Prolonged coma from refractory status epilepticus

Long-term outcome of status epilepticus-related to systemic lupus erythematosus: An observational study and a systematic review

OBJECTIVES

Status epilepticus-related to systemic lupus erythematosus (SE-SLE) is in general attributed to fulminate neuropsychiatric lupus disease activity, yet the long-term outcome of SE-SLE is not well recognized. This is an observational study of 40 SE-SLE patients pooled from 8 cases at a single tertiary care hospital, and 32 SE-SLE patients identified on a systematic review, with focus on electro-clinical characteristics, imaging studies and the underlying etiology of SE-SLE in correlation with long-term outcome.

RESULTS

Clinical phenotypes of SE-SLE were heterogeneous, ranging from patients with aura continua to patients in coma. Convulsive SE-SLE occurred among patients with heightened global lupus disease activity and increased cortical and subcortical brain lesion burden localized mostly in the frontal and temporal regions. There were no specific neuroimaging or laboratory abnormalities that allowed early SE-SLE diagnosis where a cluster of cases were of unclear etiology (17.5%). Most SE-SLE cases evolved to refractory SE-SLE with resistance to multiple anti-seizure medications and intravenous anesthetics requiring aggressive immune therapy that led to resolution of SE-SLE active phase. Seizure freedom occurred in 60.0% of patients and the median time to cessation of SE-SLE seizure activity after aggressive therapy was 14 days. Poor long-term outcomes were apparent in SE-SLE patients with one-year mortality (12.5%), recurrent SE-SLE (25.0%), subsequent epilepsy (37.5.1%), poor functional outcome (55.0%) and cognitive impairment (47.5%). A prolonged time to cessation of SE-SLE seizure activity was associated with unfavorable long-term outcome.

CONCLUSIONS

Diagnostic accuracy of SE-SLE requires better understanding of the etio-pathogenesis and the spectrum of clinical presentations of SE-SLE. Prompt initiation of immune therapy improve SE-SLE outcome, yet optimal therapeutic strategies remain to be determined. Identifying novel biomarkers that distinguish between different forms of SE-SLE and target cellular inflammatory response will help with specific SE-SLE treatment guidelines and prevent poor outcome.

Treatment of Super-Refractory Status Epilepticus

Super-refractory status epilepticus (SRSE) is a devastating neurological condition with limited treatment options. We conducted an extensive literature search to identify and summarize the therapeutic options for SRSE. The search mainly resulted in case reports of various pharmacologic and non-pharmacologic treatments. The success rate of each of the following agents, ketamine, inhaled anesthetics, intravenous immunoglobulin G (IVIG), IV steroids, ketogenic diet, hypothermia, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and vagal nerve stimulation (VNS), are discussed in greater detail. The choice of appropriate treatment options for a given patient is based on clinical presentation. This review focuses on evidence-based, pharmacotherapeutic strategies for patients in SRSE.

Prolonged pentobarbital-induced coma for the treatment of severe seizures related to posterior reversible encephalopathy syndrome

In this report, we describe a case of posterior reversible encephalopathy syndrome in a female patient after deceased donor liver transplantation. She developed posterior reversible encephalopathy syndrome on postoperative day 3 and did not improve despite adjustments in immunosuppressive therapy. The patient had symptoms of severe brain edema requiring maximal therapy, which included cooling, mannitol, 3% saline, and a pentobarbital infusion. Attempts to lighten the level of sedation failed because of recurring intractable seizure activity. Reductions in therapeutic support were ultimately successful after 62 days of continuous pentobarbital therapy. The patient awoke neurologically intact and was discharged to a rehabilitation center in good condition.

Status epilepticus: current treatment strategies

Status epilepticus is a neurological emergency that is commonly encountered by the neurohospitalist. Successful treatment depends upon the recognition of prolonged seizure activity and the acute mobilization of available resources. Pharmacologic treatment regimens have been shown to decrease the time needed for successful control of seizures and have provided for the rapid administration of anticonvulsant medications. Treatment strategies have evolved so that clinicians can administer effective doses of medication by whatever routes of administration are immediately available. Traditional algorithms for the treatment of status epilepticus have used a stepwise approach to the administration of first-, second-, and third-order medications. More recent options have included aggressive anesthetic doses of medications while second-line medications are being titrated.

Guidelines for the evaluation and management of status epilepticus

Status epilepticus (SE) treatment strategies vary substantially from one institution to another due to the lack of data to support one treatment over another. To provide guidance for the acute treatment of SE in critically ill patients, the Neurocritical Care Society organized a writing committee to evaluate the literature and develop an evidence-based and expert consensus practice guideline. Literature searches were conducted using PubMed and studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using standardized assessment methods from the American Heart Association and Grading of Recommendations Assessment, Development, and Evaluation systems, as well as expert opinion when sufficient data were lacking.

Management of refractory status epilepticus in adults: still more questions than answers

Refractory status epilepticus (RSE) is defined as status epilepticus that continues despite treatment with benzodiazepines and one antiepileptic drug. RSE should be treated promptly to prevent morbidity and mortality; however, scarce evidence is available to support the choice of specific treatments. Major independent outcome predictors are age (not modifiable) and cause (which should be actively targeted). Recent recommendations for adults suggest that the aggressiveness of treatment for RSE should be tailored to the clinical situation. To minimise intensive care unit-related complications, focal RSE without impairment of consciousness might initially be approached conservatively; conversely, early induction of pharmacological coma is advisable in generalised convulsive forms of the disorder. At this stage, midazolam, propofol, or barbiturates are the most commonly used drugs. Several other treatments, such as additional anaesthetics, other antiepileptic or immunomodulatory compounds, or non-pharmacological approaches (eg, electroconvulsive treatment or hypothermia), have been used in protracted RSE. Treatment lasting weeks or months can sometimes result in a good outcome, as in selected patients after encephalitis or autoimmune disorders. Well designed prospective studies of RSE are urgently needed.

Survivors and nonsurvivors of very prolonged status epilepticus

Several studies have shown reliable predictive factors for outcome in status epilepticus (SE), especially etiology and presentation in coma. Duration of SE is predictive, but probably only in the first few hours, and there have been many reports of patients treated successfully for SE lasting many days or weeks. Nevertheless, there are many other patients with SE treated for prolonged periods without success, sometimes apparently futilely. We compared clinical features of 10 survivors of prolonged SE with those of a matched cohort treated for similarly prolonged episodes but unsuccessfully, looking for exceptions to known predictive factors. Multiple medical problems (i.e., etiologies) and coma on presentation were confirmed as predictors of a poor outcome. Analysis of individual exceptions to these predictors showed that age, overall background health, and family input on the value of prolonged treatment, on the one hand, and earlier epilepsy plus rapid and accurate diagnosis and treatment, on the other, contributed to results different from what would have been expected.

Prolonged refractory status epilepticus related to thrombotic thrombocytopenic purpura

BACKGROUND

Thrombotic thrombocytopenic purpura (TTP) is an extremely rare cause of status epilepticus. Review of literature demonstrated only four cases of brief status epilepticus (SE) associated with TTP.

CASE

We describe a young woman with yet incomplete neurological recovery after prolonged refractory status epilepticus. Management required pentobarbital-induced coma for 60 days. Five months after onset, she was conversant and oriented with continued neuromuscular deficits.

CONCLUSIONS

This is an unusual presentation of severe refractory SE associated with TTP. With aggressive life support and prolonged pentobarbital infusion, however, survival and the chance of meaningful recovery appear to be possible.

Reversible focal neurological deficits in systemic lupus erythematosus: report of 2 cases and review of the literature

We report two cases presenting focal neurological deficits with high intensity lesions in fluid attenuated inversion recovery (FLAIR) images on brain magnetic resonance imaging (MRI), which almost completely improved by corticosteroid therapy. Marked elevation of cerebrospinal fluid IL-6 was also noted when these patients showed neurological deficits. As far as we explored, there have been thirteen published case reports of systemic lupus erythematosus patients with reversible focal neurological deficits. The neurological symptoms varied from case to case, but could be attributed to the lesions on MRI scans. The completely reversible feature of neurological manifestations as well as MRI findings on corticosteroid therapy is distinct from any other disorder, including cerebrovascular disease and demyelinating syndrome, in the 1999 American College of Rheumatology nomenclature. Therefore, we propose that reversible focal neurological deficits should be added to the 1999 nomenclature and classification and case definitions.