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Karim T, Das MC, Muhit M, Badawi N, Khandaker G, Mohammad SS. Improving epilepsy control among children with cerebral palsy in rural Bangladesh: a prospective cohort-based study. BMJ Open 2022; 12:e052578. [PMID: 35383059 PMCID: PMC8984049 DOI: 10.1136/bmjopen-2021-052578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To define the prevalence and seizure subtypes among children with cerebral palsy (CP) in rural Bangladesh and explore barriers to optimum epilepsy control. DESIGN Prospective cohort study. SETTING The study was conducted in Shahjadpur, a rural subdistrict of Bangladesh. PARTICIPANTS Children (<18 years) with CP and epilepsy identified using the Bangladesh CP Register (BCPR) in the study site. METHODS Assessments were conducted in three focused epilepsy clinics overseen by a paediatric neurologist between December 2016 and January 2018, with intervening phone and video-conference follow-ups. Details of event type, frequency and medication compliance were collected. Antiepileptic drugs (AEDs) were prescribed based on seizure type, family income, comorbidity and medication availability. RESULTS 23.4% (170/726) of the BCPR cohort had a clinical diagnosis of epilepsy of whom 166 were assessed. Following the focused epilepsy clinics, 62.0% (103/166) children were clinically determined to have ongoing epileptic seizures. 62.1% (64/103) had generalised onset tonic clonic seizures, 27.2% (28/103) had focal onset seizures with impaired awareness and 10.7% (11/103) had other seizure types. None of the children with prolonged seizures (31/103) had an emergency seizure management plan. Non-epileptic events were being pharmacologically treated as seizures in 18.1% (30/166) children. Financial constraints were the main reason for non-compliance on follow-up. CONCLUSIONS Gaps in optimum epilepsy management in rural Bangladesh are amenable to improvement anchored with local healthcare workers. Training and clinical care focused on recognition of common seizure types, seizure mimics and rationalising use of available AEDs can be facilitated by better referral pathways and telehealth support.
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Affiliation(s)
- Tasneem Karim
- Discipline of Child and Adolescent Health, Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- CSF Global, Dhaka, Bangladesh
- Asian Institute of Disability and Development, University of South Asia, Dhaka, Bangladesh
| | - Manik Chandra Das
- CSF Global, Dhaka, Bangladesh
- Asian Institute of Disability and Development, University of South Asia, Dhaka, Bangladesh
| | - Mohammad Muhit
- CSF Global, Dhaka, Bangladesh
- Asian Institute of Disability and Development, University of South Asia, Dhaka, Bangladesh
| | - Nadia Badawi
- Discipline of Child and Adolescent Health, Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- Cerebral Palsy Alliance Research Institute, Specialty of Child & Adolescent Health, Sydney Medical School, Faculty of Medicine & Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Gulam Khandaker
- Discipline of Child and Adolescent Health, Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- CSF Global, Dhaka, Bangladesh
- Asian Institute of Disability and Development, University of South Asia, Dhaka, Bangladesh
- Dept of Public Health, Central Queensland Hospital and Health Service, Rockhampton, Queensland, Australia
| | - Shekeeb S Mohammad
- Discipline of Child and Adolescent Health, Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
- TY Nelson Dept of Neurology and Neurosurgery, The Children's Hospital at Westmead, Sydney Children's Hospitals Network, Westmead, NSW, Australia
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Cruickshank M, Imamura M, Booth C, Aucott L, Counsell C, Manson P, Scotland G, Brazzelli M. Pre-hospital and emergency department treatment of convulsive status epilepticus in adults: an evidence synthesis. Health Technol Assess 2022; 26:1-76. [PMID: 35333156 PMCID: PMC8977974 DOI: 10.3310/rsvk2062] [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] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Convulsive status epilepticus is defined as ≥ 5 minutes of either continuous seizure activity or repetitive seizures without regaining consciousness. It is regarded as an emergency condition that requires prompt treatment to avoid hospitalisation and to reduce morbidity and mortality. Rapid pre-hospital first-line treatment of convulsive status epilepticus is currently benzodiazepines, administered either by trained caregivers in the community (e.g. buccal midazolam, rectal diazepam) or by trained health professionals via intramuscular or intravenous routes (e.g. midazolam, lorazepam). There is a lack of clarity about the optimal treatment for convulsive status epilepticus in the pre-hospital setting. OBJECTIVES To assess the current evidence on the clinical effectiveness and cost-effectiveness of treatments for adults with convulsive status epilepticus in the pre-hospital setting. DATA SOURCES We searched major electronic databases, including MEDLINE, EMBASE, PsycInfo®, CINAHL, CENTRAL, NHS Economic Evaluation Database, Health Technology Assessment Database, Research Papers in Economics, and the ISPOR Scientific Presentations Database, with no restrictions on publication date or language of publication. Final searches were carried out on 21 July 2020. REVIEW METHODS Systematic review of randomised controlled trials assessing adults with convulsive status epilepticus who received treatment before or on arrival at the emergency department. Eligible treatments were any antiepileptic drugs offered as first-line treatments, regardless of their route of administration. Primary outcomes were seizure cessation, seizure recurrence and adverse events. Two reviewers independently screened all citations identified by the search strategy, retrieved full-text articles, extracted data and assessed the risk of bias of the included trials. Results were described narratively. RESULTS Four trials (1345 randomised participants, of whom 1234 were adults) assessed the intravenous or intramuscular use of benzodiazepines or other antiepileptic drugs for the pre-hospital treatment of convulsive status epilepticus in adults. Three trials at a low risk of bias showed that benzodiazepines were effective in stopping seizures. In particular, intramuscular midazolam was non-inferior to intravenous lorazepam. The addition of levetiracetam to clonazepam did not show clear advantages over clonazepam alone. One trial at a high risk of bias showed that phenobarbital plus optional phenytoin was more effective in terminating seizures than diazepam plus phenytoin. The median time to seizure cessation from drug administration varied from 1.6 minutes to 15 minutes. The proportion of people with recurrence of seizures ranged from 10.4% to 19.1% in two trials reporting this outcome. Across trials, the rates of respiratory depression among participants receiving active treatments were generally low (from 6.4% to 10.6%). The mortality rate ranged from 2% to 7.6% in active treatment groups and from 6.2% to 15.5% in control groups. Only one study based on retrospective observational data met the criteria for economic evaluation; therefore, it was not possible to draw any robust conclusions on cost-effectiveness. LIMITATIONS The limited number of identified trials and their differences in terms of treatment comparisons and outcomes hindered any meaningful pooling of data. None of the included trials was conducted in the UK and none assessed the use of buccal midazolam or rectal diazepam. The review of economic evaluations was hampered by lack of suitable data. CONCLUSIONS Both intravenous lorazepam and intravenous diazepam administered by paramedics are more effective than a placebo in the treatments of adults with convulsive status epilepticus, and intramuscular midazolam is non-inferior to intravenous lorazepam. Large well-designed clinical trials are needed to establish which benzodiazepines are more effective and preferable in the pre-hospital setting. STUDY REGISTRATION This study is registered as PROSPERO CRD42020201953. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 26, No. 20. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Mari Imamura
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Carl Counsell
- Institute of Applied Health Sciences, University of Aberdeen, UK
- NHS Grampian, Aberdeen, UK
| | - Paul Manson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Services Research Unit and Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Jacq G, Chelly J, Quenot JP, Soulier P, Lesieur O, Beuret P, Holleville M, Bruel C, Bailly P, Sauneuf B, Sejourne C, Rigaud JP, Galbois A, Arrayago M, Plantefeve G, Stoclin A, Schnell D, Fontaine C, Perier F, Bougouin W, Pichon N, Mongardon N, Ledoux D, Lascarrou JB, Legriel S. Multicentre observational status-epilepticus registry: protocol for ICTAL. BMJ Open 2022; 12:e059675. [PMID: 35168989 PMCID: PMC8852755 DOI: 10.1136/bmjopen-2021-059675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Status epilepticus (SE) is a common life-threatening neurological emergency that can cause long-term impairments. Overall outcomes remain poor. Major efforts are required to clarify the epidemiology of SE and the determinants of outcomes, thereby identifying targets for improved management. METHODS AND ANALYSIS ICTAL Registry is a multicentre open cohort of critically ill patients with convulsive, non-convulsive or psychogenic non-epileptic SE. Observational methods are applied to collect uniform data. The goal of the ICTAL Registry is to collect high-quality information on a large number of patients, thereby allowing elucidation of the pathophysiological mechanisms involved in mortality and morbidity. The registry structure is modular, with a large core data set and the opportunity for research teams to create satellite data sets for observational or interventional studies (eg, cohort multiple randomised controlled trials, cross-sectional studies and short-term and long-term longitudinal outcome studies). The availability of core data will hasten patient recruitment to studies, while also decreasing costs. Importantly, the vast amount of data from a large number of patients will allow valid subgroup analyses, which are expected to identify patient populations requiring specific treatment strategies. The results of the studies will have a broad spectrum of application, particularly given the multidisciplinary approach used by the IctalGroup research network. ETHICS AND DISSEMINATION The ICTAL Registry protocol was approved by the ethics committee of the French Intensive Care Society (#CE_SRLF 19-68 and 19-68a). Patients or their relatives/proxies received written information to the use of the retrospectively collected and pseudonymised data, in compliance with French law. Prospectively included patients receive written consent form as soon as they recover decision-making competency; if they refuse consent, they are excluded from the registry. Data from the registry will be disseminated via conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT03457831.
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Affiliation(s)
- Gwenaelle Jacq
- Service de réanimation et unité de soins continus, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Jonathan Chelly
- Service de réanimation, Centre Hospitalier Intercommunal Toulon La Seyne sur Mer, Toulon, France
| | | | - Pauline Soulier
- Service de réanimation, Groupe Hospitalier Sud Ile-de-France, Melun, France
| | - Olivier Lesieur
- Service de réanimation, Centre hospitalier de la Rochelle, La Rochelle, Nouvelle-Aquitaine, France
| | - Pascal Beuret
- Service de Réanimation et Soins Continus, Centre Hospitalier de Roanne, Roanne, Rhône-Alpes, France
| | | | - Cedric Bruel
- Service de réanimation, Groupe hospitalier Paris Saint Joseph, Paris, France
| | - Pierre Bailly
- Médecine Intensive Réanimation, CHU de Brest, Brest, France
| | - Bertrand Sauneuf
- Service de réanimation, Centre Hospitalier Louis Pasteur de Cherbourg, Cherbourg-Octeville, Basse-Normandie, France
| | | | - Jean Philippe Rigaud
- Service de réanimation, Centre Hospitalier de Dieppe, Dieppe, Haute-Normandie, France
| | - Arnaud Galbois
- Intensive Care Unit, Claude Galien Private Hospital, Quincy-sous-Senart, Île-de-France, France
| | - Marine Arrayago
- Department of Intensive Care, Cannes Hospital, Cannes, France
| | - Gaetan Plantefeve
- Service de Médecine Intensive Réanimation, Centre Hospitalier d'Argenteuil, Argenteuil, Île-de-France, France
| | | | - David Schnell
- Service de réanimation, Hospital Centre Angouleme, Angouleme, Poitou-Charentes, France
| | - Candice Fontaine
- Service de réanimation et unité de soins continus, Centre Hospitalier de Versailles, Le Chesnay, France
| | - François Perier
- Service de réanimation et unité de soins continus, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Wulfran Bougouin
- Intensive Care Unit, Jacques Cartier Private Hospital, Massy, France
| | - Nicolas Pichon
- Service de réanimation, Centre Hospitalier de Brive, Brive-la-Gaillarde, France
| | - Nicolas Mongardon
- Service de Médecine Intensive-Réanimation, Hôpital Henri Mondor, Creteil, Île-de-France, France
| | - Didier Ledoux
- Department of Intensive Care, University Hospital of Liege, Sart, Belgium
| | | | - Stephane Legriel
- Service de réanimation et unité de soins continus, Centre Hospitalier de Versailles, Le Chesnay, France
- University Paris-Saclay, UVSQ, INSERM, Team « PsyDev », CESP, Villejuif, France
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Vuu I, Patterson EE, Wu CY, Zolkowska D, Leppik IE, Rogawski MA, Worrell GA, Kremen V, Cloyd JC, Coles LD. Intravenous and Intramuscular Allopregnanolone for Early Treatment of Status Epilepticus: Pharmacokinetics, Pharmacodynamics, and Safety in Dogs. J Pharmacol Exp Ther 2022; 380:104-113. [PMID: 34862270 PMCID: PMC11048262 DOI: 10.1124/jpet.121.000736] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 11/30/2021] [Indexed: 11/22/2022] Open
Abstract
Allopregnanolone (ALLO) is a neurosteroid that modulates synaptic and extrasynaptic GABAA receptors. We hypothesize that ALLO may be useful as first-line treatment of status epilepticus (SE). Our objectives were to (1) characterize ALLO pharmacokinetics-pharmacodynamics PK-PD after intravenous (IV) and intramuscular (IM) administration and (2) compare IV and IM ALLO safety and tolerability. Three healthy dogs and two with a history of epilepsy were used. Single ALLO IV doses ranging from 1-6 mg/kg were infused over 5 minutes or injected IM. Blood samples, vital signs, and sedation assessment were collected up to 8 hours postdose. Intracranial EEG (iEEG) was continuously recorded in one dog. IV ALLO exhibited dose-proportional increases in exposure, which were associated with an increase in absolute power spectral density in all iEEG frequency bands. This relationship was best described by an indirect link PK-PD model where concentration-response was described by a sigmoidal maximum response (Emax) equation. Adverse events included site injection pain with higher IM volumes and ataxia and sedation associated with higher doses. IM administration exhibited incomplete absorption and volume-dependent bioavailability. Robust iEEG changes after IM administration were not observed. Based on PK-PD simulations, a 2 mg/kg dose infused over 5 minutes is predicted to achieve plasma concentrations above the EC50, but below those associated with heavy sedation. This study demonstrates that ALLO is safe and well tolerated when administered at 1-4 mg/kg IV and up to 2 mg/kg IM. The rapid onset of effect after IV infusion suggests that ALLO may be useful in the early treatment of SE. SIGNIFICANCE STATEMENT: The characterization of the pharmacokinetics and pharmacodynamics of allopregnanolone is essential in order to design clinical studies evaluating its effectiveness as an early treatment for status epilepticus in dogs and people. This study has proposed a target dose/therapeutic range for a clinical trial in canine status epilepticus.
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Affiliation(s)
- Irene Vuu
- Clinical Pharmacology Modeling and Simulation, Amgen Inc., Thousand Oaks, California (I.V.); Department of Veterinary Clinical Sciences, University of Minnesota College of Veterinary Medicine, St. Paul, Minnesota (E.E.P.); Department of Neurology, University of California Davis School of Medicine, Sacramento, California (C.-Y.W., D.Z., M.A.R.); Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota (I.E.L., J.C.C., L.D.C.); and Department of Neurology, Mayo Clinic, Rochester, Minnesota (G.A.W., V.K.)
| | - Edward E Patterson
- Clinical Pharmacology Modeling and Simulation, Amgen Inc., Thousand Oaks, California (I.V.); Department of Veterinary Clinical Sciences, University of Minnesota College of Veterinary Medicine, St. Paul, Minnesota (E.E.P.); Department of Neurology, University of California Davis School of Medicine, Sacramento, California (C.-Y.W., D.Z., M.A.R.); Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota (I.E.L., J.C.C., L.D.C.); and Department of Neurology, Mayo Clinic, Rochester, Minnesota (G.A.W., V.K.)
| | - Chun-Yi Wu
- Clinical Pharmacology Modeling and Simulation, Amgen Inc., Thousand Oaks, California (I.V.); Department of Veterinary Clinical Sciences, University of Minnesota College of Veterinary Medicine, St. Paul, Minnesota (E.E.P.); Department of Neurology, University of California Davis School of Medicine, Sacramento, California (C.-Y.W., D.Z., M.A.R.); Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota (I.E.L., J.C.C., L.D.C.); and Department of Neurology, Mayo Clinic, Rochester, Minnesota (G.A.W., V.K.)
| | - Dorota Zolkowska
- Clinical Pharmacology Modeling and Simulation, Amgen Inc., Thousand Oaks, California (I.V.); Department of Veterinary Clinical Sciences, University of Minnesota College of Veterinary Medicine, St. Paul, Minnesota (E.E.P.); Department of Neurology, University of California Davis School of Medicine, Sacramento, California (C.-Y.W., D.Z., M.A.R.); Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota (I.E.L., J.C.C., L.D.C.); and Department of Neurology, Mayo Clinic, Rochester, Minnesota (G.A.W., V.K.)
| | - Ilo E Leppik
- Clinical Pharmacology Modeling and Simulation, Amgen Inc., Thousand Oaks, California (I.V.); Department of Veterinary Clinical Sciences, University of Minnesota College of Veterinary Medicine, St. Paul, Minnesota (E.E.P.); Department of Neurology, University of California Davis School of Medicine, Sacramento, California (C.-Y.W., D.Z., M.A.R.); Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota (I.E.L., J.C.C., L.D.C.); and Department of Neurology, Mayo Clinic, Rochester, Minnesota (G.A.W., V.K.)
| | - Michael A Rogawski
- Clinical Pharmacology Modeling and Simulation, Amgen Inc., Thousand Oaks, California (I.V.); Department of Veterinary Clinical Sciences, University of Minnesota College of Veterinary Medicine, St. Paul, Minnesota (E.E.P.); Department of Neurology, University of California Davis School of Medicine, Sacramento, California (C.-Y.W., D.Z., M.A.R.); Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota (I.E.L., J.C.C., L.D.C.); and Department of Neurology, Mayo Clinic, Rochester, Minnesota (G.A.W., V.K.)
| | - Gregory A Worrell
- Clinical Pharmacology Modeling and Simulation, Amgen Inc., Thousand Oaks, California (I.V.); Department of Veterinary Clinical Sciences, University of Minnesota College of Veterinary Medicine, St. Paul, Minnesota (E.E.P.); Department of Neurology, University of California Davis School of Medicine, Sacramento, California (C.-Y.W., D.Z., M.A.R.); Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota (I.E.L., J.C.C., L.D.C.); and Department of Neurology, Mayo Clinic, Rochester, Minnesota (G.A.W., V.K.)
| | - Vaclav Kremen
- Clinical Pharmacology Modeling and Simulation, Amgen Inc., Thousand Oaks, California (I.V.); Department of Veterinary Clinical Sciences, University of Minnesota College of Veterinary Medicine, St. Paul, Minnesota (E.E.P.); Department of Neurology, University of California Davis School of Medicine, Sacramento, California (C.-Y.W., D.Z., M.A.R.); Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota (I.E.L., J.C.C., L.D.C.); and Department of Neurology, Mayo Clinic, Rochester, Minnesota (G.A.W., V.K.)
| | - James C Cloyd
- Clinical Pharmacology Modeling and Simulation, Amgen Inc., Thousand Oaks, California (I.V.); Department of Veterinary Clinical Sciences, University of Minnesota College of Veterinary Medicine, St. Paul, Minnesota (E.E.P.); Department of Neurology, University of California Davis School of Medicine, Sacramento, California (C.-Y.W., D.Z., M.A.R.); Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota (I.E.L., J.C.C., L.D.C.); and Department of Neurology, Mayo Clinic, Rochester, Minnesota (G.A.W., V.K.)
| | - Lisa D Coles
- Clinical Pharmacology Modeling and Simulation, Amgen Inc., Thousand Oaks, California (I.V.); Department of Veterinary Clinical Sciences, University of Minnesota College of Veterinary Medicine, St. Paul, Minnesota (E.E.P.); Department of Neurology, University of California Davis School of Medicine, Sacramento, California (C.-Y.W., D.Z., M.A.R.); Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota (I.E.L., J.C.C., L.D.C.); and Department of Neurology, Mayo Clinic, Rochester, Minnesota (G.A.W., V.K.)
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Fan JM, Singhal NS, Guterman EL. Management of Status Epilepticus and Indications for Inpatient Electroencephalography Monitoring. Neurol Clin 2022; 40:1-16. [PMID: 34798964 DOI: 10.1016/j.ncl.2021.08.001] [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] [Indexed: 11/22/2022]
Abstract
Status epilepticus (SE) is a neurologic emergency requiring immediate time-sensitive treatment to minimize neuronal injury and systemic complications. Minimizing time to administration of first- and second-line therapy is necessary to optimize the chances of successful seizure termination in generalized convulsive SE (GCSE). The approach to refractory and superrefractory GCSE is less well defined. Multiple agents with differing complementary actions that facilitate seizure termination are recommended. Nonconvulsive SE (NCSE) has a wide range of presentations and approaches to treatment. Continuous electroencephalography is critical to the management of both GCSE and NCSE, while its use for patients without seizure continues to expand.
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Affiliation(s)
- Joline M Fan
- Department of Neurology, University of California, San Francisco, 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA 94143, USA; Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA 94143, USA.
| | - Neel S Singhal
- Department of Neurology, University of California, San Francisco, 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA 94143, USA; Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA 94143, USA
| | - Elan L Guterman
- Department of Neurology, University of California, San Francisco, 505 Parnassus Avenue, M798 Box 0114, San Francisco, CA 94143, USA; Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA 94143, USA
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Husain AM. What You Don’t Look for, You Won’t Find: Value of EEG After Clinical Resolution of Convulsive Status Epilepticus. Epilepsy Curr 2022; 22:33-35. [PMID: 35233194 PMCID: PMC8832344 DOI: 10.1177/15357597211051936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Aatif M. Husain
- Aatif M. Husain, M.D, Department of Neurology, Duke
University Medical Center and Neurodiagnostic Center, Veterans Affairs Medical Center,
299B Hanes House, 315 Trent Drive Box 102350, Durham, NC 27710, USA.
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Hoshiyama E, Kumasawa J, Uchida M, Hifumi T, Moriya T, Ajimi Y, Miyake Y, Kondo Y, Yokobori S. Phenytoin versus other antiepileptic drugs as treatments for status epilepticus in adults: a systematic review and meta-analysis. Acute Med Surg 2022; 9:e717. [PMID: 35028156 PMCID: PMC8739045 DOI: 10.1002/ams2.717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 11/17/2021] [Accepted: 11/24/2021] [Indexed: 11/21/2022] Open
Abstract
Aim Status epilepticus (SE) is a life‐threatening neurological emergency. There is insufficient evidence regarding which antiepileptic therapy is most effective in patients with benzodiazepine‐refractory convulsive SE. Therefore, this study aimed to evaluate intravenous phenytoin (PHT) and other intravenous antiepileptic medications for SE. Methods We searched PubMed, the Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi for published randomized controlled trials (RCTs) in humans up to August 2019. We compared outcomes between intravenous PHT and other intravenous medications. The important primary composite outcomes were the successful clinical cessation of seizures, mortality, and neurological outcomes at discharge. The reliability of the level of evidence for each outcome was compared using the Grading of Recommendations Assessment, Development, and Evaluation approach. Results A total of 1,103 studies were identified from the databases, and 10 RCTs were included in the analysis. The ratio of successful clinical seizure cessation was significantly lower (risk ratio [RR] 0.89; 95% confidence interval [CI], 0.82–0.97) for patients treated with intravenous PHT than with other medications. When we compared mortality and neurological outcomes at discharge, we observed no significant differences between patients treated with PHT and those treated with other medications. The RRs were 1.07 (95% CI, 0.55–2.08) and 0.91 (95% CI, 0.72–1.15) for mortality and neurological outcomes at discharge, respectively. Conclusions Our findings showed that intravenous PHT was significantly inferior to other medications in terms of the cessation of seizures. No significant differences were observed in mortality or neurological outcomes between PHT and other medications.
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Affiliation(s)
- Eisei Hoshiyama
- Department of Emergency and Critical Care Medical Center Dokkyo Medical University Tochigi Japan.,Department of Neurology Dokkyo Medical University Tochigi Japan
| | - Junji Kumasawa
- Department of Critical Care Medicine Sakai City Medical Center Sakai Japan
| | - Masatoshi Uchida
- Department of Emergency and Critical Care Medical Center Dokkyo Medical University Tochigi Japan
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine Emergency Medical Center St. Luke's International Hospital Chuo Japan
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine Saitama Medical Center Jichi Medical University Tochigi Japan
| | - Yasuhiko Ajimi
- Department of Emergency Medicine Teikyo University School of Medicine Tokyo Japan
| | - Yasufumi Miyake
- Department of Emergency Medicine Teikyo University School of Medicine Tokyo Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine Juntendo University Urayasu Hospital Urayasu Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
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Benzodiazepines in the Management of Seizures and Status Epilepticus: A Review of Routes of Delivery, Pharmacokinetics, Efficacy, and Tolerability. CNS Drugs 2022; 36:951-975. [PMID: 35971024 PMCID: PMC9477921 DOI: 10.1007/s40263-022-00940-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2022] [Indexed: 02/05/2023]
Abstract
Status epilepticus (SE) is an acute, life-threatening medical condition that requires immediate, effective therapy. Therefore, the acute care of prolonged seizures and SE is a constant challenge for healthcare professionals, in both the pre-hospital and the in-hospital settings. Benzodiazepines (BZDs) are the first-line treatment for SE worldwide due to their efficacy, tolerability, and rapid onset of action. Although all BZDs act as allosteric modulators at the inhibitory gamma-aminobutyric acid (GABA)A receptor, the individual agents have different efficacy profiles and pharmacokinetic and pharmacodynamic properties, some of which differ significantly. The conventional BZDs clonazepam, diazepam, lorazepam and midazolam differ mainly in their durations of action and available routes of administration. In addition to the common intravenous, intramuscular and rectal administrations that have long been established in the acute treatment of SE, other administration routes for BZDs-such as intranasal administration-have been developed in recent years, with some preparations already commercially available. Most recently, the intrapulmonary administration of BZDs via an inhaler has been investigated. This narrative review provides an overview of the current knowledge on the efficacy and tolerability of different BZDs, with a focus on different routes of administration and therapeutic specificities for different patient groups, and offers an outlook on potential future drug developments for the treatment of prolonged seizures and SE.
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Halliday AJ, Santamaria J, D'Souza WJ. Pre-hospital benzodiazepines associated with improved outcomes in out-of-hospital status epilepticus: A 10-year retrospective cohort study. Epilepsy Res 2022; 179:106846. [PMID: 34954464 DOI: 10.1016/j.eplepsyres.2021.106846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/05/2021] [Accepted: 12/16/2021] [Indexed: 11/03/2022]
Abstract
Outcomes of status epilepticus have not substantially changed over the last decade. Given onset is most often in the community, early termination strategies that are implementable outside of hospitals are of public health importance. This 10-year retrospective single-centre cohort study aimed to determine whether pre-hospital benzodiazepine administration is associated with improved health outcomes in patients with out-of-hospital onset status epilepticus. METHODS We reviewed the medical records of all patients admitted with status epilepticus between 2008 and 2018 at St Vincent's Hospital Melbourne. Data regarding onset setting, medical history, management and outcomes were extracted. RESULTS 72 patients meeting inclusion criteria were identified. Onset of status epilepticus was out-of-hospital for 74% (53/72) of patients, 66% (35/53) of whom were administered a benzodiazepine before reaching hospital, most often by ambulance officers (30/35, 86%). Pre-hospital benzodiazepine administration was associated with a 90% reduction in duration time to seizure cessation (0.65 vs 5.8 days, p = 0.012) and 50% reduction in length of hospital stay (7.6 vs 15.8 days, p = 0.045). In-hospital onset status epilepticus was associated with higher mortality than out-of-hospital onset (26% vs 4%, RR 6.5, p = 0.004). CONCLUSION Pre-hospital benzodiazepines shorten the time to seizure control and length of hospital stay in patients with out-of-hospital status epilepticus, although is under-utilised by both ambulance staff and home carers. Health policy measures to improve ambulance officer and home carer administration skills and confidence may address these issues.
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Affiliation(s)
- Amy J Halliday
- Department of Clinical Neurosciences, St Vincent's Hospital Melbourne, 41 Victoria Pde, Fitzroy, Melbourne, Victoria 3065, Australia.
| | - John Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, 41 Victoria Pde, Fitzroy, Melbourne, Victoria 3065, Australia
| | - Wendyl J D'Souza
- Department of Clinical Neurosciences, St Vincent's Hospital Melbourne, 41 Victoria Pde, Fitzroy, Melbourne, Victoria 3065, Australia
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Epilepsy. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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61
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Clay JL, Fountain NB. A critical review of fosphenytoin sodium injection for the treatment of status epilepticus in adults and children. Expert Rev Neurother 2021; 22:1-13. [PMID: 34726961 DOI: 10.1080/14737175.2021.2001328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Status epilepticus (SE) is a neurological emergency that can occur in patients with or without epilepsy. Rapid treatment is paramount to mitigate risks of neuronal injury, morbidity/mortality, and healthcare-cost burdens associated with SE. Fosphenytoin is the prodrug of phenytoin designed to enable faster administration and improved tolerability as compared to intravenous (IV) phenytoin in the treatment of SE. AREAS COVERED This review evaluates the chemistry, pharmacokinetics, pharmacodynamics, safety, and tolerability of fosphenytoin. Efficacy data for fosphenytoin in the treatment of SE in adults and children are analyzed from initial phase I trials in 1988 through current phase III trials, including the Established Status Epilepticus Treatment Trial (ESETT). EXPERT OPINION IV phenytoin is an established treatment of SE, but its alkaline aqueous vehicle is associated with dermatologic irritation and systemic complications when rapidly infused. The water-soluble nature of its prodrug, fosphenytoin, allows for rapid infusion, and it is rapidly converted to phenytoin when administered intravenously or intramuscularly. In the ESETT, IV fosphenytoin demonstrated similar efficacy in treatment of established SE when compared to IV levetiracetam and IV valproate in adults and children, making it a reasonable choice in the treatment of SE that is unresponsive to benzodiazepines.
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Affiliation(s)
- Jordan L Clay
- University of Kentucky Comprehensive Epilepsy Program, Department of Neurology, University of Kentucky College of Medicine, Lexington, Kentucky, USA
| | - Nathan B Fountain
- F.E. Dreifuss Comprehensive Epilepsy Program, Department of Neurology, University of Virginia Health Systems, Charlottesville, VA, USA
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Zhou R, Wang Y, Cao X, Li Z, Yu J. Diazepam Monotherapy or Diazepam-Ketamine Dual Therapy at Different Time Points Terminates Seizures and Reduces Mortality in a Status Epilepticus Animal Model. Med Sci Monit 2021; 27:e934043. [PMID: 34866132 PMCID: PMC8662960 DOI: 10.12659/msm.934043] [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: 07/16/2021] [Accepted: 11/08/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Being refractory to drugs remains an urgent treatment problem in status epilepticus (SE). The fact that γ-aminobutyric acid A receptors (GABAARs) become internalized and inactive, N-methyl-D-aspartate receptors (NMDARs) become externalized and active during SE may explain the refractoriness to benzodiazepine. However, the real-time dynamic efficacy of antiepileptic drugs remains unclear. Therefore, we propose a hypothesis that diazepam monotherapy or diazepam-ketamine dual therapy could terminate seizures and reduce mortality in the SE model at different time points during ongoing SE. MATERIAL AND METHODS An SE model was established in adult Sprague-Dawley rats with lithium and pilocarpine. The GABAAR agonist diazepam was injected at 5, 10, 20, or 30 min when SE continued. In addition, diazepam and the NMDAR antagonist ketamine were injected at 10 to 60 min at 6 different time points. We measured seizure-free rates, seizure duration, degree of behavioral seizure, and mortality. RESULTS Diazepam monotherapy at 5 min and 10 min from the beginning of SE was able to terminate seizures and improved survival rates. Diazepam-ketamine dual therapy at 10 min, 20 min, and 30 min from the beginning of SE terminated seizures and achieved high survival rates. CONCLUSIONS In this parallel randomized controlled trial with a rat model, we found that diazepam monotherapy was an effective antiepileptic strategy at the early stage of SE less than 10 min after SE onset. If SE lasts more than 10 min but less than 30 min, the diazepam-ketamine dual therapy strategy may be an appropriate choice.
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Affiliation(s)
- Ruijiao Zhou
- Department of Neurology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, PR China
| | - Yanlin Wang
- Department of Clinical Medicine, North Sichuan Medical College, Nanchong, Sichuan, PR China
| | - Xing Cao
- Department of Neurology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, PR China
| | - Zhimin Li
- Department of Neurology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, PR China
| | - Juming Yu
- Department of Neurology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, PR China
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Cheung DL, Cooke MJ, Goulton CS, Chaichim C, Cheung LF, Khoshaba A, Nabekura J, Moorhouse AJ. Global transgenic upregulation of KCC2 confers enhanced diazepam efficacy in treating sustained seizures. Epilepsia 2021; 63:e15-e22. [PMID: 34791657 DOI: 10.1111/epi.17097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/25/2021] [Accepted: 09/29/2021] [Indexed: 11/30/2022]
Abstract
Reduced anticonvulsant efficacy of benzodiazepines is a problem in the treatment of status epilepticus, with up to 50% of patients failing to respond to their first dose. KCC2 is a neuronal K+ -Cl- co-transporter that helps set and maintain intracellular Cl- concentrations. KCC2 functional downregulation is a potential contributor to benzodiazepine resistance. We tested this idea using male and female doxycycline-inducible, conditional transgenic mice to increase the functional expression of KCC2 in pyramidal neurons. We administered mice with two doses of the chemoconvulsant kainic acid (5 mg/kg, i.p.) 60 min apart and quantified the resultant seizures with electroencephalography (EEG) recordings. Overexpression of KCC2 prior to the chemoconvulsant challenge did not affect seizure latency or other measures of seizure severity, but it did increase diazepam's efficacy in stopping EEG seizures. Spike rate, time in seizure, and EEG spectral power following diazepam (5 mg/kg, i.p) were all significantly lower in KCC2 overexpression mice as compared to control mice. Our results indicate that, in the context of benzodiazepine resistance during sustained seizures, addressing impaired Cl- homeostasis alone appreciably improves the efficacy of γ-aminobutyric acid (GABA)ergic inhibition. We therefore suggest the simultaneous targeting of KCC2 and GABAA receptors as a pathway for improving current anticonvulsant therapeutic strategies.
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Affiliation(s)
- Dennis L Cheung
- Department of Physiology, School of Medical Sciences, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia.,Division of Homeostatic Development, Department of Fundamental Neuroscience, National Institute for Physiological Sciences, Okazaki, Japan
| | - Matthew J Cooke
- School of Electrical Engineering and Telecommunications, Faculty of Engineering, UNSW Sydney, Sydney, New South Wales, Australia
| | - Chelsea S Goulton
- Department of Physiology, School of Medical Sciences, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia.,School of Psychology, Faculty of Science, UNSW Sydney, Sydney, New South Wales, Australia
| | - Chanchanok Chaichim
- Department of Physiology, School of Medical Sciences, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Louis F Cheung
- School of Computer Science and Engineering, Faculty of Engineering, University of New South Wales, Sydney, New South Wales, Australia
| | - Ashor Khoshaba
- Department of Physiology, School of Medical Sciences, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
| | - Junichi Nabekura
- Division of Homeostatic Development, Department of Fundamental Neuroscience, National Institute for Physiological Sciences, Okazaki, Japan
| | - Andrew J Moorhouse
- Department of Physiology, School of Medical Sciences, Faculty of Medicine, UNSW Sydney, Sydney, New South Wales, Australia
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Knox KM, Zierath DK, White HS, Barker-Haliski M. Continuous seizure emergency evoked in mice with pharmacological, electrographic, and pathological features distinct from status epilepticus. Epilepsia 2021; 62:3076-3090. [PMID: 34625953 DOI: 10.1111/epi.17089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Benzodiazepines are the standard of care for the management of sustained seizure emergencies, including status epilepticus (SE) and seizure clusters. Seizure clusters are a variably defined seizure emergency wherein a patient has multiple seizures above a baseline rate, with intervening periods of recovery, distinguishing clusters from SE. Although these seizure emergencies are phenotypically distinct, the precise pathophysiological and mechanistic differences between SE and seizure clusters are understudied. Emergency-specific preclinical models may differentiate the behavioral and pathological mechanisms that are acutely associated with seizure emergencies and seizure termination to better manage these events. METHODS Herein we characterize a novel model of sustained seizure emergency induced in CF-1 mice through the combined administration of high-dose phenytoin (PHT; 50 mg/kg, i.p.) and pentylenetetrazol (PTZ; 100 mg/kg, s.c.). RESULTS We presently describe a mouse model of sustained seizure emergency that is pathologically, pharmacologically, and behaviorally distinct from SE. Acute administration of PHT 1 h prior to PTZ led to significantly more mice with unremitting continuous seizure activity (CSA; 73.4%) vs vehicle-pretreated mice (13.8%; p < .0001). CSA was sensitive to lorazepam and valproic acid when administered at seizure onset and 30 minutes later. Carbamazepine worsened seizure control and post-CSA survival. Mice in CSA exhibited electroencephalography (EEG) patterns distinct from kainic acid-induced SE and PTZ alone, clearly differentiating CSA from SE and PTZ-induced myoclonic seizures. Neuropathological assessment by Fluoro-Jade C staining of brains collected 24 h post-CSA revealed no neurodegeneration in any mouse that underwent CSA, whereas there was widespread neuronal death in brains from KA-SE mice. Finally, immunohistochemistry revealed acute seizure-induced astrogliosis (glial fibrillary acid protein; GFAP) in hippocampal structures, whereas hippocampal neuronal nuclei (NeuN) protein expression was only reduced in KA-SE mice. SIGNIFICANCE We present a novel mouse model on which to further elucidate the mechanistic differences between sustained seizure emergencies (ie, SE and seizure clusters) to improve clinical interventions and define mechanisms of seizure termination.
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Affiliation(s)
- Kevin M Knox
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Dannielle K Zierath
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - H Steve White
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Melissa Barker-Haliski
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, USA
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Al-Faraj AO, Abdennadher M, Pang TD. Diagnosis and Management of Status Epilepticus. Semin Neurol 2021; 41:483-492. [PMID: 34619776 DOI: 10.1055/s-0041-1733787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Seizures are among the most common neurological presentations to the emergency room. They present on a spectrum of severity from isolated new-onset seizures to acute repetitive seizures and, in severe cases, status epilepticus. The latter is the most serious, as it is associated with high morbidity and mortality. Prompt recognition and treatment of both seizure activity and associated acute systemic complications are essential to improve the overall outcome of these patients. The purpose of this review is to provide the current viewpoint on the diagnostic evaluation and pharmacological management of patients presenting with status epilepticus, and the common associated systemic complications.
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Affiliation(s)
- Abrar O Al-Faraj
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Myriam Abdennadher
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Trudy D Pang
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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66
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Rosenthal ES. Seizures, Status Epilepticus, and Continuous EEG in the Intensive Care Unit. Continuum (Minneap Minn) 2021; 27:1321-1343. [PMID: 34618762 DOI: 10.1212/con.0000000000001012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW This article discusses the evolving definitions of seizures and status epilepticus in the critical care environment and the role of critical care EEG in both diagnosing seizure activity and serving as a predictive biomarker of clinical trajectory. RECENT FINDINGS Initial screening EEG has been validated as a tool to predict which patients are at risk of future seizures. However, accepted definitions of seizures and nonconvulsive status epilepticus encourage a treatment trial when the diagnosis on EEG is indeterminate because of periodic or rhythmic patterns or uncertain clinical correlation. Similarly, recent data have demonstrated the diagnostic utility of intracranial EEG in increasing the yield of seizure detection. EEG has additionally been validated as a diagnostic biomarker of covert consciousness, a predictive biomarker of cerebral ischemia and impending neurologic deterioration, and a prognostic biomarker of coma recovery and status epilepticus resolution. A recent randomized trial concluded that patients allocated to continuous EEG had no difference in mortality than those undergoing intermittent EEG but could not demonstrate whether this lack of difference was because of studying heterogeneous conditions, examining a monitoring tool rather than a therapeutic approach, or examining an outcome measure (mortality) perhaps more strongly associated with early withdrawal of life-sustaining therapy than to a sustained response to pharmacotherapy. SUMMARY Seizures and status epilepticus are events of synchronous hypermetabolic activity that are either discrete and intermittent or, alternatively, continuous. Seizures and status epilepticus represent the far end of a continuum of ictal-interictal patterns that include lateralized rhythmic delta activity and periodic discharges, which not only predict future seizures but may be further classified as status epilepticus on the basis of intracranial EEG monitoring or a diagnostic trial of antiseizure medication therapy. In particularly challenging cases, neuroimaging or multimodality neuromonitoring may be a useful adjunct documenting metabolic crisis. Specialized uses of EEG as a prognostic biomarker have emerged in traumatic brain injury for predicting language function and covert consciousness, cardiac arrest for predicting coma recovery, and subarachnoid hemorrhage for predicting neurologic deterioration due to delayed cerebral ischemia.
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Su Y, Huang H, Jiang M, Pan S, Ding L, Zhang L, Jiang W, Zhuang X. Phenobarbital versus valproate for generalized convulsive status epilepticus in adults (2): A multicenter prospective randomized controlled trial in China (China 2-P vs. V). Epilepsy Res 2021; 177:106755. [PMID: 34517272 DOI: 10.1016/j.eplepsyres.2021.106755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/29/2021] [Accepted: 09/07/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A multicenter study of phenobarbital versus valproate (i.e., the China 2-P vs. V study) was conducted to compare the efficacy and safety of phenobarbital and valproate for generalized convulsive status epilepticus (SE) in a multicenter trial design. METHODS Three improvements (uniform intravenous pumping, pump speed adjustment according to adverse events and blood drug level monitoring) over a previous study were made regarding an intravenous regimen of phenobarbital and valproate in a multicenter, prospective, randomized, controlled study. Long-term electroencephalography (EEG) monitoring was performed after initial drug treatment. Termination, relapse, adverse event and poor prognosis rates in patients with generalized convulsive status epilepticus (GCSE) were compared. RESULTS The rate of GCSE termination within one hour were significantly higher in the phenobarbital group (33 cases) than in the valproate group (36 cases) (84.8 % vs. 63.9 %, P = 0.048), but the rates of nontermination of EEG epileptic discharge within one hour were similar between the two groups (12.1 % vs. 8.3 %, P = 0.702). The relapse and adverse event rates were not significantly different between groups, but 3 hypoventilation events and 1 hypotension event occurred in the phenobarbital group compared to 0 in the valproate group. There were no cases of epileptiform EEG discharge relapse in the phenobarbital group, compared to 1 case in the valproate group. CONCLUSIONS The phenobarbital regimen evaluated in this study has a higher GCSE termination rate than the valproate regimen, indicating that the former is suitable for countries, regions and individuals with limited access to new antiepileptic drugs or limited economic means.
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Affiliation(s)
- Yingying Su
- Neurocritical Care Committee of the Chinese Society of Neurology (CSN/NCC) and the Neurocritical Care Committee of the China Neurologist Association (CNA/NCC), Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing 100053, China.
| | - Huijin Huang
- Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Mengdi Jiang
- Neurointensive Care Unit, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Suyue Pan
- Department of Neurology, Nanfang Hospital of Southern Medical University, Guangzhou 510515, China
| | - Li Ding
- Department of Neurology, The Affiliated Hospital of Kunming University of Science and Technology, Kunming 654100, China
| | - Le Zhang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, Hunan, 410008, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, China
| | - Xiaorong Zhuang
- Department of Neurology, Zhongshan Hospital, Xiamen University, Xiamen, 200032, China
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Feng Y, Chen Y, Jia Y, Wang Z, Wang X, Jiang L, Ai C, Li W, Liu Y. Efficacy and safety of levetiracetam versus (fos)phenytoin for second-line treatment of epilepticus: a meta-analysis of latest randomized controlled trials. Seizure 2021; 91:339-345. [PMID: 34284302 DOI: 10.1016/j.seizure.2021.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 07/06/2021] [Accepted: 07/09/2021] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES To assess the efficiency and safety profiles of levetiracetam and (fos)phenytoin (phenytoin or fosphenytoin) for second-line treatment of seizures by performing a meta-analysis of RCTs. METHODS We systematically searched PubMed, Embase, Cochrane, FDA.gov, and ClinicalTrials.gov for RCTs (published before July 31, 2020; no language restrictions). Two independent reviewers screened abstracts and titles against inclusion and exclusion criteria published previously in the PROSPERO: CRD42020202736. Eleven studies fulfilled the established criteria. We assessed pooled data by using a random-effects model. Quality analysis was performed by using version 2 of the Cochrane risk-of-bias tool (RoB 2). RevMan v.5.3 was used to perform statistical analyses, and publication bias (egger's test) was assessed with Stata MP v.14.0. RESULTS Levetiracetam was similar to (fos)phenytoin in seizure termination rate (risk ratio [RR] 0.94; 95% CI 0.87 to 1.01), time of seizure termination (mean difference [MD] 0.44; -0.60 to 1.49), and drug resistance ([RR] 1.12, 0.86 to 1.45). The safety outcome showed a significant statistical difference between fosphenytoin group and levetiracetam group ([RR] 1.44, 1.14 to 1.81), while there was no significant difference observed between phenytoin treatment and levetiracetam treatment ([RR] 1.26, 0.99 to 1.60). CONCLUSION Levetiracetam was similar to (fos)phenytoin in cessation rate convulsive status epilepticus, and drug resistance, while it was superior (fos)phenytoin in pooled safety outcome. Further exploration is still needed as to whether it is the first choice for second-line drugs.
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Affiliation(s)
- Yuyi Feng
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin 124221, China
| | - Yueyue Chen
- Translational Medicine Research Institute, College of Medicine, Yangzhou University, Yangzhou 225001, China
| | - Yaqin Jia
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin 124221, China
| | - Zhe Wang
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin 124221, China
| | - Xiaoyu Wang
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin 124221, China
| | - Lili Jiang
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin 124221, China
| | - Chunzhi Ai
- State Key Laboratory for the Chemistry and Molecular Engineering of Medicinal Resources, School of Chemistry and Pharmaceutical Sciences, Guangxi Normal University, Guilin 541004, China
| | - Wei Li
- Translational Medicine Research Institute, College of Medicine, Yangzhou University, Yangzhou 225001, China; Jiangsu Co-innovation Center for Prevention and Control of Important Animal Infectious Diseases and Zoonoses, College of Veterinary Medicine, Yangzhou University, Yangzhou 225009, China.
| | - Yong Liu
- School of Life and Pharmaceutical Sciences, Dalian University of Technology, Panjin 124221, China.
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Kirmani BF, Au K, Ayari L, John M, Shetty P, Delorenzo RJ. Super-Refractory Status Epilepticus: Prognosis and Recent Advances in Management. Aging Dis 2021; 12:1097-1119. [PMID: 34221552 PMCID: PMC8219503 DOI: 10.14336/ad.2021.0302] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is a life-threatening neurological emergency with high morbidity and mortality. It is defined as “status epilepticus (SE) that continues or recurs 24 hours or more after the onset of anesthesia, including those cases in which SE recurs on the reduction or withdrawal of anesthesia.” This condition is resistant to normal protocols used in the treatment of status epilepticus and exposes patients to increased risks of neuronal death, neuronal injury, and disruption of neuronal networks if not treated in a timely manner. It is mainly seen in patients with severe acute onset brain injury or presentation of new-onset refractory status epilepticus (NORSE). The mortality, neurological deficits, and functional impairments are significant depending on the duration of status epilepticus and the resultant brain damage. Research is underway to find the cure for this devastating neurological condition. In this review, we will discuss the wide range of therapies used in the management of SRSE, provide suggestions regarding its treatment, and comment on future directions. The therapies evaluated include traditional and alternative anesthetic agents with antiepileptic agents. The other emerging therapies include hypothermia, steroids, immunosuppressive agents, electrical and magnetic stimulation therapies, emergent respective epilepsy surgery, the ketogenic diet, pyridoxine infusion, cerebrospinal fluid drainage, and magnesium infusion. To date, there is a lack of robust published data regarding the safety and effectiveness of various therapies, and there continues to be a need for large randomized multicenter trials comparing newer therapies to treat this refractory condition.
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Affiliation(s)
- Batool F Kirmani
- 1Texas A&M University College of Medicine, College Station, TX, USA.,3Epilepsy and Functional Neurosurgery Program, Department of Neurology, CHI St. Joseph Health, Bryan, TX, USA
| | - Katherine Au
- 2George Washington University, School of Medicine & Health Sciences, Washington DC, USA
| | - Lena Ayari
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Marita John
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Padmashri Shetty
- 4M. S. Ramaiah Medical College, M. S. Ramaiah Nagar, Bengaluru, Karnataka, India
| | - Robert J Delorenzo
- 5Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA
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Wabl R, Terman SW, Kwok M, Elm J, Chamberlain J, Silbergleit R, Hill CE. Efficacy of Home Anticonvulsant Administration for Second-Line Status Epilepticus Treatment. Neurology 2021; 97:e720-e727. [PMID: 34187862 DOI: 10.1212/wnl.0000000000012414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 05/11/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate whether receiving a second-line anticonvulsant medication that is part of a patient's home regimen influences outcomes in benzodiazepine-refractory convulsive status epilepticus. METHODS Using the Established Status Epilepticus Treatment Trial data, allocation to a study drug included in the patient's home anticonvulsant medication regimen was compared to receipt of an alternative second-line study medication. The primary outcome was cessation of clinical seizures with improved consciousness by 60 minutes after study drug initiation. Secondary outcomes were seizure cessation adjudicated from medical records and adverse events. We performed inverse probability of treatment-weighted (IPTW) logistic regressions. RESULTS Of 462 patients, 232 (50%) were taking 1-2 of the 3 study medications at home. The primary outcome was observed in 39/89 (44%) patients allocated to their home medication vs 76/143 (53%) allocated to a nonhome medication (IPTW odds ratio [OR] 0.66, 95% confidence interval [CI] 0.39-1.14). The adjudicated outcome occurred in 37/89 (42%) patients vs 82/143 (57%), respectively (IPTW OR 0.52, 95% CI 0.30-0.89). There was no interaction between study levetiracetam and home levetiracetam and there were no differences in adverse events. CONCLUSION There was no difference in the primary outcome for patients who received a home medication vs nonhome medication. However, the retrospective evaluation suggested an association between receiving a nonhome medication and seizure cessation. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for patients with refractory convulsive status epilepticus, use of a home second-line anticonvulsant compared to a nonhome anticonvulsant did not significantly affect the probability of stopping seizures.
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Affiliation(s)
- Rafael Wabl
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC.
| | - Samuel W Terman
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - Maria Kwok
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - Jordan Elm
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - James Chamberlain
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - Robert Silbergleit
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
| | - Chloe E Hill
- From the Department of Neurology (R.W.), University of Washington, Seattle; Departments of Neurology (S.W.T., C.E.H.) and Emergency Medicine (R.S.), University of Michigan, Ann Arbor; Department of Emergency Medicine (M.K.), Irving Medical Center, Columbia University, New York, NY; Department of Public Health Sciences (J.E.), Medical University of South Carolina, Charleston; and Division of Emergency Medicine (J.C.), Children's National Medical Center, Washington, DC
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Bermeo-Ovalle A. Pick Your Poison but Pick It Wisely: Choosing a Second-Line Medication for the Management of Status Epilepticus. Epilepsy Curr 2021; 20:278-281. [PMID: 34025242 PMCID: PMC7653661 DOI: 10.1177/1535759720949252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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Nakamura K, Marushima A, Takahashi Y, Kimura A, Asami M, Egawa S, Kaneko J, Kondo Y, Yonekawa C, Hoshiyama E, Yamada T, Maruo K, Inoue Y. Levetiracetam versus fosphenytoin as a second-line treatment after diazepam for status epilepticus: study protocol for a multicenter non-inferiority designed randomized control trial. Trials 2021; 22:317. [PMID: 33934714 PMCID: PMC8091776 DOI: 10.1186/s13063-021-05269-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 04/13/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Status epilepticus (SE) is an emergency condition for which rapid and secured cessation is important. Phenytoin and fosphenytoin, the prodrug of phenytoin with less severe adverse effects, have been recommended as second-line treatments. However, fosphenytoin causes severe adverse events, such as hypotension and arrhythmia. Levetiracetam reportedly has similar efficacy and higher safety for SE; however, evidence to support its use for adult SE is lacking. In the present study, a non-inferiority designed multicenter randomized controlled trial (RCT) is being conducted to compare levetiracetam with fosphenytoin after diazepam as a second-line treatment for SE. METHODS This multicenter, prospective, and open-label RCT is conducted in emergency departments. Between December 23, 2019, and March 31, 2023, 176 patients with convulsive SE transported to an emergency room will be randomized into a fosphenytoin group and levetiracetam group at a ratio of 1:1. The definition of SE is "continuous seizures longer than 5 min or discrete seizures longer than 2 min with intervening consciousness disturbance." In both groups, diazepam is initially administered at 1-20 mg, followed by intravenous fosphenytoin at 22.5 mg/kg or intravenous levetiracetam at 1000-3000 mg. The primary outcome is the seizure cessation rate within 30 min. Seizure recurrence within 24 h, severe adverse events, and intubation rate within 24 h are secondary outcomes. DISCUSSION The present study was approved and conducted as an initiative study of the Japanese Association for Acute Medicine. If non-inferiority is identified, the society will pursue an application for the national health insurance coverage of levetiracetam for SE via a public knowledge-based application. TRIAL REGISTRATION Japan Registry of Clinical Trials jRCTs031190160 . Registered on December 13, 2019.
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Affiliation(s)
- Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1 Jonan-cho, Hitachi, Ibaraki, 317-0077, Japan.
| | - Aiki Marushima
- Department of Emergency and Critical Care Medicine, Tsukuba University Hospital, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan
| | - Yuji Takahashi
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1 Jonan-cho, Hitachi, Ibaraki, 317-0077, Japan
| | - Akio Kimura
- Department of Emergency Medicine and Critical Care, National Center for Global Health and Medicine, 1-21-1 Toyama Shinjuku, Tokyo, Japan
| | - Masahiro Asami
- Department of Emergency Medicine, Teikyo University Hospital, 2-11-1, Kaga Itabashi, Tokyo, 173-8606, Japan
| | - Satoshi Egawa
- Neurointensive Care Unit, Neurosurgery, Stroke and Epilepsy Center, TMG Asaka Medical Center, 1340-1 Mizonuma, Asaka city, Saitama, 351-0023, Japan
| | - Junya Kaneko
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama, Tokyo, 206-8512, Japan
| | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital, 2-1-1, Tomioka, Urayasu, Chiba, 279-0021, Japan
| | - Chikara Yonekawa
- Department of Emergency Medicine, Jichi medical University Hospital, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Eisei Hoshiyama
- Emergency and Critical Care Medical Center, Dokkyo Medical University, 880 Kitakobayashi Mibu, Shimotsuga, Tochigi, 321-0293, Japan
| | - Takeshi Yamada
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan
| | - Kazushi Maruo
- Tsukuba Clinical Research & Development Organization, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan
| | - Yoshiaki Inoue
- Department of Emergency and Critical Care Medicine, Tsukuba University Hospital, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan
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Nagano M, Tagami T, Kaneko J, Kondo M, Hotta M, Kubota M, Sugaya K, Takase H, Kuno M, Unemoto K. Blood concentration of levetiracetam after bolus administration in patients with status epilepticus. Seizure 2021; 89:41-44. [PMID: 33984709 DOI: 10.1016/j.seizure.2021.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 04/08/2021] [Accepted: 04/21/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE We aimed to evaluate the blood concentration of levetiracetam (LEV), as a second-line drug, in patients with status epilepticus (SE) in an emergency clinical setting. METHODS We prospectively evaluated 20 consecutive patients with SE admitted to our department between July 2017 and July 2019. LEV (2500 mg) was administered via bolus infusion after diazepam infusion, followed by 500 mg every 12 h for 48 h and then 500 mg orally. The primary outcomes were LEV blood concentration 15 min, 12 h, 48 h, and 96 h after administration and the proportion of patients showing trough LEV concentration within the therapeutic range. The secondary outcomes were the discontinuation of apparent convulsive seizure, epileptic wave on electroencephalogram, tracheal intubation, adverse events related to blood parameters, and abnormal findings in vital signs examination. RESULTS Median blood LEV (2500 mg) concentration at 15 min after administration was 81.6 μg/mL. The median trough concentration after 12, 48, and 96 h was 28.8, 10.5, and 9.1 μg/mL, respectively. Moreover, 95% of patients had trough concentration above the lower limit of the therapeutic blood concentration (>12 μg/mL) after 12 h. Regarding secondary outcomes, endotracheal intubation, seizure suppression, and abnormal electroencephalogram findings were observed in approximately 40%, 90%-95%, and 41% of patients, respectively. No abnormal findings were noted in blood tests and vital sign examination, although the AST/ALT levels increased in 10% of the patients. CONCLUSION After bolus administration of 2500 mg, the blood LEV concentration reached the therapeutic window in patients with early-stage SE.
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Affiliation(s)
- Makihiko Nagano
- Department of Pharmacy, Nippon Medical School, Tama-Nagayama Hospital, 1-7-1 Nagayama, Tama City, Tokyo 2068512, Japan.
| | - Takashi Tagami
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Musashi-Kosugi Hospital, 1-396 Kosugimachi, Nakahara-ku, Kawasaki-shi, Kanagawa 2118533, Japan
| | - Junya Kaneko
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tama-Nagayama Hospital, 1-7-1 Nagayama, Tama City, Tokyo 2068512, Japan
| | - Masayoshi Kondo
- Department of Pharmacy, Nippon Medical School, Tama-Nagayama Hospital, 1-7-1 Nagayama, Tama City, Tokyo 2068512, Japan
| | - Mio Hotta
- Akiru Municipal Medical Center, 78-1, Hikida, Akiruno-shi, Tokyo 1970834, Japan
| | - Minoru Kubota
- Department of Clinical Laboratory, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 1138603, Japan
| | - Kazutoshi Sugaya
- Department of Pharmacy, Nippon Medical School, Tama-Nagayama Hospital, 1-7-1 Nagayama, Tama City, Tokyo 2068512, Japan
| | - Hisamitsu Takase
- Department of Pharmacy, Nippon Medical School, Tama-Nagayama Hospital, 1-7-1 Nagayama, Tama City, Tokyo 2068512, Japan
| | - Masamune Kuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tama-Nagayama Hospital, 1-7-1 Nagayama, Tama City, Tokyo 2068512, Japan
| | - Kyoko Unemoto
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tama-Nagayama Hospital, 1-7-1 Nagayama, Tama City, Tokyo 2068512, Japan
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Almohaish S, Sandler M, Brophy GM. Time Is Brain: Acute Control of Repetitive Seizures and Status Epilepticus Using Alternative Routes of Administration of Benzodiazepines. J Clin Med 2021; 10:jcm10081754. [PMID: 33920722 PMCID: PMC8073514 DOI: 10.3390/jcm10081754] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/13/2021] [Accepted: 04/13/2021] [Indexed: 12/15/2022] Open
Abstract
Time plays a major role in seizure evaluation and treatment. Acute repetitive seizures and status epilepticus are medical emergencies that require immediate assessment and treatment for optimal therapeutic response. Benzodiazepines are considered the first-line agent for rapid seizure control. Thus, various routes of administration of benzodiazepines have been studied to facilitate a quick, effective, and easy therapy administration. Choosing the right agent may vary based on the drug and route properties, patient’s environment, caregiver’s skills, and drug accessibility. The pharmacokinetic and pharmacodynamic aspects of benzodiazepines are essential in the decision-making process. Ultimately, agents and routes that give the highest bioavailability, fastest absorption, and a modest duration are preferred. In the outpatient setting, intranasal and buccal routes appear to be equally effective and more rapidly administered than rectal diazepam. On the other hand, in the inpatient setting, if available, the IV route is ideal for benzodiazepine administration to avoid any potential absorption delay. In this article, we will provide an overview and comparison of the various routes of benzodiazepine administration for acute control of repetitive seizures and status epilepticus.
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Affiliation(s)
- Sulaiman Almohaish
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.A.); (M.S.)
- College of Clinical Pharmacy, King Faisal University, Al-Ahsa 3198, Saudi Arabia
| | - Melissa Sandler
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.A.); (M.S.)
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Gretchen M. Brophy
- Department of Pharmacotherapy and Outcomes Science, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.A.); (M.S.)
- Correspondence: ; Tel.: +1-(804)-828-1201
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Llauradó A, Quintana M, Fonseca E, Abraira L, Toledo M, Requena M, Olivé M, Ballvé A, Campos D, Sueiras M, Santamarina E. Implications of initiating antiseizure drugs prior to the performance of EEG in first epileptic seizures. Neurologia 2021; 38:S0213-4853(21)00053-0. [PMID: 33875301 DOI: 10.1016/j.nrl.2021.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/11/2021] [Accepted: 02/17/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION This study aimed to determine whether the administration of antiepileptic drugs (AED) alters the likelihood of detecting epileptiform abnormalities in electroencephalographies (EEG) performed early after a first epileptic seizure. METHOD We performed a retrospective, observational study including patients with a first seizure attended at our centre's emergency department between July 2014 and November 2019. We collected clinical data, as well as technical data on the acquisition and interpretation of the EEG performed within the first 72hours after the seizure, and the factors related with seizure recurrence. RESULTS We recruited 155 patients with a mean (SD) age of 48.6 (22.5) years; 61.3% were men. Regarding seizure type, 51% presented tonic-clonic seizures of unknown onset and 12% presented focal to bilateral tonic-clonic seizures. Thirty-nine patients (25.2%) received AED treatment before the EEG was performed: 33 received a non-benzodiazepine AED and 6 received a benzodiazepine. Epileptiform abnormalities were observed in 29.7% of patients. Previous administration of AEDs was not significantly associated with the probability of detecting interictal epileptiform abnormalities (P=.25) or with the risk of recurrence within 6 months (P=.63). CONCLUSIONS Administration of AEDs before an early EEG following a first seizure does not decrease the likelihood of detecting epileptiform abnormalities. These findings suggest that starting AED treatment immediately in patients with a high risk of early recurrence does not imply a reduction in the diagnostic accuracy of the test.
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Affiliation(s)
- A Llauradó
- Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - M Quintana
- Unidad de Epilepsia; Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - E Fonseca
- Unidad de Epilepsia; Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - L Abraira
- Unidad de Epilepsia; Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - M Toledo
- Unidad de Epilepsia; Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - M Requena
- Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - M Olivé
- Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - A Ballvé
- Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - D Campos
- Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - M Sueiras
- Servicio, de Neurofisiología Clínica, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - E Santamarina
- Unidad de Epilepsia; Servicio de Neurología, Hospital Universitari Vall d'Hebron, Barcelona, España.
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Pharmacotherapy for Nonconvulsive Seizures and Nonconvulsive Status Epilepticus. Drugs 2021; 81:749-770. [PMID: 33830480 DOI: 10.1007/s40265-021-01502-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 12/22/2022]
Abstract
Most seizures in critically ill patients are nonconvulsive. A significant number of neurological and medical conditions can be complicated by nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE), with brain infections, hemorrhages, global hypoxia, sepsis, and recent neurosurgery being the most prominent etiologies. Prolonged NCSs and NCSE can lead to adverse neurological outcomes. Early recognition requires a high degree of suspicion and rapid and appropriate duration of continuous electroencephalogram (cEEG) monitoring. Although high quality research evaluating treatment with antiseizure medications and long-term outcome is still lacking, it is probable that expeditious pharmacological management of NCSs and NCSE may prevent refractoriness and further neurological injury. There is limited evidence on pharmacotherapy for NCSs and NCSE, although a few clinical trials encompassing both convulsive and NCSE have demonstrated similar efficacy of different intravenous (IV) antiseizure medications (ASMs), including levetiracetam, valproate, lacosamide and fosphenytoin. The choice of specific ASMs lies on tolerability and safety since critically ill patients frequently have impaired renal and/or hepatic function as well as hematological/hemodynamic lability. Treatment frequently requires more than one ASM and occasionally escalation to IV anesthetic drugs. When multiple ASMs are required, combining different mechanisms of action should be considered. There are several enteral ASMs that could be used when IV ASM options have been exhausted. Refractory NCSE is not uncommon, and its treatment requires a very judicious selection of ASMs aiming at reducing seizure burden along with management of the underlying condition.
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Abstract
Cancer and cancer therapies have the potential to affect the nervous system in a host of different ways. Cerebral edema, increased intracranial pressure, cerebrovascular events, status epilepticus, and epidural spinal cord compression are among those most often presenting as emergencies. Neurologic side-effects of cancer therapies are often mild, but occasionally result in serious illness. Immunotherapies cause autoimmune-related neurologic side-effects that are generally responsive to immunosuppressive therapies. Emergency management of neuro-oncologic problems benefits from early identification and close collaboration among interdisciplinary team members and patients or surrogate decision-makers.
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Affiliation(s)
- Zachary D Threlkeld
- Division of Neurocritical Care, Department of Neurology, Stanford University School of Medicine, 300 Pasteur Drive MC 5778, Stanford, CA 94305, USA
| | - Brian J Scott
- Division of Neurohospitalist Medicine, Department of Neurology, Stanford University School of Medicine, 453 Quarry Rd, 2nd Floor, Stanford, CA 94305, USA.
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Abstract
Context Refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE) are neurological emergencies with considerable mortality and morbidity. In this paper, we provide an overview of causes, evaluation, treatment, and consequences of RSE and SRSE, reflecting the lack of high-quality evidence to inform therapeutic approach. Sources This is a narrative review based on personal practice and experience. Nevertheless, we searched MEDLINE (using PubMed and OvidSP vendors) and Cochrane central register of controlled trials, using appropriate keywords to incorporate recent evidence. Results Refractory status epilepticus is commonly defined as an acute convulsive seizure that fails to respond to two or more anti-seizure medications including at least one nonbenzodiazepine drug. Super-refractory status epilepticus is a status epilepticus that continues for ≥24 hours despite anesthetic treatment, or recurs on an attempted wean of the anesthetic regimen. Both can occur in patients known to have epilepsy or de novo, with increasing recognition of autoimmune and genetic causes. Electroencephalography monitoring is essential to monitor treatment response in refractory/super-refractory status epilepticus, and to diagnose non-convulsive status epilepticus. The mainstay of treatment for these disorders includes anesthetic infusions, primarily midazolam, ketamine, and pentobarbital. Dietary, immunological, and surgical treatments are viable in selected patients. Management is challenging due to multiple acute complications and long-term adverse consequences. Conclusions We have provided a synopsis of best practices for diagnosis and management of refractory/superrefractory status epilepticus and highlighted the lack of sufficient high-quality evidence to drive decision making, ending with a brief foray into avenues for future research.
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Affiliation(s)
- Debopam Samanta
- Child Neurology Division, Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Lisa Garrity
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ravindra Arya
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; USA. Correspondence to: Dr Ravindra Arya, Division of Neurology, Cincinnati Children's Hospital Medical Center, MLC 2015, 3333 Burnet Avenue, Cincinnati, Ohio, 45229 USA.
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Neligan A, Rajakulendran S, Walker MC. Advances in the management of generalized convulsive status epilepticus: what have we learned? Brain 2021; 144:1336-1341. [PMID: 33778866 DOI: 10.1093/brain/awab049] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/18/2020] [Accepted: 12/09/2020] [Indexed: 12/15/2022] Open
Abstract
Convulsive status epilepticus is the most serious manifestation of an epileptic diathesis. In the early stages (5-30 min), there exists class A evidence to support the efficacy of benzodiazepines as first-line treatment. As status epilepticus progresses into the later stages, the evidence for treatment becomes less robust until we are depending upon short case series and case reports for the treatment of refractory status epilepticus. However, the past year saw the publication of three randomized controlled trials in the setting of benzodiazepine-resistant established convulsive status epilepticus: the EcLiPSE and ConSEPT studies, compared levetiracetam to phenytoin in children; and the ESETT study compared fosphenytoin, levetiracetam and sodium valproate in adults and children. In addition, the emergence of data from the SENSE study, a multicentre multinational prospective cohort study and the publication of a systematic review and meta-analysis of the mortality of status epilepticus over the past 30 years, has brought the treatment of status epilepticus into sharp focus. In this update we provide a detailed analysis of these studies and their impact on clinical practice. We review contentious areas of management in status epilepticus where a consensus is lacking and advance the case for more research on existing and alternative treatment strategies.
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Affiliation(s)
- Aidan Neligan
- Homerton University Hospital NHS Foundation Trust, Homerton Row, London E9 6SR, UK.,DCEE, UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - Sanjeev Rajakulendran
- DCEE, UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK.,National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK.,North Middlesex University Hospital, Sterling Way, London N18 1QX, UK
| | - Matthew C Walker
- DCEE, UCL Queen Square Institute of Neurology, Queen Square, London WC1N 3BG, UK.,National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
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[S2k guidelines: status epilepticus in adulthood : Guidelines of the German Society for Neurology]. DER NERVENARZT 2021; 92:1002-1030. [PMID: 33751150 PMCID: PMC8484257 DOI: 10.1007/s00115-020-01036-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 01/16/2023]
Abstract
This S2k guideline on diagnosis and treatment of status epilepticus (SE) in adults is based on the last published version from 2021. New definitions and evidence were included in the guideline and the clinical pathway. A seizures lasting longer than 5 minutes (or ≥ 2 seizures over more than 5 mins without intermittend recovery to the preictal neurological state. Initial diagnosis should include a cCT or, if possible, an MRI. The EEG is highly relevant for diagnosis and treatment-monitoring of non-convulsive SE and for the exclusion or diagnosis of psychogenic non-epileptic seizures. As the increasing evidence supports the relevance of inflammatory comorbidities (e.g. pneumonia) related clinical chemistry should be obtained and repeated over the course of a SE treatment, and antibiotic therapy initiated if indicated.Treatment is applied on four levels: 1. Initial SE: An adequate dose of benzodiazepine is given i.v., i.m., or i.n.; 2. Benzodiazepine-refractory SE: I.v. drugs of 1st choice are levetiracetam or valproate; 3. Refractory SE (RSE) or 4. Super-refractory SE (SRSE): I.v. propofol or midazolam alone or in combination or thiopental in anaesthetic doses are given. In focal non-convulsive RSE the induction of a therapeutic coma depends on the circumstances and is not mandatory. In SRSE the ketogenic diet should be given. I.v. ketamine or inhalative isoflorane can be considered. In selected cased electroconvulsive therapy or, if a resectable epileptogenic zone can be defined epilepsy surgery can be applied. I.v. allopregnanolone or systemic hypothermia should not be used.
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Mantoan Ritter L, Nashef L. New-onset refractory status epilepticus (NORSE). Pract Neurol 2021; 21:practneurol-2020-002534. [PMID: 33674412 DOI: 10.1136/practneurol-2020-002534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2021] [Indexed: 11/04/2022]
Abstract
New-onset refractory status epilepticus and its subcategory febrile infection-related epilepsy syndrome are rare devastating clinical presentations in those without pre-existing relevant history, often in schoolchildren or young adults, without a clear cause on initial investigations. A cause is later identified in up to half of adults, but in many fewer children. Patients often require protracted intensive care and are at significant risk of dying. Functional disability is common and subsequent chronic epilepsy is the norm, but some people do have good outcomes, even after prolonged status epilepticus. Patients need prompt investigations and treatment. Anaesthetic and antiseizure medications are supplemented by other treatment modalities, including the ketogenic diet. Despite limited evidence, it is appropriate to try to modify the presumed underlying pathogenesis with immune modulation early, with a more recent focus on using interleukin inhibitors. Optimising management will require concerted multicentre international efforts.
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Affiliation(s)
- Laura Mantoan Ritter
- Department of Neurology, King's College Hospital, London, UK
- Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
| | - Lina Nashef
- Department of Neurology, King's College Hospital, London, UK
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Charalambous M, Volk HA, Van Ham L, Bhatti SFM. First-line management of canine status epilepticus at home and in hospital-opportunities and limitations of the various administration routes of benzodiazepines. BMC Vet Res 2021; 17:103. [PMID: 33663513 PMCID: PMC7934266 DOI: 10.1186/s12917-021-02805-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/16/2021] [Indexed: 12/22/2022] Open
Affiliation(s)
- Marios Charalambous
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium.
| | - Holger A Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, 30559, Hannover, Germany
| | - Luc Van Ham
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium
| | - Sofie F M Bhatti
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium
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83
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Lumley L, Niquet J, Marrero-Rosado B, Schultz M, Rossetti F, de Araujo Furtado M, Wasterlain C. Treatment of acetylcholinesterase inhibitor-induced seizures with polytherapy targeting GABA and glutamate receptors. Neuropharmacology 2021; 185:108444. [PMID: 33359073 PMCID: PMC7944923 DOI: 10.1016/j.neuropharm.2020.108444] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/30/2020] [Accepted: 12/17/2020] [Indexed: 12/12/2022]
Abstract
The initiation and maintenance of cholinergic-induced status epilepticus (SE) are associated with decreased synaptic gamma-aminobutyric acid A receptors (GABAAR) and increased N-methyl-d-aspartate receptors (NMDAR) and amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors (AMPAR). We hypothesized that trafficking of synaptic GABAAR and glutamate receptors is maladaptive and contributes to the pharmacoresistance to antiseizure drugs; targeting these components should ameliorate the pathophysiological consequences of refractory SE (RSE). We review studies of rodent models of cholinergic-induced SE, in which we used a benzodiazepine allosteric GABAAR modulator to correct loss of inhibition, concurrent with the NMDA antagonist ketamine to reduce excitation caused by increased synaptic localization of NMDAR and AMPAR, which are NMDAR-dependent. Models included lithium/pilocarpine-induced SE in rats and soman-induced SE in rats and in Es1-/- mice, which similar to humans lack plasma carboxylesterase, and may better model soman toxicity. These model human soman toxicity and are refractory to benzodiazepines administered at 40 min after seizure onset, when enough synaptic GABAAR may not be available to restore inhibition. Ketamine-midazolam combination reduces seizure severity, epileptogenesis, performance deficits and neuropathology following cholinergic-induced SE. Supplementing that treatment with valproate, which targets a non-benzodiazepine site, effectively terminates RSE, providing further benefit against cholinergic-induced SE. The therapeutic index of drug combinations is also reviewed and we show the improved efficacy of simultaneous administration of midazolam, ketamine and valproate compared to sequential drug administration. These data suggest that future clinical trials should treat both the lack of sufficient inhibition and the excess excitation that characterize RSE, and include early combination drug therapies. This article is part of the special issue entitled 'Acetylcholinesterase Inhibitors: From Bench to Bedside to Battlefield'.
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Affiliation(s)
- Lucille Lumley
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense (USAMRICD), Aberdeen Proving Ground, MD, USA.
| | - Jerome Niquet
- Department of Neurology, David Geffen School of Medicine at UCLA, Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Brenda Marrero-Rosado
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense (USAMRICD), Aberdeen Proving Ground, MD, USA
| | - Mark Schultz
- Neuroscience Department, US Army Medical Research Institute of Chemical Defense (USAMRICD), Aberdeen Proving Ground, MD, USA
| | - Franco Rossetti
- Military Psychiatry and Neuroscience Department, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | | | - Claude Wasterlain
- Department of Neurology, David Geffen School of Medicine at UCLA, Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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84
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Sharshar T, Ben Hadj Salem O, Porcher R, Grimaldi-Bensouda L, Heming N, Clair B, Azabou E, Mazeraud A, Rohaut B, Outin H. Valproic Acid as an Adjuvant Treatment for Generalized Convulsive Status Epilepticus in Adults Admitted to Intensive Care Units: Protocol for a Double-Blind, Multicenter Randomized Controlled Trial. JMIR Res Protoc 2021; 10:e22511. [PMID: 33625371 PMCID: PMC7946594 DOI: 10.2196/22511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/13/2020] [Accepted: 11/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background Generalized convulsive status epilepticus (GCSE) is a frequent medical emergency. GCSE treatment focuses on the administration of benzodiazepines followed by a second-line antiepileptic drug (AED). Despite this stepwise strategy, GCSE is not controlled in one-quarter of patients and is associated with protracted hospitalization, high mortality, and long-term disability. Valproic acid (VPA) is an AED with good tolerability and neuroprotective properties. Objective This study aims to demonstrate that administration of VPA as an adjuvant for first- and second-line treatment in GCSE can improve outcomes. Methods A multicenter, double-blind, randomized controlled trial was conducted, comparing VPA with a placebo in adults admitted to intensive care units (ICUs) for GCSE in France. GCSE was diagnosed by specifically trained ICU physicians according to standard criteria. All patients received standard of care, including a benzodiazepine and a second-line AED (not VPA), at the discretion of the treating medical team. In the intervention arm, VPA was administered intravenously at a loading dose of 30 mg/kg over 15 minutes, followed by a continuous infusion of 1 mg/kg/hour over the next 12 hours. In the placebo group, an identical intravenous administration of 0.9% saline was used. The primary outcome was the proportion of patients discharged alive from the hospital by day 15. Secondary outcomes were frequency of refractory and super refractory GCSE, ICU-related morbidity, adverse events related to VPA, and cognitive dysfunction at 3 months. Statistical analyses will be performed according to the intent-to-treat principle. Results The first patient was randomized on February 18, 2013, and the last patient was randomized on July 7, 2018. Of 248 planned patients, 98.7% (245/248) were enrolled across 20 ICUs. At present, data management is still ongoing, and all parties involved in the trial remain blinded. Conclusions The Valproic Acid as an Adjuvant Treatment for Generalized Convulsive Status Epilepticus (VALSE) trial will evaluate whether the use of VPA as an adjuvant for first- and second-line treatment in GCSE improves outcomes. Trial Registration ClinicalTrials.gov NCT01791868; https://clinicaltrials.gov/ct2/show/NCT01791868. International Registered Report Identifier (IRRID) DERR1-10.2196/22511
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Affiliation(s)
- Tarek Sharshar
- Groupement Hospitalo-Universitaire Paris Psychiatrie et Neurosciences, Paris, France.,Université de Paris, Paris, France
| | | | - Raphaël Porcher
- Université de Paris, Paris, France.,Center for Clinical Epidemiology, Assistance Publique Hôpitaux de Paris, Hôtel Dieu Hospital, Paris, France
| | - Lamiae Grimaldi-Bensouda
- Clinical Research Unit, Ambroise Paré Hospital, University of Versailles Saint-Quentin en Yvelines, Saint-Quentin en Yveline, France
| | - Nicholas Heming
- Centre Hospitalo-Universitaire Raymond Poincaré, Assistance de Paris - Hôpitaux de Paris, Garches, France
| | - Bernard Clair
- Centre Hospitalo-Universitaire Raymond Poincaré, Assistance de Paris - Hôpitaux de Paris, Garches, France
| | - Eric Azabou
- Centre Hospitalo-Universitaire Raymond Poincaré, Assistance de Paris - Hôpitaux de Paris, Garches, France
| | - Aurélien Mazeraud
- Groupement Hospitalo-Universitaire Paris Psychiatrie et Neurosciences, Paris, France.,Université de Paris, Paris, France
| | - Benjamin Rohaut
- Centre Hospitalo-Universitaire Pitié Salpétrière, Paris, France.,Sorbonne Université, Paris, France
| | - Hervé Outin
- Centre Hospitalier Poissy Saint Germain en Laye, Poissy, France
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85
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Llauradó A, Quintana M, Ballvé A, Campos D, Fonseca E, Abraira L, Toledo M, Santamarina E. Factors associated with resistance to benzodiazepines in status epilepticus. J Neurol Sci 2021; 423:117368. [PMID: 33652289 DOI: 10.1016/j.jns.2021.117368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate factors related to benzodiazepine (BZD) resistance in status epilepticus (SE) with a focus on their relationship with the etiology of the episode. METHODS All SE cases in patients aged >16 years treated with BZDs were prospectively collected in our center from February 2011 to April 2019. The registry included demographics, SE type and etiology, the timing and duration of BZD administration, and the outcome. In total, 371 episodes were analyzed. RESULTS Median age at SE onset was 61.3 years; the most frequent etiology was acute symptomatic (55.8%). SE with prominent motor symptoms occurred in 63.3%. Median time to BZD administration was 2 h. We studied the correlation between two-time variables: time from SE onset to BZD administration and time from BZD administration to resolution of SE (response); we observed that timely administration correlated with a faster response in patients with prominent motor symptoms (p = 0.017), SE due to a chronic structural cerebral lesion (p = 0.004), and patients with a history of seizures (p = 0.013). In these subgroups (prominent motor symptoms or chronic structural lesion) BZD administration within the first 4.5 h was highly associated with shorter post-BZD SE duration (p < 0.001). SIGNIFICANCE The relationship between prompt BZD administration and subsequent duration of SE was found to depend to some extent on the etiology of the episode: patients with chronic structural lesions and those with previous epilepsy responded faster to BZDs. Semiology may have also its impact, as the presence of prominent motor symptoms showed also a faster response.
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Affiliation(s)
- Arnau Llauradó
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Alejandro Ballvé
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Daniel Campos
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Elena Fonseca
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Laura Abraira
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Manuel Toledo
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Estevo Santamarina
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain.
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86
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Weant KA, Barré SL, Bruner S, Smiley R, Hall GA. Assessment of benzodiazepine dosing strategies for the management of status epilepticus in the emergency department. Am J Emerg Med 2021; 44:106-111. [PMID: 33588249 DOI: 10.1016/j.ajem.2021.01.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/27/2021] [Accepted: 01/31/2021] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Although guidelines recommend specific benzodiazepine doses for the treatment of generalized convulsive status epilepticus (GCSE), underdosing appears to be common. The purpose of this investigation was to assess benzodiazepine dosing strategies for the initial management of GCSE in patients presenting to the Emergency Department (ED). METHODS This was a retrospective review of adult patients who received benzodiazepines in the ED for treatment of GCSE. Characteristics of those achieving seizure cessation following initial benzodiazepine therapy were assessed. RESULTS 222 patients presented to the ED and received 403 doses of benzodiazepines, of which 1.5% conformed with recommendations. First-line therapy was successful in 86.8% of patients with an average dose of 1.6 mg (0.02 mg/kg). No difference in dosing was noted between those experiencing early cessation and those that did not (p = 0.132). Patients experiencing early cessation were significantly less likely to receive further doses, be intubated, or be admitted to the intensive care unit (ICU) or hospital (p < 0.05 for all comparisons). Those that received early antiepileptic drug therapy were significantly less likely to receive additional benzodiazepine doses, be intubated, or be admitted to the ICU or hospital (p < 0.05 for all comparisons). CONCLUSIONS According to guideline recommendations, there was consistent underdosing of benzodiazepines noted in both prehospital and ED settings. Early seizure cessation and the early receipt of an antiepileptic drug were found to be associated with multiple significant clinical outcomes. Future investigations should explore optimal dosing strategies for benzodiazepines as well as the impact of early antiepileptic drug administration.
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Affiliation(s)
- Kyle A Weant
- Department of Clinical Pharmacy and Outcome Sciences, College of Pharmacy, University of South Carolina, Columbia, SC, United States of America.
| | - Stephanie L Barré
- Department of Pharmacy, Louisiana State University Health, Shreveport, LA, United States of America
| | - Sara Bruner
- Medical University of South Carolina, College of Pharmacy, Charleston, SC, United States of America
| | - Ryan Smiley
- Medical University of South Carolina, College of Pharmacy, Charleston, SC, United States of America
| | - Gregory A Hall
- Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC, United States of America
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87
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Abstract
PURPOSE OF REVIEW Randomized controlled trials investigating the initial pharmacological treatment of status epilepticus have been recently published. Furthermore, status epilepticus arising in comatose survivors after cardiac arrest has received increasing attention in the last years. This review offers an updated assessment of status epilepticus treatment in these different scenarios. RECENT FINDINGS Initial benzodiazepines underdosing is common and correlates with development of status epilepticus refractoriness. The recently published ESETT trial provides high-level evidence regarding the equivalence of fosphenytoin, valproate, and levetiracetam as a second-line option. Myoclonus or epileptiform transients on electroencephalography occur in up to 1/3 of patients surviving a cardiac arrest. Contrary to previous assumptions regarding an almost invariable association with death, at least 1/10 of them may awaken with reasonably good prognosis, if treated. Multimodal prognostication including clinical examination, EEG, somatosensory evoked potentials, biochemical markers, and neuroimaging help identifying patients with a chance to recover consciousness, in whom a trial with antimyoclonic compounds and at times general anesthetics is indicated. SUMMARY There is a continuous, albeit relatively slow progress in knowledge regarding different aspect of status epilepticus; recent findings refine some treatment strategies and help improving patients' outcomes. Further high-quality studies are clearly needed to further improve the management of these patients, especially those with severe, refractory status epilepticus forms.
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88
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Byun JI, Kim DW, Kim KT, Yang KI, Lee ST, Seo JG, No YJ, Kang KW, Kim D, Cho YW, Kim JM. Treatments for Convulsive and Nonconvulsive Status Epilepticus in Adults: An Expert Opinion Survey in South Korea. J Clin Neurol 2021; 17:20-25. [PMID: 33480194 PMCID: PMC7840316 DOI: 10.3988/jcn.2021.17.1.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND PURPOSE The aim of this study was to survey the expert opinions on treatments for convulsive status epilepticus (CSE) and nonconvulsive status epilepticus (NCSE) in adults. METHODS Forty-two South Korean epileptologists participated in this survey. They completed an online questionnaire regarding various patient scenarios and evaluated the appropriateness of medications used to treat CSE and NCSE. RESULTS Initial treatment with a benzodiazepine (BZD) followed by either a second BZD or an antiepileptic drug (AED) monotherapy was the preferred treatment strategy. More than two-thirds of the experts used a second BZD when the first one failed, and consensus was reached for 84.8% of the survey items. The preferred BZD was intravenous (IV) lorazepam for the initial treatment of status epilepticus. IV fosphenytoin and IV levetiracetam were chosen for AED monotherapy after the failure of BZD. The treatments for NCSE were similar to those for CSE. Continuous IV midazolam infusion was the treatment of choice for iatrogenic coma in refractory CSE, but other AEDs were preferred over iatrogenic coma in refractory NCSE. CONCLUSIONS The results of this survey are consistent with previous guidelines, and can be cautiously applied in clinical practice when treating patients with CSE or NCSE.
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Affiliation(s)
- Jung Ick Byun
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Kyung Hee University, School of Medicine, Seoul, Korea
| | - Dong Wook Kim
- Department of Neuroloy, Konkuk University School of Medicine, Seoul, Korea
| | - Keun Tae Kim
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - Kwang Ik Yang
- Department of Neurology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Soon Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jong Geun Seo
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Young Joo No
- Department of Neurology, Samsung Noble County, Yongin, Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Daeyoung Kim
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea
| | - Yong Won Cho
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea.
| | - Jae Moon Kim
- Department of Neurology, Chungnam National University Hospital, Daejeon, Korea.
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89
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Gömceli Y, Altındağ E, Baykan B. Different attitudes in the management of different types of status epilepticus: A survey study among neurologists demonstrating evidence gap. NEUROL SCI NEUROPHYS 2021. [DOI: 10.4103/nsn.nsn_70_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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90
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Kim D, Kim JM, Cho YW, Yang KI, Kim DW, Lee ST, No YJ, Seo JG, Byun JI, Kang KW, Kim KT. Antiepileptic Drug Therapy for Status Epilepticus. J Clin Neurol 2021; 17:11-19. [PMID: 33480193 PMCID: PMC7840311 DOI: 10.3988/jcn.2021.17.1.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 12/31/2022] Open
Abstract
Status epilepticus (SE) is one of the most serious neurologic emergencies. SE is a condition that encompasses a broad range of semiologic subtypes and heterogeneous etiologies. The treatment of SE primarily involves the management of the underlying etiology and the use of antiepileptic drug therapy to rapidly terminate seizure activities. The Drug Committee of the Korean Epilepsy Society performed a review of existing guidelines and literature with the aim of providing practical recommendations for antiepileptic drug therapy. This article is one of a series of review articles by the Drug Committee and it summarizes staged antiepileptic drug therapy for SE. While evidence of good quality supports the use of benzodiazepines as the first-line treatment of SE, such evidence informing the administration of second- or third-line treatments is lacking; hence, the recommendations presented herein concerning the treatment of established and refractory SE are based on case series and expert opinions. The choice of antiepileptic drugs in each stage should consider the characteristics and circumstances of each patient, as well as their estimated benefit and risk to them. In tandem with the antiepileptic drug therapy, careful searching for and treatment of the underlying etiology are required.
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Affiliation(s)
- Daeyoung Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae Moon Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea.
| | - Yong Won Cho
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea.
| | - Kwang Ik Yang
- Department of Neurology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Dong Wook Kim
- Department of Neurology, Konkuk University School of Medicine, Seoul, Korea
| | - Soon Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Young Joo No
- Department of Neurology, Samsung Noble County, Yongin, Korea
| | - Jong Geun Seo
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jung Ick Byun
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Keun Tae Kim
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
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91
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Tarulli A. Seizures and Epilepsy. Neurology 2021. [DOI: 10.1007/978-3-030-55598-6_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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92
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Vafaee-Shahi M, Soltanieh E, Saidi H, Riahi A. Etiology, Risk Factors, Mortality and Morbidity of Status Epilepticus in Children: A Retrospective Cross-Sectional Study in Tehran, Iran. Open Neurol J 2020. [DOI: 10.2174/1874205x02014010095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:Risk factors identification associated with status epilepticus is valuable in order to prevent morbidity and mortality in children. This study aimed to consider the etiology, risk factors, morbidity and mortality in children with status epilepticus.Methods:This retrospective cross-sectional study was performed on 119 patients aged from one month old to 15 years old. Patients’ data were recorded, including basic demographic, etiology and clinical information. The different risk factors correlated to morbidity and mortality were evaluated in this study.Results:The most common etiologies were acute symptomatic and febrile status epilepticus by 32.8% and 22.7%, respectively. Abnormal brain imaging results were reported far more frequently in patients with a history of neurodevelopmental delay and previous status epilepticus (p<0.001). The overall morbidity and mortality rates were 18.9% and 10.9%, respectively; while these rates in patients with delayed development (45.16% and 18.42%, respectively) were significantly higher than patients with normal development (8% and 7.4%, respectively). The morbidity rates in patients with previous seizures and previous status epilepticus were remarkably higher than those without previous history of seizure (26.41% vs 11.32%; p=0.047) and without previous status epilepticus (36.36%versus14.28%; p=0.018). The length of hospital stay in patients with mortality was considerably longer than patients without mortality (12.30 ± 16.1 days vs 7.29 ± 6.24 days; p=0.033). The mortality rate in patients with normal Lumbar Puncture result was notably lower than those with abnormal LP result (2.9% vs 50%). The morbidity rate in patients with abnormal brain imaging results (p<0.001) was significantly greater than those in patients with normal results. The mortality rate was relatively higher in patients with abnormal imaging results compared to those normal results. Etiology was an important predictor of mortality and morbidity rates; acute symptomatic (32.8%), febrile status epilepticus (22.7%) and remote symptomatic (16.8%) etiologies were the most common underlying causes of S.E. While in children less than 3 years old, the acute symptomatic etiology and febrile status epilepticus etiologies were estimated as the most common, in most patients older than 3 years old the most common etiology of status epilepticus was unknown. Congenital brain defects etiology had the highest mortality (36.36%) and morbidity (42.85%) rate. The lowest morbidity (3.84%) and mortality (0%) rates were for patients with febrile status epilepticus etiology.Conclusion:Age, developmental delay, history of previous status epilepticus, the length of hospital stay, abnormal brain imaging results and the underlying etiology of status epilepticus were associated with increased morbidity and mortality among children with status epilepticus.
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93
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Wieruszewski ED, Brown CS, Leung JG, Wieruszewski PM. Pharmacologic Management of Status Epilepticus. AACN Adv Crit Care 2020; 31:349-356. [PMID: 33313702 DOI: 10.4037/aacnacc2020907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Erin D Wieruszewski
- Erin D. Wieruszewski is Clinical Pharmacy Specialist, Emergency Medicine and Neurocritical Care, Mayo Clinic, Department of Pharmacy, 1216 2nd Street SW, Rochester, MN 55902
| | - Caitlin S Brown
- Caitlin S. Brown is Clinical Pharmacy Specialist, Emergency Medicine and Neurocritical Care, Mayo Clinic, Department of Pharmacy, Rochester, Minnesota
| | - Jonathan G Leung
- Jonathan G. Leung is Clinical Pharmacy Specialist, Psychiatry, Mayo Clinic, Department of Pharmacy, Rochester, Minnesota
| | - Patrick M Wieruszewski
- Patrick M. Wieruszewski is Clinical Pharmacy Specialist, Cardiothoracic Surgery and Anesthesia Critical Care, Mayo Clinic, Department of Pharmacy, Rochester, Minnesota
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94
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Treatment of established status epilepticus in the elderly - a study protocol for a prospective multicenter double-blind comparative effectiveness trial (ToSEE). BMC Neurol 2020; 20:438. [PMID: 33272223 PMCID: PMC7713039 DOI: 10.1186/s12883-020-02001-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Status epilepticus (SE) is a common neurological emergency condition that especially affects the elderly and old population. Older people with SE frequently have non-convulsive SE (NCSE) and are also at special risk of suffering a poor outcome. The application of benzodiazepines fails to control SE in about one third of the cases. For benzodiazepine refractory SE (BRSE) in elderly, there is little evidence that would justify the choice of one of the commonly used antiepileptic drugs. The present study aims to generate evidence for the treatment of BRSE in this age group. METHODS We will conduct a prospective, randomized, double-blind comparative effectiveness study in more than twenty hospitals in Germany over a four-year period. Four hundred and seventy-seven elderly patients (≥ 65 years old) diagnosed with BRSE will be allocated by 1:1 randomization to receive either levetiracetam or valproate. All types of SE will be considered. For the diagnosis NCSE a verification by EEG is required. Levetiracetam or valproate will be administered in one single infusion. The primary endpoint is the stable cessation of ictal activity 15 min after the start of infusion persisting for the following 45 min of observation. EEG recording is maintained over the whole observation period, clinical examinations are conducted in predefined intervals. In case of treatment success patients and study staff remain blinded until 60 min after the start of the infusion. Adverse events will be recorded until the end of the study. EEG data will be reviewed by two external independent experts. To obtain data about the further treatment of SE, intrahospital complications and the functional outcome in the short term the study participants will be observed until the day of discharge or day 30 whichever is earliest. DISCUSSION ToSEE is the first study which shall deliver evidence for the SE-therapy in the elderly and old population in a controlled prospective comparator study. By design it also shall collect information about therapy regimes and outcome aspects of this disease. TRIAL REGISTRATION The trial has been registered at the German Clinical Trials Register on 3 July, 2020 ( DRKS00022308 , https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00022308 ).
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Levetiracetam versus Phenytoin for the Pharmacotherapy of Benzodiazepine-Refractory Status Epilepticus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. CNS Drugs 2020; 34:1205-1215. [PMID: 33111213 DOI: 10.1007/s40263-020-00770-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Recent studies have shown conflicting results regarding the effectiveness of levetiracetam for treating benzodiazepine-refractory status epilepticus (SE) compared with phenytoin. Therefore, a meta-analysis was carried out to assess the value of levetiracetam versus phenytoin in the pharmacotherapy of benzodiazepine-refractory SE. OBJECTIVE The aim of this systematic review and meta-analysis was to compare the efficacy and safety of levetiracetam and phenytoin in the treatment of benzodiazepine-refractory SE. METHODS The MEDLINE, EMBASE, CENTRAL and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs) that had been conducted to evaluate levetiracetam versus phenytoin for benzodiazepine-refractory SE, to April 2020. The data were assessed using Review Manager 5.3 software. The risk ratio (RR) was analyzed using dichotomous outcomes, and calculated using a random-effect model. RESULTS We pooled 1850 patients from 12 RCTs. Patients in the levetiracetam group had a significantly higher rate of clinical seizure cessation than in the phenytoin group (75.2% vs. 67.8%; RR 1.14, 95% confidence interval [CI] 1.05-1.25, p = 0.003). Moreover, less adverse events were observed in the levetiracetam group than in the phenytoin group (17.8% vs. 21.4%; RR 0.82, 95% CI 0.70-0.97, p = 0.02). In subgroup analysis, clinical seizure cessation was achieved more frequently with a higher dose of levetiracetam (> 30 mg/kg) [RR 1.15, 95% CI 1.00-1.32, p = 0.05]. Furthermore, in the subgroup of children, levetiracetam showed a higher rate of clinical seizure cessation than phenytoin (RR 1.13, 95% CI 1.02-1.25, p = 0.02). CONCLUSION Pharmacotherapy for BZD-refractory SE by LEV is superior to PHT in efficacy and safety outcomes.
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96
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Meziane-Tani A, Foreman B, Mizrahi MA. Status Epilepticus: Work-Up and Management in Adults. Semin Neurol 2020; 40:652-660. [PMID: 33176372 DOI: 10.1055/s-0040-1719112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Status epilepticus is one of the most common neurological emergencies and is likely to have increasing prevalence in coming years given an aging "baby boomer" population in the United States. Because status epilepticus is associated with significant morbidity and mortality, identification and treatment are paramount. Care should be taken to exclude nonorganic mimics and infectious and metabolic causes. Status epilepticus can be classified into stages with associated recommendations for escalation in therapy, increasing from push-dose benzodiazepines to continuous anesthetic infusions and other nontraditional therapies. Concurrent electroencephalogram monitoring helps to identify, localize, and assess resolution of ictal patterns alongside antiseizure drug administration. A protocol is proposed for the management of status epilepticus in a step-wise fashion.
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Affiliation(s)
- Assia Meziane-Tani
- Division of Neurocritical Care, Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Moshe A Mizrahi
- Division of Neurocritical Care, Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
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97
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Rubinos C, Alkhachroum A, Der-Nigoghossian C, Claassen J. Electroencephalogram Monitoring in Critical Care. Semin Neurol 2020; 40:675-680. [PMID: 33176375 DOI: 10.1055/s-0040-1719073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Seizures are common in critically ill patients. Electroencephalogram (EEG) is a tool that enables clinicians to provide continuous brain monitoring and to guide treatment decisions-brain telemetry. EEG monitoring has particular utility in the intensive care unit as most seizures in this setting are nonconvulsive. Despite the increased use of EEG monitoring in the critical care unit, it remains underutilized. In this review, we summarize the utility of EEG and different EEG modalities to monitor patients in the critical care setting.
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Affiliation(s)
- Clio Rubinos
- Division of Critical Care Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ayham Alkhachroum
- Department of Neurology, Miller School of Medicine, Jackson Memorial Health System, University of Miami, Miami, Florida
| | - Caroline Der-Nigoghossian
- Neurosciences Intensive Care Unit, Department of Pharmacy, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Jan Claassen
- Department of Neurology, Columbia University, New York
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98
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Der-Nigoghossian C, Tesoro EP, Strein M, Brophy GM. Principles of Pharmacotherapy of Seizures and Status Epilepticus. Semin Neurol 2020; 40:681-695. [PMID: 33176370 DOI: 10.1055/s-0040-1718721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Status epilepticus is a neurological emergency with an outcome that is highly associated with the initial pharmacotherapy management that must be administered in a timely fashion. Beyond first-line therapy of status epilepticus, treatment is not guided by robust evidence. Optimal pharmacotherapy selection for individual patients is essential in the management of seizures and status epilepticus with careful evaluation of pharmacokinetic and pharmacodynamic factors. With the addition of newer antiseizure agents to the market, understanding their role in the management of status epilepticus is critical. Etiology-guided therapy should be considered in certain patients with drug-induced seizures, alcohol withdrawal, or autoimmune encephalitis. Some patient populations warrant special consideration, such as pediatric, pregnant, elderly, and the critically ill. Seizure prophylaxis is indicated in select patients with acute neurological injury and should be limited to the acute postinjury period.
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Affiliation(s)
- Caroline Der-Nigoghossian
- Department of Pharmacy, Neurosciences Intensive Care Unit, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Eljim P Tesoro
- Department of Pharmacy Practice (MC 886), College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Micheal Strein
- Pharmacotherapy and Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia
| | - Gretchen M Brophy
- Pharmacotherapy and Outcomes Science and Neurosurgery, Medical College of Virginia Campus, Virginia Commonwealth University, Richmond, Virginia
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99
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Barcia Aguilar C, Sánchez Fernández I, Loddenkemper T. Status Epilepticus-Work-Up and Management in Children. Semin Neurol 2020; 40:661-674. [PMID: 33155182 DOI: 10.1055/s-0040-1719076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Status epilepticus (SE) is one of the most common neurological emergencies in children and has a mortality of 2 to 4%. Admissions for SE are very resource-consuming, especially in refractory and super-refractory SE. An increasing understanding of the pathophysiology of SE leaves room for improving SE treatment protocols, including medication choice and timing. Selecting the most efficacious medications and giving them in a timely manner may improve outcomes. Benzodiazepines are commonly used as first line and they can be used in the prehospital setting, where most SE episodes begin. The diagnostic work-up should start simultaneously to initial treatment, or as soon as possible, to detect potentially treatable causes of SE. Although most etiologies are recognized after the first evaluation, the detection of more unusual causes may become challenging in selected cases. SE is a life-threatening medical emergency in which prompt and efficacious treatment may improve outcomes. We provide a summary of existing evidence to guide clinical decisions regarding the work-up and treatment of SE in pediatric patients.
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Affiliation(s)
- Cristina Barcia Aguilar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Child Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Child Neurology, Hospital Sant Joan de Déu, University of Barcelona, Spain
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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100
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Moosavi R, Swisher CB. Acute Provoked Seizures-Work-Up and Management in Adults. Semin Neurol 2020; 40:595-605. [PMID: 33155185 DOI: 10.1055/s-0040-1719075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Acute provoked seizures, also known as acute symptomatic seizures, occur secondary to a neurological or systemic precipitant, commonly presenting as a first-time seizure. In this article, we will discuss etiology, emergent protocols, medical work-up, initial treatment, and management of these seizures. The definitions, classifications, and management of convulsive status epilepticus and nonconvulsive status epilepticus in an acute setting will also be reviewed.
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Affiliation(s)
- Rana Moosavi
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Christa B Swisher
- Department of Neurology, Duke University Medical Center, Durham, North Carolina
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