Treatment of Refractory and Super-refractory Status Epilepticus

Independent Functional Outcomes after Prolonged Coma following Cardiac Arrest: A Mechanistic Hypothesis

OBJECTIVE

Survivors of prolonged (>2 weeks) post-cardiac arrest (CA) coma are expected to remain permanently disabled. We aimed to investigate 3 outlier patients who ultimately achieved independent functional outcomes after prolonged post-CA coma to identify electroencephalographic (EEG) markers of their recovery potential. For validation purposes, we also aimed to evaluate these markers in an independent cohort of post-CA patients.

METHODS

We identified 3 patients with late recovery from coma (17-37 days) following CA who recovered to functionally independent behavioral levels. We performed spectral power analyses of available EEGs during prominent burst suppression patterns (BSP) present in all 3 patients. Using identical methods, we also assessed the relationship of intraburst spectral power and outcomes in a prospectively enrolled cohort of post-CA patients. We performed chart reviews of common clinical, imaging, and EEG prognostic variables and clinical outcomes for all patients.

RESULTS

All 3 patients with late recovery from coma lacked evidence of overwhelming cortical injury but demonstrated prominent BSP on EEG. Spectral analyses revealed a prominent theta (~4-7Hz) feature dominating the bursts during BSP in these patients. In the prospective cohort, similar intraburst theta spectral features were evident in patients with favorable outcomes; patients with BSP and unfavorable outcomes showed either no features, transient burst features, or decreasing intraburst frequencies with time.

INTERPRETATION

BSP with theta (~4-7Hz) peak intraburst spectral power after CA may index a recovery potential. We discuss our results in the context of optimizing metabolic substrate availability and stimulating the corticothalamic system during recovery from prolonged post-CA coma. ANN NEUROL 2020;87:618-632.

A case report of microcephaly and refractory West syndrome associated with WDR62 mutation

The autosomal recessive form of primary microcephaly (MCPH) is a rare disorder characterized by microcephaly with variable degree of intellectual disability. WDR62 has been reported as the second causative gene of MCPH2. West syndrome is a severe epilepsy syndrome composed of the triad of spasms, hypsarrhythmia, and mental retardation. There are limited clinical reports regarding WDR62 mutation and West syndrome. Here we report a boy who was identified with WDR62 mutation and was followed up from age 3 months to 5 months and 14 days. He had the first seizure as the classic epileptic spasm at the age of 3 months. Psychomotor retardation was noted before the seizure occurred. The head circumference was 38.5 cm (SD 2.6) when he was 4 months old, no dysmorphic facial features were observed. He couldn’t support his head steadily or turn over. He was able to laugh when tricked by the parents, but couldn’t track the sound and light. At the early stage, the electroencephalogram showed multifocal discharges, which evolved into hypsarrhythmia one month later, and brain MRI showed developmental malformation of cerebral gyrus. Two heterozygous mutations were identified in WDR62 by whole exome sequencing c.1535G > A, p.R512Q and c.2618dupT, p.K874Qfs*40. The patient was administrated with oral sodium valproate, nitrazepam, intramuscular adrenocorticotropic hormone for 2 weeks, and followed by prednisone, levetiracetam, topiramate and vigabatrin. However, there was no significant improvement on the seizure control after these treatments. According to the genetic report and clinical manifestation, we speculated that the WDR62 compound heterozygous mutation is responsible for the serious clinical phenotype.

Effects of Diazepam and Ketamine on Pilocarpine-Induced Status Epilepticus in Mice

Status epilepticus (SE) is a life-threatening condition needing immediate care to prevent brain damage. SE with electrographic and behavioral features similar to those seen in humans is reproduced in rodents by i.p. pilocarpine injection, and can be terminated by diazepam and ketamine treatment but only behaviourally, not electrographically. Little is known on the behavioral and EEG effects induced by a delayed administration of ketamine (25 mg/kg) after diazepam (10 mg/kg) or vice versa. Therefore, we analysed behavior and EEG activity recorded from the mouse hippocampal CA3 region before, during SE and after anticonvulsant treatments. In the first group (n = 4), diazepam was administered one hour before ketamine whereas in the second group (n = 4) ketamine was administered one hour before diazepam. The EEG SE did not disappear after each of the two treatments but progressed within 4 h to a pattern of interictal discharges. However, diazepam administration before ketamine significantly shortened the time of behavioral recovery compared to when ketamine was administered before diazepam (p < 0.05). The two protocols were also associated to distinct EEG changes in gamma and high frequency oscillations. In conclusion, although diazepam and ketamine are not effective in stopping EEG SE, diazepam administration one hour before ketamine shortens behavioral recovery in pilocarpine-treated mice.

Status epilepticus in Auckland, New Zealand: Incidence, etiology, and outcomes

OBJECTIVE

To determine the incidence, etiology, and outcome of status epilepticus (SE) in Auckland, New Zealand, using the latest International League Against Epilepsy (ILAE) SE semiological classification.

METHODS

We prospectively identified patients presenting to the public or major private hospitals in Auckland (population = 1.61 million) between April 6, 2015 and April 5, 2016 with a seizure lasting 10 minutes or longer, with retrospective review to confirm completeness of data capture. Information was recorded in the EpiNet database.

RESULTS

A total of 477 episodes of SE occurred in 367 patients. Fifty-one percent of patients were aged <15 years. SE with prominent motor symptoms comprised 81% of episodes (387/477). Eighty-four episodes (18%) were nonconvulsive SE. Four hundred fifty episodes occurred in 345 patients who were resident in Auckland. The age-adjusted incidence of 10-minute SE episodes and patients was 29.25 (95% confidence interval [CI] = 27.34-31.27) and 22.22 (95% CI = 20.57-23.99)/100 000/year, respectively. SE lasted 30 minutes or longer in 250 (56%) episodes; age-adjusted incidence was 15.95 (95% CI = 14.56-17.45) SE episodes/100 000/year and 12.92 (95% CI = 11.67-14.27) patients/100 000/year. Age-adjusted incidence (10-minute SE) was 25.54 (95% CI = 23.06-28.24) patients/100 000/year for males and 19.07 (95% CI = 16.91-21.46) patients/100 000/year for females. The age-adjusted incidence of 10-minute SE was higher in Māori (29.31 [95% CI = 23.52-37.14]/100 000/year) and Pacific Islanders (26.55 [95% CI = 22.05-31.99]/100 000/year) than in patients of European (19.13 [95% CI = 17.09-21.37]/100 000/year) or Asian/other descent (17.76 [95% CI = 14.73-21.38]/100 000/year). Seventeen of 367 patients in the study died within 30 days of the episode of SE; 30-day mortality was 4.6%.

SIGNIFICANCE

In this population-based study, incidence and mortality of SE in Auckland lie in the lower range when compared to North America and Europe. For pragmatic reasons, we only included convulsive SE if episodes lasted 10 minutes or longer, although the 2015 ILAE SE classification was otherwise practical and easy to use.

Focal status epilepticus: a review of pharmacological treatment

INTRODUCTION

Status epilepticus (SE) is a neurological emergency associated with high morbidity and mortality. One prognostic factor is the type of SE. The purpose of this review is to analyse the most recent recommendations of different scientific societies and expert groups on the treatment of SE, and the latest studies, to assess the literature on the management of focal SE.

METHODS

We searched PubMed for studies published between 1 August 2008 and 1 August 2018 on the pharmacological treatment of focal SE and its different types in adults.

RESULTS

We identified 29 publications among reviews, treatment guidelines, meta-analyses, clinical trials, and case series on the treatment of SE. Only 3 of them accounted for whether SE was focal or generalised; 4 focused exclusively on focal SE, and 7 differentiated between convulsive and non-convulsive SE and also record the presence of focal seizures. Treatment recommendations for focal SE do not differ from those of generalised SE in stages I and II: initially intravenous lorazepam or diazepam, if the intravenous route is available, and otherwise intramuscular midazolam, followed by intravenous phenytoin, valproate, levetiracetam, or lacosamide if seizures persist. Use of anaesthetic drugs should be delayed for as long as possible in patients with refractory focal SE.

CONCLUSIONS

The available scientific evidence is insufficient to claim that pharmacological treatment of focal SE should be different from treatment for generalised SE. More studies with a greater number of patients are needed.

Neurosurgical therapy for Status Epilepticus in Oligoastrocytoma Patient: A case report

BACKGROUND

Super refractory epilepticus status (SRSE) is a life-threatening neurologic emergency defined as 'status epilepticus (SE) that continues 24 hours or more after the onset of anaesthesia, including those cases in which the SE recurs on the reduction or withdrawal of anaesthesia', which occur in 10-15% of SE patients and rarely has been resolved surgically.

METHODS

A 20-year-old man with SRSE and a long history of left parieto-occipital oligoastrocytoma was admitted for convulsive SE that become SRSE and underwent lesionectomy guided by electrocorticography and neuro-navigation for local tumor recurrence. Histopathological diagnosis was oligoastrocytoma.

RESULTS

SRSE was aborted and the patient recovery fully without any functional deficits.

CONCLUSIONS

The lesionectomy guided by electrocorticography and neuro- navigation should be considered as a treatment option for patients with SRSE.