1
|
Legriel S. Burst Suppression as a Treatment Goal in Refractory Status Epilepticus. Neurocrit Care 2024; 40:847-848. [PMID: 37921931 DOI: 10.1007/s12028-023-01880-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/06/2023] [Indexed: 11/05/2023]
Affiliation(s)
- Stephane Legriel
- Intensive Care Unit, Centre Hospitalier de Versailles, 78150, Le Chesnay, France.
- IctalGroup, Le Chesnay, France.
- University Paris-Saclay, UVSQ, INSERM, CESP, Villejuif, France.
| |
Collapse
|
2
|
Hawkes MA, Eliliwi M, Wijdicks EFM. The Origin of the Burst-Suppression Paradigm in Treatment of Status Epilepticus. Neurocrit Care 2024; 40:849-854. [PMID: 37921932 DOI: 10.1007/s12028-023-01877-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 09/26/2023] [Indexed: 11/05/2023]
Abstract
After electroencephalography (EEG) was introduced in hospitals, early literature recognized burst-suppression pattern (BSP) as a distinctive EEG pattern characterized by intermittent high-power oscillations alternating with isoelectric periods in coma and epileptic encephalopathies of childhood or the pattern could be induced by general anesthesia and hypothermia. The term was introduced by Swank and Watson in 1949 but was initially described by Derbyshire et al. in 1936 in their study about the anesthetic effects of tribromoethanol. Once the EEG/BSP pattern emerged in the literature as therapeutic goal in refractory status epilepticus, researchers began exploring whether the depth of EEG suppression correlated with improved seizure control and clinical outcomes. We can conclude that, from a historical perspective, the evidence to suppress the brain to a BSP when treating status epilepticus is inconclusive.
Collapse
Affiliation(s)
- Maximiliano A Hawkes
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mouhanned Eliliwi
- Division of Pulmonary Critical Care, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Eelco F M Wijdicks
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| |
Collapse
|
3
|
Ruttkowski L, Wallot I, Korell M, Daur E, Seipelt P, Leonhardt A, Weber S, Mand N. Case report: Febrile infection-related epilepsy syndrome in a 14-year-old girl with multiple organ failure and lethal outcome. Front Neurosci 2024; 18:1255841. [PMID: 38505775 PMCID: PMC10948546 DOI: 10.3389/fnins.2024.1255841] [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: 07/09/2023] [Accepted: 02/07/2024] [Indexed: 03/21/2024] Open
Abstract
We report a case of an otherwise healthy 14-year-old girl with febrile infection-related epilepsy syndrome (FIRES), multiple organ failure (MOF), and ultimately a lethal outcome. This is a rare case of FIRES with MOF and consecutive death. Only a few cases have been described in the literature. The adolescent girl was initially admitted to our pediatric emergency department with a first episode of generalized tonic-clonic seizures after a short history of fever a week before admission. Seizures progressed rapidly into refractory status epilepticus without any evidence of the underlying cause, and treatment subsequently had to be escalated to thiopental anesthesia. Since the initial diagnostics showed no promising leads, the rare syndrome of FIRES was suspected, representing a catastrophic epileptic encephalopathy linked to a prior benign febrile infection. Methylprednisolone, intravenous immunoglobulins, and a ketogenic diet were initiated. Respiratory, circulatory, kidney, and liver failure developed during treatment, requiring increasing intensive care. Multiple attempts to deescalate antiepileptic treatment resulted in recurrent status epilepticus. A cranial MRI on the 10th day of treatment revealed diffuse brain edema and no cerebral perfusion. The patient was declared dead on the 11th day of treatment. FIRES should be taken into account in previously healthy children with a new onset of difficult-to-treat seizures after a short febrile infection when no other cause is apparent. First-line treatment, besides seizure control, is the early initiation of immunomodulatory therapy and the start of a ketogenic diet. As treatment is difficult and MOF may develop, patients should be transferred to a specialized children's hospital providing full intensive care.
Collapse
Affiliation(s)
- Lars Ruttkowski
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Ines Wallot
- Pediatric Neurology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Marie Korell
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Elke Daur
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Peter Seipelt
- Pediatric Neurology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Andreas Leonhardt
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Stefanie Weber
- Pediatric Nephrology, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| | - Nadine Mand
- Pediatric Intensive Care, Department of Pediatrics, Philipps-University Marburg, Marburg, Germany
| |
Collapse
|
4
|
Association Between Induced Burst-Suppression and Clinical Outcomes in Patients With Refractory Status Epilepticus: A 9-Year Cohort Study. Neurology 2024; 102:e209181. [PMID: 38295330 DOI: 10.1212/wnl.0000000000209181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
|
5
|
Shehata IM, Kohaf NA, ElSayed MW, Latifi K, Aboutaleb AM, Kaye AD. Ketamine: Pro or antiepileptic agent? A systematic review. Heliyon 2024; 10:e24433. [PMID: 38293492 PMCID: PMC10826813 DOI: 10.1016/j.heliyon.2024.e24433] [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: 07/19/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/01/2024] Open
Abstract
Purpose of Review: This evidence-based systematic review evaluated the safety of ketamine as regard the potential to provoke epilepsy to help better guide anesthesiologists in their practice. Recent findings Ketamine, originally developed as a dissociative anesthetic, has gained attention for its potential therapeutic applications in various medical conditions, including epilepsy. Ketamine is generally well-tolerated and widely used in anesthesia, however, conflicting data are confusing the anesthesiologists regarding the potential risk of seizures associated with its use. The literature that claimed the proepileeptic property are inconsistent and the mechanism of action is unclear. Moreover, the case reports had been in same certain contexts, such as procedural sedation where ketamine was used as a single agent. On the other hand, the retrospective data analysis confirmed the positive role ketamine plays as antiepileptic agent. Summary Many studies have shown promising results for the use of ketamine as antiepileptic agent. In case of epileptic patients, there is no contraindication for using ketamine, however, combining with benzodiazepine or propofol may enhance the safety.
Collapse
Affiliation(s)
| | - Neveen A. Kohaf
- Department of Clinical Pharmacy, Alazhar, University, Cairo, 11651, Egypt
| | - Mohamed W. ElSayed
- Geisel School of Medicine at Dartmouth, New Hampshire Hospital, SUNY School of Graduate Studies, USA
| | - Kaveh Latifi
- Department of Anesthesiology and Pain Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Alan David Kaye
- Departments of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| |
Collapse
|
6
|
Fisch U, Jünger AL, Baumann SM, Semmlack S, De Marchis GM, Rüegg SJ, Hunziker S, Marsch S, Sutter R. Association Between Dose Escalation of Anesthetics and Outcomes in Patients With Refractory Status Epilepticus. Neurology 2024; 102:e207995. [PMID: 38165316 DOI: 10.1212/wnl.0000000000207995] [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: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES To investigate the association between dose escalation of continuously administered IV anesthetics and its duration with short-term outcomes in adult patients treated for refractory status epilepticus (RSE). METHODS Clinical and electroencephalographic data of patients with RSE without hypoxic-ischemic encephalopathy who were treated with anesthetics at a Swiss academic medical center from 2011 to 2019 were assessed. The frequency of anesthetic dose escalation (i.e., dose increase) and its associations with in-hospital death or return to premorbid neurologic function were primary endpoints. Multivariable logistic regression analysis was performed to identify associations with endpoints. RESULTS Among 111 patients with RSE, doses of anesthetics were escalated in 57%. Despite patients with dose escalation having a higher morbidity (lower Glasgow Coma Scale [GCS] score at status epilepticus [SE] onset, more presumably fatal etiologies, longer duration of SE and intensive care, more infections, and arterial hypotension) as compared with patients without, the primary endpoints did not differ between these groups in univariable analyses. Multivariable analyses revealed decreased odds for death with dose escalation (odds ratio 0.09, 95% CI 0.01-0.86), independent of initial GCS score, presumably fatal etiology, SE severity score, SE duration, and nonconvulsive SE with coma, with similar functional outcome among survivors compared with patients without dose escalation. DISCUSSION Our study reveals that anesthetic dose escalation in adult patients with RSE is associated with decreased odds for death without increasing the proportion of surviving patients with worse neurofunctional state than before RSE. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that anesthetic dose escalation decreases the odds of death in patients with RSE.
Collapse
Affiliation(s)
- Urs Fisch
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Anja L Jünger
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sira M Baumann
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Saskia Semmlack
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Gian Marco De Marchis
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan J Rüegg
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sabina Hunziker
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Marsch
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Raoul Sutter
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| |
Collapse
|
7
|
Damien C, Leitinger M, Kellinghaus C, Strzelczyk A, De Stefano P, Beier CP, Sutter R, Kämppi L, Strbian D, Taubøll E, Rosenow F, Helbok R, Rüegg S, Damian M, Trinka E, Gaspard N. Sustained effort network for treatment of status epilepticus/European academy of neurology registry on adult refractory status epilepticus (SENSE-II/AROUSE). BMC Neurol 2024; 24:19. [PMID: 38178048 PMCID: PMC10765797 DOI: 10.1186/s12883-023-03505-y] [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: 07/14/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Status Epilepticus (SE) is a common neurological emergency associated with a high rate of functional decline and mortality. Large randomized trials have addressed the early phases of treatment for convulsive SE. However, evidence regarding third-line anesthetic treatment and the treatment of nonconvulsive status epilepticus (NCSE) is scarce. One trial addressing management of refractory SE with deep general anesthesia was terminated early due to insufficient recruitment. Multicenter prospective registries, including the Sustained Effort Network for treatment of Status Epilepticus (SENSE), have shed some light on these questions, but many answers are still lacking, such as the influence exerted by distinct EEG patterns in NCSE on the outcome. We therefore initiated a new prospective multicenter observational registry to collect clinical and EEG data that combined may further help in clinical decision-making and defining SE. METHODS Sustained effort network for treatment of status epilepticus/European Academy of Neurology Registry on refractory Status Epilepticus (SENSE-II/AROUSE) is a prospective, multicenter registry for patients treated for SE. The primary objectives are to document patient and SE characteristics, treatment modalities, EEG, neuroimaging data, and outcome of consecutive adults admitted for SE treatment in each of the participating centers and to identify factors associated with outcome and refractoriness. To reach sufficient statistical power for multivariate analysis, a cohort size of 3000 patients is targeted. DISCUSSION The data collected for the registry will provide both valuable EEG data and information about specific treatment steps in different patient groups with SE. Eventually, the data will support clinical decision-making and may further guide the planning of clinical trials. Finally, it could help to redefine NCSE and its management. TRIAL REGISTRATION NCT number: NCT05839418.
Collapse
Affiliation(s)
- Charlotte Damien
- Department of Neurology, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Markus Leitinger
- Department of Neurology Neurointensive Care and Neurorehabilitation, Centre for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, European Reference Network EpiCARE, Salzburg, Austria
- Neuroscience Institute, Department of Neurology, Centre for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | | | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Pia De Stefano
- EEG & Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Christoph P Beier
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Raoul Sutter
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Intensive Care Units, University Hospital Basel, Basel, Switzerland
| | - Leena Kämppi
- Department of Neurology, Epilepsia Helsinki, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Epilepsia Helsinki, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Erik Taubøll
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Felix Rosenow
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Raimund Helbok
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria
| | - Stephan Rüegg
- Department of Neurology, Epilepsia Helsinki, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maxwell Damian
- Department of Critical Care, Essex Cardiothoracic Centre, Basildon, UK
| | - Eugen Trinka
- Department of Neurology Neurointensive Care and Neurorehabilitation, Centre for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, European Reference Network EpiCARE, Salzburg, Austria
- Neuroscience Institute, Department of Neurology, Centre for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute of Neurorehabilitation and Space Neurology, Salzburg, Austria
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall en Tyrol, Austria
| | - Nicolas Gaspard
- Department of Neurology, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Brussels, Belgium.
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
| |
Collapse
|
8
|
Rossetti AO, Claassen J, Gaspard N. Status epilepticus in the ICU. Intensive Care Med 2024; 50:1-16. [PMID: 38117319 DOI: 10.1007/s00134-023-07263-w] [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: 07/14/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
Status epilepticus (SE) is a common medical emergency associated with significant morbidity and mortality. Management that follows published guidelines is best suited to improve outcomes, with the most severe cases frequently being managed in the intensive care unit (ICU). Diagnosis of convulsive SE can be made without electroencephalography (EEG), but EEG is required to reliably diagnose nonconvulsive SE. Rapidly narrowing down underlying causes for SE is crucial, as this may guide additional management steps. Causes may range from underlying epilepsy to acute brain injuries such as trauma, cardiac arrest, stroke, and infections. Initial management consists of rapid administration of benzodiazepines and one of the following non-sedating intravenous antiseizure medications (ASM): (fos-)phenytoin, levetiracetam, or valproate; other ASM are increasingly used, such as lacosamide or brivaracetam. SE that continues despite these medications is called refractory, and most commonly treated with continuous infusions of midazolam or propofol. Alternatives include further non-sedating ASM and non-pharmacologic approaches. SE that reemerges after weaning or continues despite management with propofol or midazolam is labeled super-refractory SE. At this step, management may include non-sedating or sedating compounds including ketamine and barbiturates. Continuous video EEG is necessary for the management of refractory and super-refractory SE, as these are almost always nonconvulsive. If possible, management of the underlying cause of seizures is crucial particularly for patients with autoimmune encephalitis. Short-term mortality ranges from 10 to 15% after SE and is primarily related to increasing age, underlying etiology, and medical comorbidities. Refractoriness of treatment is clearly related to outcome with mortality rising from 10% in responsive cases, to 25% in refractory, and nearly 40% in super-refractory SE.
Collapse
Affiliation(s)
- Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
| |
Collapse
|
9
|
Fisch U, Sutter R. Author Response: Association Between Induced Burst Suppression and Clinical Outcomes in Patients With Refractory Status Epilepticus: A 9-Year Cohort Study. Neurology 2023; 101:283. [PMID: 37550077 PMCID: PMC10424829 DOI: 10.1212/wnl.0000000000207719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023] Open
|
10
|
Sethi NK. Reader Response: Association Between Induced Burst Suppression and Clinical Outcomes in Patients With Refractory Status Epilepticus: A 9-Year Cohort Study. Neurology 2023; 101:282. [PMID: 37550078 PMCID: PMC10424830 DOI: 10.1212/wnl.0000000000207718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023] Open
|