Alain Combes
- Medical Intensive Care Unit, Institute of Cardiology, Hôpital Pitié-Salpêtrière, APHP.Sorbonne, Paris, France
| | - Vincent Navarro
- Department of Clinical Neurophysiology and Epileptology, Hôpital Pitié-Salpêtrière, APHP.Sorbonne, Paris, France
| | - Sophie Demeret
- Department of Neurology, Neuro Intensive Care Unit, Hôpital Pitié-Salpêtrière, APHP.Sorbonne, Paris, France.
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Caronna E, Vilaseca A, Maria Gràcia Gozalo R, Sanchez Corral A, Santafé M, Sueiras M, Guzmán L, Quintana M, Toledo‐Argany M, Santamarina E. Long-term prognosis related to deep sedation in refractory status Epilepticus. Acta Neurol Scand 2020; 142:555-562. [PMID: 32614067 DOI: 10.1111/ane.13302] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/10/2020] [Accepted: 06/19/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate long-term prognosis in patients with refractory status epilepticus according to the level of sedation reached during drug-induced coma. MATERIALS AND METHODS Longitudinal study of patients with status epilepticus who received anesthetics to induce therapeutic coma. Demographic data, clinical, and electroencephalographic characteristics were collected, as well as variables related to sedation. We considered as deep sedation the EEG burst-suppression patterns (suppression ratio > 50%). A GOSE (Glasgow Outcome Scale Extended) score of 7 or 8 was considered as good prognosis. A comparative study was carried out to identify predictors of good or poor prognosis at discharge, at 1 and 2 years of follow-up. RESULTS We included 61 patients: 63.9% were men; mean age 53.5 ± 16.8 years (range 16-86 years), 39.3% reached deep sedation; 62.3% had > 48 h induced coma. The median hospital stay was 21 days, while 10 days in the intensive care unit (ICU). In the multiple regression analysis, an ICU length of stay ≥ 7 days was associated with poor prognosis at discharge and at long-term (P < .05), while deep sedation was associated only with poor long-term prognosis (1 and 2 years, P < .05). The Kaplan-Meier curve showed higher survival in the group that did not undergo deep sedation (P < .05). CONCLUSIONS In refractory status epilepticus, deep sedation is associated with poor prognosis at long-term.
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Affiliation(s)
- Edoardo Caronna
- Epilepsy Unit Neurology Department Hospital Universitari Vall d’Hebron Barcelona Spain
| | - Andreu Vilaseca
- Epilepsy Unit Neurology Department Hospital Universitari Vall d’Hebron Barcelona Spain
| | | | | | - Manel Santafé
- Intensive Care Unit Hospital Universitari Vall d’Hebron Barcelona Spain
| | - María Sueiras
- Neurophysiology Department Hospital Universitari Vall d’Hebron Barcelona Spain
| | - Lorena Guzmán
- Neurophysiology Department Hospital Universitari Vall d’Hebron Barcelona Spain
| | - Manuel Quintana
- Epilepsy Unit Neurology Department Hospital Universitari Vall d’Hebron Barcelona Spain
| | - Manuel Toledo‐Argany
- Epilepsy Unit Neurology Department Hospital Universitari Vall d’Hebron Barcelona Spain
| | - Estevo Santamarina
- Epilepsy Unit Neurology Department Hospital Universitari Vall d’Hebron Barcelona Spain
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14
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Vilaseca-Jolonch A, Abraira L, Quintana M, Sueiras M, Thonon V, Toledo M, Salas-Puig J, Fonseca E, Cordero E, Martínez-Ricarte F, Santamarina E. Tumor-associated status epilepticus: A prospective cohort in a tertiary hospital. Epilepsy Behav 2020; 111:107291. [PMID: 32702656 DOI: 10.1016/j.yebeh.2020.107291] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/14/2020] [Accepted: 06/17/2020] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Tumor-associated status epilepticus (TASE) follows a relatively benign course compared with SE in the general population. Little, however, is known about associated prognostic factors. METHODS We conducted a prospective, observational study of all cases of TASE treated at a tertiary hospital in Barcelona, Spain between May 2011 and May 2019. We collected data on tumor and SE characteristics and baseline functional status and analyzed associations with outcomes at discharge and 1-year follow-up. RESULTS Eighty-two patients were studied; 58.5% (n = 48) had an aggressive tumor (glioblastoma or brain metastasis). Fifty-one patients (62.2%) had a favorable outcome at discharge compared with just 30 patients (25.8%) at 1-year follow-up. Fourteen patients (17.1%) died during hospitalization. Lateralized period discharges (LPDs) on the baseline electroencephalography (EEG), presence of metastasis, and SE severity were significantly associated with a worse outcome at discharge. The independent predictors of poor prognosis at 1-year follow-up were SE duration of at least 21 h, an aggressive brain tumor, and a nonsurgical treatment before SE onset. Lateralized period discharges, super-refractory SE, and an aggressive tumor type were independently associated with increased mortality. CONCLUSIONS Status epilepticus duration is the main modifiable factor associated with poor prognosis at 1-year follow-up. Accordingly, patients with TASE, like those with SE of any etiology, should receive early, aggressive treatment.
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Affiliation(s)
- Andreu Vilaseca-Jolonch
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Department of Medicine, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Laura Abraira
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Department of Medicine, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Department of Medicine, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - María Sueiras
- Neurophysiology Department, Vall d'Hebron Hospital, Department of Medicine, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Vanessa Thonon
- Neurophysiology Department, Vall d'Hebron Hospital, Department of Medicine, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Manuel Toledo
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Department of Medicine, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Javier Salas-Puig
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Department of Medicine, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Elena Fonseca
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Department of Medicine, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Esteban Cordero
- Neurosurgery Department, Vall d'Hebron Hospital, Department of Surgery, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Francisco Martínez-Ricarte
- Neurosurgery Department, Vall d'Hebron Hospital, Department of Surgery, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Estevo Santamarina
- Epilepsy Unit, Neurology Department, Vall d'Hebron Hospital, Department of Medicine, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain.
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15
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García-López B, Gómez-Menéndez AI, Vázquez-Sánchez F, Pérez-Cabo E, Isidro-Mesas F, Zabalegui-Pérez A, Muñoz-Siscart I, Lloria-Gil MC, Soto-Cámara R, González-Bernal JJ, González-Santos J, Aguilar-Parra JM, Trigueros R, López-Liria R, Kjær TW. Electroconvulsive Therapy in Super Refractory Status Epilepticus: Case Series with a Defined Protocol. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E4023. [PMID: 32516983 PMCID: PMC7312395 DOI: 10.3390/ijerph17114023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 02/06/2023]
Abstract
Super-refractory status epilepticus (SRSE) represents a neurological emergency that is characterized by a lack of response to the third line of antiepileptic treatment, including intravenous general anesthetics. It is a medical challenge with high morbidity and mortality. Electroconvulsive therapy (ECT) has been recommended as a nonpharmacologic option of treatment after other alternatives are unsuccessful. Its effect on the cessation of SRSE has been minimally investigated. The objective of this article is to analyze the effect of ECT on SRSE. For this purpose, a multidisciplinary team created a protocol based on clinical guidelines similar to those described previously by Ray et al. (2017). ECT was applied to six patients with SRSE after the failure of antiepileptic treatment and pharmacologic coma.The objective of each ECT session was to elicit a motor seizure for at least 20 s. SRSE was resolved in all patients after several days of treatment, including ECT as a therapy, without relevant adverse effects. Thus, ECT is an effective and feasible option in the treatment of SRSE, and its place in the algorithm in treatment should be studied due to the uncommon adverse effects and the noninvasive character of the therapy.
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Affiliation(s)
- Beatriz García-López
- Neurophysiology Department, Burgos University Hospital, 09006 Burgos, Spain; (B.G.-L.); (A.I.G.-M.); (F.I.-M.); (M.C.L.-G.)
| | - Ana Isabel Gómez-Menéndez
- Neurophysiology Department, Burgos University Hospital, 09006 Burgos, Spain; (B.G.-L.); (A.I.G.-M.); (F.I.-M.); (M.C.L.-G.)
| | | | - Eva Pérez-Cabo
- Intensive Care Unit, Burgos University Hospital, 09006 Burgos, Spain; (E.P.-C.); (A.Z.-P.)
| | - Francisco Isidro-Mesas
- Neurophysiology Department, Burgos University Hospital, 09006 Burgos, Spain; (B.G.-L.); (A.I.G.-M.); (F.I.-M.); (M.C.L.-G.)
| | - Arturo Zabalegui-Pérez
- Intensive Care Unit, Burgos University Hospital, 09006 Burgos, Spain; (E.P.-C.); (A.Z.-P.)
| | | | - María Carmen Lloria-Gil
- Neurophysiology Department, Burgos University Hospital, 09006 Burgos, Spain; (B.G.-L.); (A.I.G.-M.); (F.I.-M.); (M.C.L.-G.)
| | - Raúl Soto-Cámara
- Department of Health Sciences, University of Burgos, 09001 Burgos, Spain
| | | | | | - José M. Aguilar-Parra
- Department of Psychology, Health Research Centre, University of Almeria, 04120 Almeria, Spain; (J.M.A.-P.); (R.T.)
| | - Rubén Trigueros
- Department of Psychology, Health Research Centre, University of Almeria, 04120 Almeria, Spain; (J.M.A.-P.); (R.T.)
| | - Remedios López-Liria
- Department of Nursing, Physiotherapy and Medicine, Health Research Centre, University of Almería, 04120 Almeria, Spain;
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Tuppurainen KM, Ritvanen JG, Mustonen H, Kämppi LS. Predictors of mortality at one year after generalized convulsive status epilepticus. Epilepsy Behav 2019; 101:106411. [PMID: 31668580 DOI: 10.1016/j.yebeh.2019.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 07/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Status epilepticus (SE) is a life-threatening neurologic emergency, which requires prompt medical treatment. Little is known of the long-term survival of SE. The aim of this study was to investigate which factors influence 90 days and 1-year mortality after SE. MATERIALS AND METHODS This retrospective study includes all consecutive adult (>16 years) patients (N = 70) diagnosed with generalized convulsive SE (GCSE) in Helsinki University Central Hospital (HUCH) emergency department (ED) over 2 years. We defined specific factors including patient demographics, GCSE characteristics, treatment, complications, delays in treatment, and outcome at hospital discharge and determined their relation to 90 days and 1-year mortality after GCSE by using logistic regression models. Survival analyses at 1 year after GCSE were performed with Cox proportional hazards regression analysis. RESULTS In-hospital mortality was 7.1%. Mortality rate was 14.3% at 90 days and 24.3% at 1 year after GCSE. In the univariate logistic regression analysis, Status Epilepticus Severity Score > 4 (STESS) (ODDS = 7.30, p = 0.012), worse-than-baseline condition at hospital discharge (ODDS = 3.5, p = 0.006), long delays in attaining seizure freedom (ODDS = 2.2, p = 0.041), and consciousness (ODDS = 3.4, p = 0.014) were risk factors for mortality at 90 days whereas epilepsy (ODDS = 0.2, p = 0.014) and Glasgow Outcome Scale (GOS) >3 at hospital discharge (ODDS = 0.05, p = 0.006) were protective factors. Risk factors for mortality at 1 year were STESS >4 (ODDS = 5.1, p = 0.028), use of vasopressors (ODDS = 8.2, p = 0.049), and worse-than-baseline condition at discharge (ODDS = 7.8, p = 0.010) while GOS >3 (ODDS = 0.2, p = 0.005) was protective. The univariate survival analysis at 1 year confirmed the significant findings regarding parameters STESS >4 (Hazard ratio (HR) = 4.1, p = 0.009), worse-than-baseline condition (HR = 6.2, p = 0.015), GOS >3 (HR = 0.2, p = 0.004) at hospital discharge and epilepsy (HR = 0.4, p = 0.044). Additionally, diagnostic delay over 6 h (HR = 3.8, p = 0.022) and Complication Burden Index (CBI) as an ordinal variable (0-2, 3-6, >6) (HR = 2.7, p = 0.027) were predictive for mortality. In the multivariate survival analysis, STESS > 4 (HR = 5.1, p = 0.007), CBI (HR = 3.2, p = 0.025, ordinal variable), diagnostic delay over 6 h (HR = 7.2, p = 0.003), and worse-than-baseline condition at hospital discharge (HR = 5.8, p = 0.027) were all independent risk factors for mortality at 1 year. CONCLUSIONS Severe form of SE, delayed recognition of GCSE, high number of complications during treatment period, and poor condition at hospital discharge are all independent predictors of long-term mortality. Most of these factors are also associated with mortality at 90 days, though at that point, delays in treatment seem to have a greater impact on prognosis than at 1 year. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures.
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Affiliation(s)
- Kati Marjatta Tuppurainen
- Clinical Neurosciences, Neurology, University of Helsinki and Department of Neurology, Helsinki University Central Hospital, Finland.
| | - Jaakko Gabriel Ritvanen
- Clinical Neurosciences, Neurology, University of Helsinki and Department of Neurology, Helsinki University Central Hospital, Finland.
| | - Harri Mustonen
- Department of Surgery, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.
| | - Leena Sinikka Kämppi
- Clinical Neurosciences, Neurology, University of Helsinki and Department of Neurology, Helsinki University Central Hospital, Finland.
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Electrographic seizure burden and outcomes following pediatric status epilepticus. Epilepsy Behav 2019; 101:106409. [PMID: 31420288 DOI: 10.1016/j.yebeh.2019.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 07/04/2019] [Indexed: 12/11/2022]
Abstract
Pediatric status epilepticus carries a substantial risk for morbidity and mortality, but the relationship between seizure burden, treatment, and outcome remains incompletely understood. This review summarizes the evidence linking seizure burden and outcomes among critically ill children in the intensive care unit (ICU), a population in whom accurate quantification of seizure burden is possible using continuous electroencephalographic monitoring. Several high-quality observational studies among critically ill children have reported an association between higher seizure burden and worse outcome, even after adjusting for potential confounders such as age, etiology, and illness severity. Although these studies support the hypothesis that seizures contribute to brain injury and worsen outcome, a causal link between seizures and outcome remains to be proven. The relationship between seizures and outcome is likely complex, and dependent on factors such as etiology, preexisting neurological disability, medication exposure, and possibly individual genetic factors. Studies attempting to define this complex relationship will need to measure and account for these factors in their analyses. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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18
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Rossetti AO, Hirsch LJ, Drislane FW. Nonconvulsive seizures and nonconvulsive status epilepticus in the neuro ICU should or should not be treated aggressively: A debate. Clin Neurophysiol Pract 2019; 4:170-177. [PMID: 31886441 PMCID: PMC6921236 DOI: 10.1016/j.cnp.2019.07.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 07/01/2019] [Accepted: 07/07/2019] [Indexed: 12/29/2022] Open
Abstract
This article presents a "debate" about the appropriate level of aggressiveness of treatment for nonconvulsive status epilepticus (NCSE), held at the International Congress of Clinical Neurophysiology in Washington D.C. on 4 May 2018. The proposition for discussion was "Nonconvulsive seizures and status epilepticus in the intensive care unit should be treated aggressively." Dr. Andrea O. Rossetti from Lausanne, Switzerland, spoke in support of the proposition and Dr. Lawrence J. Hirsch from New Haven, Connecticut, discussed reasons for rejecting the proposal. Dr. Frank W. Drislane from Boston, Massachusetts, was asked by the conference organizers to add comments and perspective.
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Affiliation(s)
- Andrea O Rossetti
- Département des neurosciences cliniques, University Hospital and Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Lawrence J Hirsch
- Division of Epilepsy and EEG Yale University School of Medicine, PO Box 208018, New Haven Conn. 06520-8018, USA
| | - Frank W Drislane
- KS 479, Neurology Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02460, USA
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Malta JR, Greco J, Lodolo M, Ghosh S. A school-aged boy with super-refractory status epilepticus secondary to cortical dysplasia treated with dexmedetomidine. J Clin Neurosci 2019; 64:21-22. [DOI: 10.1016/j.jocn.2019.03.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 03/25/2019] [Indexed: 12/22/2022]
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20
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Sutter R, Semmlack S, Kaplan PW, Opić P, Marsch S, Rüegg S. Prolonged status epilepticus: Early recognition and prediction of full recovery in a 12-year cohort. Epilepsia 2018; 60:42-52. [DOI: 10.1111/epi.14603] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 10/22/2018] [Accepted: 10/22/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Raoul Sutter
- Clinic for Intensive Care Medicine; University Hospital Basel; Basel Switzerland
- Department of Neurology; University Hospital Basel; Basel Switzerland
- Medical Faculty of the University of Basel; Basel Switzerland
| | - Saskia Semmlack
- Clinic for Intensive Care Medicine; University Hospital Basel; Basel Switzerland
| | - Peter W. Kaplan
- Department of Neurology; Johns Hopkins Bayview Medical Center; Baltimore Maryland
| | - Petra Opić
- Clinic for Intensive Care Medicine; University Hospital Basel; Basel Switzerland
| | - Stephan Marsch
- Clinic for Intensive Care Medicine; University Hospital Basel; Basel Switzerland
- Medical Faculty of the University of Basel; Basel Switzerland
| | - Stephan Rüegg
- Department of Neurology; University Hospital Basel; Basel Switzerland
- Medical Faculty of the University of Basel; Basel Switzerland
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Sculier C, Gaínza‐Lein M, Sánchez Fernández I, Loddenkemper T. Long-term outcomes of status epilepticus: A critical assessment. Epilepsia 2018; 59 Suppl 2:155-169. [PMID: 30146786 PMCID: PMC6221081 DOI: 10.1111/epi.14515] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2018] [Indexed: 11/29/2022]
Abstract
We reviewed 37 studies reporting long-term outcomes after a status epilepticus (SE) episode in pediatric and adult populations. Study design, length of follow-up, outcome measures, domains investigated (mortality, SE recurrence, subsequent epilepsy, cognitive outcome, functional outcome, or quality of life), and predictors of long-term outcomes are summarized. Despite heterogeneity in the design of prior studies, overall risk of poor long-term outcome after SE is high in both children and adults. Etiology is the main determinant of outcome, and the effect of age or SE duration is often difficult to distinguish from the underlying cause. The effect of the treatment on long-term outcome after SE is still unknown.
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Affiliation(s)
- Claudine Sculier
- Division of Epilepsy and Clinical NeurophysiologyDepartment of NeurologyBoston Children's HospitalHarvard Medical SchoolBostonMassachusetts
- Department of NeurologyErasmus HospitalFree University of BrusselsBrusselsBelgium
| | - Marina Gaínza‐Lein
- Division of Epilepsy and Clinical NeurophysiologyDepartment of NeurologyBoston Children's HospitalHarvard Medical SchoolBostonMassachusetts
- Faculty of MedicineAustral University of ChileValdiviaChile
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical NeurophysiologyDepartment of NeurologyBoston Children's HospitalHarvard Medical SchoolBostonMassachusetts
- Department of Child NeurologyHospitalSant Joan de Déu, Universidad deBarcelonaSpain
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical NeurophysiologyDepartment of NeurologyBoston Children's HospitalHarvard Medical SchoolBostonMassachusetts
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Factors associated with refractoriness and outcome in an adult status epilepticus cohort. Seizure 2018; 61:111-118. [DOI: 10.1016/j.seizure.2018.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/25/2018] [Accepted: 07/27/2018] [Indexed: 11/20/2022] Open
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Abstract
BACKGROUND To identify the role of acute surgical intervention in the treatment of refractory status epilepticus (RSE). METHODS Retrospective review of consecutive patients who underwent epilepsy surgery from 2006 to 2015 was done to identify cases where acute surgical intervention was employed for the treatment of RSE. In addition, the adult and pediatric RSE literature was reviewed for reports of surgical treatment of RSE. RESULTS Nine patients, aged 20-68 years, with various etiologies were identified to have undergone acute surgical resection for the treatment of RSE, aided by electrocorticography. Patients required aggressive medical therapy with antiepileptic drugs and intravenous anesthetic drugs for 10-54 days and underwent extensive neurodiagnostic testing prior to resective surgery. Eight out of nine patients survived and five patients were seizure-free at the last follow-up. The literature revealed 13 adult and 48 pediatric cases where adequate historical detail was available for review and comparison. CONCLUSIONS We present the largest cohort of consecutive adult patients who underwent resective surgery in the setting of RSE. We also reveal that surgery can be efficacious in aborting status and in some can lead to long-term seizure freedom. Acute surgical intervention is a viable option in prolonged RSE and proper evaluation for such intervention should be conducted, although the timing and type of surgical intervention remain poorly defined.
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Kämppi L, Ritvanen J, Strbian D, Mustonen H, Soinila S. Complication Burden Index-A tool for comprehensive evaluation of the effect of complications on functional outcome after status epilepticus. Epilepsia 2018; 59 Suppl 2:176-181. [DOI: 10.1111/epi.14491] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Leena Kämppi
- Clinical Neurosciences, Neurology; Department of Neurology; University of Helsinki and Helsinki University Central Hospital; Helsinki Finland
| | - Jaakko Ritvanen
- Clinical Neurosciences, Neurology; Department of Neurology; University of Helsinki and Helsinki University Central Hospital; Helsinki Finland
| | - Daniel Strbian
- Clinical Neurosciences, Neurology; Department of Neurology; University of Helsinki and Helsinki University Central Hospital; Helsinki Finland
| | - Harri Mustonen
- Department of Surgery; University of Helsinki and Helsinki University Central Hospital; Helsinki Finland
| | - Seppo Soinila
- Division of Clinical Neurosciences/General Neurology; Department of Neurology; Turku University Hospital; University of Turku; Turku Finland
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Abstract
Refractory and super-refractory status epilepticus (SE) are serious illnesses with a high risk of morbidity and even fatality. In the setting of refractory generalized convulsive SE (GCSE), there is ample justification to use continuous infusions of highly sedating medications-usually midazolam, pentobarbital, or propofol. Each of these medications has advantages and disadvantages, and the particulars of their use remain controversial. Continuous EEG monitoring is crucial in guiding the management of these critically ill patients: in diagnosis, in detecting relapse, and in adjusting medications. Forms of SE other than GCSE (and its continuation in a "subtle" or nonconvulsive form) should usually be treated far less aggressively, often with nonsedating anti-seizure drugs (ASDs). Management of "non-classic" NCSE in ICUs is very complicated and controversial, and some cases may require aggressive treatment. One of the largest problems in refractory SE (RSE) treatment is withdrawing coma-inducing drugs, as the prolonged ICU courses they prompt often lead to additional complications. In drug withdrawal after control of convulsive SE, nonsedating ASDs can assist; medical management is crucial; and some brief seizures may have to be tolerated. For the most refractory of cases, immunotherapy, ketamine, ketogenic diet, and focal surgery are among several newer or less standard treatments that can be considered. The morbidity and mortality of RSE is substantial, but many patients survive and even return to normal function, so RSE should be treated promptly and as aggressively as the individual patient and type of SE indicate.
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Affiliation(s)
- Samhitha Rai
- KS 457, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Frank W Drislane
- KS 457, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA.
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Misra UK, Kalita J, Dubey D. A Study of Super Refractory Status Epilepticus from India. Front Neurol 2017; 8:636. [PMID: 29234303 PMCID: PMC5712310 DOI: 10.3389/fneur.2017.00636] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 11/14/2017] [Indexed: 11/13/2022] Open
Abstract
Background Super refractory status epilepticus (SRSE) is an important and recently recognized neurological emergency. Purpose In view of paucity of studies on SRSE, we report the frequency, etiology and outcome of SRSE. Methods In a hospital-based observational study during 2013 to 2016, consecutive patients with SRSE [persistence of status epilepticus (SE) for 24 h or more, or recurrence of SE on weaning of intravenous anesthetic] were included. The demographic, clinical, and laboratory data were obtained and the severity of SE was defined using Status Epilepticus Severity Score (STESS). The outcome was defined as control of SE, hospital death, and functional status at the time of discharge. Results Fourteen (13%) patients developed SRSE. Their median age was 27.5 (2–70) years and four were below 18 years of age. The etiology of SRSE was metabolic encephalopathy and encephalitis in five patients each, cerebral venous sinus thrombosis in one and miscellaneous disorders in three patients. Six (43%) patients died. The patients with SRSE had higher admission STESS (p = 0.04), and longer intensive care unit (p < 0.01) and hospital (p = 0.004) stay compared to non-SRSE group. The patients with treatable etiology had better outcome. Conclusion SRSE occurred in 13% patients with SE and 43% of them died. The SRSE patients with treatable etiology had a better outcome.
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Affiliation(s)
- Usha K Misra
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Deepanshu Dubey
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Kortland LM, Knake S, von Podewils F, Rosenow F, Strzelczyk A. Socioeconomic Outcome and Quality of Life in Adults after Status Epilepticus: A Multicenter, Longitudinal, Matched Case-Control Analysis from Germany. Front Neurol 2017; 8:507. [PMID: 29018404 PMCID: PMC5622933 DOI: 10.3389/fneur.2017.00507] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 09/08/2017] [Indexed: 11/17/2022] Open
Abstract
Background There is a lack of data concerning socioeconomic outcome and quality of life (QoL) in patients after status epilepticus (SE) in Germany. Patients and methods Adult patients treated between 2011 and 2015 due to SE at the university hospitals in Frankfurt, Greifswald, and Marburg were asked to fill out a questionnaire regarding long-term outcome of at least 3 months after discharge. The SE cohort consisted of 25.9% patients with an acute symptomatic, 42% with a remote symptomatic and previous epilepsy, 22.2% with a new-onset remote symptomatic, and 9.9% with other or unknown etiology. A matched case–control analysis was applied for comparison with patients with drug refractory epilepsy and seizure remission, both not previously affected by SE. Results A total of 81 patients (mean age: 58.7 ± 18.0 years; 58% female) participated. A non-refractory course was present in 59.3%, while 27.2% had a refractory SE (RSE) and 13.6% had a superrefractory SE (SRSE). Before admission, a favorable modified Rankin Scale (mRS) of 0–3 was found in 82.7% (67/81), deteriorating to 38.3% (31/81) (p = 0.003) at discharge. The majority returned home [51.9% (42/81)], 32.1% entered a rehabilitation facility, while 12.3% were transferred to a nursing home and 3.7% to another hospital. The overall mRS at follow-up did not change; 61.8% (45/74) reached an mRS of 0–3. In RSE and SRSE, the proportion with a favorable mRS increased from 45.5% at discharge to 70% at follow-up, while QoL was comparable to a non-refractory SE course. Matched epilepsy controls in seizure remission were treated with a lower mean number of anticonvulsants (1.3 ± 0.7) compared to controls with drug refractory epilepsy (1.9 ± 0.8; p < 0.001) or SE (1.9 ± 1.1; p < 0.001). A major depression was found in 32.8% of patients with SE and in 36.8% of drug refractory epilepsy, but only in 20.3% of patients in seizure remission. QoL was reduced in all categories (QOLIE-31) in SE patients in comparison with patients in seizure remission, but was comparable to patients with drug refractory epilepsy. Discussion Patients after SE show substantial impairments in their QoL and daily life activities. However, in the long term, patients with RSE and SRSE had a relatively favorable outcome comparable to that of patients with a non-refractory SE course. This underlines the need for efficient therapeutic options in SE.
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Affiliation(s)
| | - Susanne Knake
- Epilepsy Center Hessen, Philipps-University, Marburg, Germany
| | - Felix von Podewils
- Epilepsy Center Greifswald, Ernst-Moritz-Arndt-University, Greifswald, Germany
| | - Felix Rosenow
- Epilepsy Center Hessen, Philipps-University, Marburg, Germany.,Epilepsy Center Frankfurt Rhine-Main, Goethe-University, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Hessen, Philipps-University, Marburg, Germany.,Epilepsy Center Frankfurt Rhine-Main, Goethe-University, Frankfurt am Main, Germany
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Madžar D, Knappe RU, Reindl C, Giede-Jeppe A, Sprügel MI, Beuscher V, Gollwitzer S, Hamer HM, Huttner HB. Factors associated with occurrence and outcome of super-refractory status epilepticus. Seizure 2017; 52:53-59. [PMID: 28963934 DOI: 10.1016/j.seizure.2017.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 08/19/2017] [Accepted: 09/07/2017] [Indexed: 02/09/2023] Open
Abstract
PURPOSE Super-refractory status epilepticus (SRSE) represents a challenging medical condition with high morbidity and mortality. In this study, we aimed to establish variables related to SRSE development and outcome. METHODS We retrospectively screened our databases for refractory SE (RSE) and SRSE episodes between January 2001 and January 2015. Baseline demographics, SE characteristics, and variables reflecting the clinical course were compared in order to identify factors independently associated with SRSE occurrence. Within the SRSE cohort, predictors of in-hospital mortality as well as good functional outcome in survivors to discharge were established through univariate and multivariable analyses. RESULTS A total of 131 episodes were included, among those 46 (35.1%) meeting the criteria of SRSE. Comparison of RSE and SRSE episodes revealed a lower premorbid mRS score (odds ratio (OR) per mRS point, 0.769; p=0.039) and non-convulsive SE (NCSE) in coma (OR, 4.216; p=0.008) as independent predictors of SRSE. SRSE in-hospital mortality was associated with age (OR, 1.091 per increasing year; p=0.020) and worse premorbid functional status (OR, 1.938 per mRS point; p=0.044). Good functional outcome in survivors was independently related to shorter SRSE duration (OR, 0.714 per day; p=0.038). CONCLUSION Better premorbid functional status and NCSE in coma as worst seizure type indicate a role of acute underlying etiologies in the development of SRSE. In-hospital mortality in SRSE is determined by nonmodifiable factors, while functional outcome in survivors depends on seizure duration underscoring the need of achieving rapid seizure termination.
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Affiliation(s)
- Dominik Madžar
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Ruben U Knappe
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Caroline Reindl
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Antje Giede-Jeppe
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Maximilian I Sprügel
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Vanessa Beuscher
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Stephanie Gollwitzer
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Hajo M Hamer
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Hagen B Huttner
- Department of Neurology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany.
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Kantanen AM, Reinikainen M, Parviainen I, Kälviäinen R. Long-term outcome of refractory status epilepticus in adults: A retrospective population-based study. Epilepsy Res 2017; 133:13-21. [DOI: 10.1016/j.eplepsyres.2017.03.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 02/07/2017] [Accepted: 03/28/2017] [Indexed: 01/21/2023]
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Santamarina E, González-Cuevas GM, Sanchez A, Gracia RM, Porta I, Toledo M, Quintana M, Sueiras M, Guzmán L, Salas-Puig J. Prognosis of status epilepticus in patients requiring intravenous anesthetic drugs (a single center experience). Seizure 2017; 45:74-79. [DOI: 10.1016/j.seizure.2016.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 11/29/2016] [Accepted: 12/02/2016] [Indexed: 11/25/2022] Open
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Sonneville R, Mariotte E, Neuville M, Minaud S, Magalhaes E, Ruckly S, Cantier M, Voiriot G, Radjou A, Smonig R, Soubirou JF, Mourvillier B, Bouadma L, Wolff M, Timsit JF. Early-onset status epilepticus in patients with acute encephalitis. Medicine (Baltimore) 2016; 95:e4092. [PMID: 27472682 PMCID: PMC5265819 DOI: 10.1097/md.0000000000004092] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Status epilepticus (SE) is a common complication of acute encephalitis, but its determinants and prognostic value in this setting are not known.Risk factors for early-onset SE (within 48 hours of intensive care unit [ICU] admission) in consecutive adult patients with all-cause encephalitis admitted to the medical ICU of a university hospital (1991-2013) were evaluated by multivariate logistic regression analysis. To examine the prognostic value of SE, patients were classified into 3 groups: no SE, nonrefractory SE (NRSE), and refractory SE (RSE). Poor neurologic outcome was defined by a modified Rankin score of 4 to 6.Among the 290 patients, 58 (20%, 95% CI: 15%-25%) developed early-onset SE, comprising 44 patients with NRSE and 14 patients with RSE. Coma (adjusted odds ratio [OR]: 3.1, 95% CI: 1.5-6.3), cortical lesions on neuroimaging (adjusted OR: 3.7, 95% CI: 1.8-7.8), and nonneurologic organ failure(s) (adjusted OR: 13.6, 95% CI: 4.9-37.7) were found to be independent risk factors for SE. By contrast, a bacterial etiology had a protective effect (adjusted OR: 0.3, 95% CI: 0.1-0.7). Age, body temperature, and blood sodium levels were not independently associated with SE. Poor neurologic outcomes were observed at day 90 in respectively 23% (95% CI: 17%-28%), 23% (95% CI: 10%-35%), and 71% (95% CI: 48%-95%) of no SE, NRSE, and RSE patients (P < 0.01). After adjusting for confounders, RSE, but not NRSE, remained independently associated with 90-day mortality (adjusted OR: 6.0, 95% CI: 1.5-23.3).Coma, cortical involvement on neuroimaging, and nonneurologic organ failure(s) are independent risk factors for SE in patients with acute encephalitis. Conversely, a bacterial etiology is associated with a lower risk of SE.These findings may help identify patients who may benefit from prophylactic antiepileptic drugs.
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Affiliation(s)
- Romain Sonneville
- Univ Paris Diderot, Sorbonne Paris Cité, Assistance Publique–Hôpitaux de Paris, Hôpital Bichat–Claude-Bernard, Service de Réanimation Médicale et des Maladies Infectieuses, rue Henri-Huchard, Paris Cedex, France
- Correspondence: Romain Sonneville, Univ Paris Diderot, Sorbonne Paris Cité, Assistance Publique–Hôpitaux de Paris, Hôpital Bichat–Claude-Bernard, Service de Réanimation Médicale et des Maladies Infectieuses, 46 rue Henri Huchard, 75877 Paris Cedex, France (e-mail: )
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Interleukin-1 receptor is a target for adjunctive control of diazepam-refractory status epilepticus in mice. Neuroscience 2016; 328:22-9. [PMID: 27133574 DOI: 10.1016/j.neuroscience.2016.04.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 04/20/2016] [Accepted: 04/23/2016] [Indexed: 12/13/2022]
Abstract
Proinflammatory cytokine interleukin-1 beta (IL-1β) may accumulate in the brain during status epilepticus, but whether it contributes to the progressive refractoriness of SE remains unclear. By using a kainic acid-induced SE mice model, we tested whether pharmacological blockade or knock-out of interleukin-1 receptor type 1 (IL-1R1) could influence the diazepam-refractory phenomenon of prolonged SE. We confirmed diazepam failed to terminate prolonged SE (allowed to continue for 40min before diazepam administration). The expression level of IL-1β in the hippocampus during prolonged SE was significantly higher than that of baseline. Interestingly, prolonged SE was not diazepam-refractory in IL-1R1 knock-out mice. Moreover, administration of interleukin-1 receptor antagonist (IL-1RA) combined with diazepam terminated established prolonged SE, while IL-1RA alone is not capable to terminate prolonged SE. On the contrary, administration of recombinant human IL-1β weakens the efficacy of diazepam by prolonging its latency to terminate non-prolonged SE. Thus, the present study provides direct evidence that accumulated IL-1β contributed to the diazepam refractoriness of prolonged SE, and suggests that interleukin-1 receptor is a target for adjunctive control of diazepam-refractory SE.
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Association of seizure duration and outcome in refractory status epilepticus. J Neurol 2016; 263:485-91. [PMID: 26725091 DOI: 10.1007/s00415-015-7992-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 12/01/2015] [Accepted: 12/08/2015] [Indexed: 10/22/2022]
Abstract
The aim of the study was to identify factors influencing long-term outcome and to evaluate the prognostic power of the Status Epilepticus Severity Score (STESS) in refractory status epilepticus (RSE). We retrospectively extracted data on baseline characteristics, RSE details, and hospital course including complications from all patients treated for RSE in our institution between January 2001 and January 2013. Functional outcome was assessed using the modified Rankin Scale (mRS) and was defined as good when either RSE did not lead to functional decline or when the resulting mRS score was 2 or below. Seventy-one episodes in 65 patients were analyzed. The median follow-up time was 12 weeks (IQR 6-35), two patients were lost to follow-up. Poor functional long-term outcome was observed in 42/69 (60.9%) episodes. In-hospital mortality occurred in 13/71 (18.3%) episodes. Multivariable analysis revealed that STESS ≥ 3, longer RSE duration, and sepsis were independently related to poor functional long-term outcome. Receiver operating characteristics (ROC) curve analyses confirmed the cut-off dichotomization into STESS ≥ 3 and STESS < 3 for optimal discrimination between good and poor outcome (AUC = 0.671, p = 0.002, YI = 0.368, NPV = 0.607, PPV = 0.756) and revealed an RSE duration of 10 days as a significant cut-off point associated with outcome (AUC = 0.712, p = 0.012, YI = 0.310; NPV = 0.545, PPV = 0.750). In conclusion, STESS and RSE duration represent relevant scores and parameters impacting long-term outcome after RSE. A shorter RSE duration is associated with better outcome and, therefore, rapid and adequate treatment for seizure termination should be enforced.
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