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Ong MJY, Lee VLL, Teo SL, Tan HJ, Trinka E, Khoo CS. Electroconvulsive Therapy in Refractory and Super-Refractory Status Epilepticus in Adults: A Scoping Review. Neurocrit Care 2024:10.1007/s12028-024-02003-4. [PMID: 38769254 DOI: 10.1007/s12028-024-02003-4] [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: 12/11/2023] [Accepted: 04/24/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) has been suggested as a treatment option for refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE). OBJECTIVE The objective of this scoping review was to conduct an extensive literature review on the role of ECT as a treatment option for RSE and SRSE. METHODS We searched Ovid MEDLINE and Scopus for journal articles from database inception until February 2024. Articles were then selected based on predetermined inclusion and exclusion criteria. RESULTS We identified five retrospective case series with 28 adult patients receiving ECT for RSE or SRSE. ECT was administered within 3-70 days (mean 20 days) after the development of SE, and the mean number of ECT courses ranged from 1 to 12 sessions for each patient. ECT was administered in fixed or titrated doses. A total of 20 out of 28 patients (71%) showed clinical improvement, with two (7%) having complete cessation of seizures. It is essential to note that given the lack of control, there could be overreporting of clinical improvement in these studies. 11 patients (39%) were reported as deceased due to causes that were not directly related to ECT treatment. Four patients (14%) reported adverse effects of ECT, including memory, concentration, and/or cognitive impairment. CONCLUSIONS There are level-4 Oxford Centre for Evidence-Based Medicine evidence and low-level Grading of Recommendations Assessment Development and Education evidence that suggest ECT as a treatment option for RSE and SRSE. In light of the limitations of the existing evidence, clinicians should carefully consider individual patients' clinical contexts when deciding on the appropriateness of ECT as a treatment option. Further research, including prospective studies with controlled designs, is needed to elucidate the efficacy, safety, and optimal regime of ECT in the management of RSE and SRSE.
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Affiliation(s)
- Marjorie Jia Yi Ong
- Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Neurology Unit, Department of Medicine, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia
| | - Vanessa Lin Lin Lee
- Neuropharmacology Research Laboratory, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Selangor, Malaysia
| | - Sze Lynn Teo
- Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Neurology Unit, Department of Medicine, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia
| | - Hui Jan Tan
- Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
- Neurology Unit, Department of Medicine, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia
| | - Eugen Trinka
- Department of Neurology, Neurocritical Care, and Neurorehabilitation, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Member of EpiCARE, Salzburg, Austria
- Neuroscience Institute, Christian-Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Salzburg, Austria
- Institute of Public Health, Medical Decision-Making and HTA, UMIT - Private University for Health Sciences, Medical Informatics and Technology, Hall in Tyrol, Austria
| | - Ching Soong Khoo
- Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
- Neurology Unit, Department of Medicine, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia.
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Singla L, Shah M, Moore-Hill D, Rosenquist P, Alfredo Garcia K. Electroconvulsive therapy for super refractory status epilepticus in pregnancy: case report and review of literature. Int J Neurosci 2023; 133:1109-1119. [PMID: 35287528 DOI: 10.1080/00207454.2022.2050371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We aim to describe use of electroconvulsive therapy (ECT) to treat super refractory status epilepticus (SRSE) in pregnancy and review the literature regarding utility and safety of ECT in refractory status epilepticus. BACKGROUND Status epilepticus (SE) is a commonly encountered emergency in neuro-critical care world. Pharmacotherapy of status epilepticus in pregnancy is very challenging given the effect of the majority of antiepileptic drugs (AEDs) on fetal development. Although there has been growing evidence for use of ECT in status epilepticus, data about its utility in pregnancy is lacking. DESIGN/METHOD A twenty-one year old Caucasian female with history of epilepsy presented at 8 weeks of gestation as status epilepticus (SE) after abrupt discontinuation of her AEDs. Treatment was initiated with standard regimen of benzodiazepine and levetiracetam, which was progressively expanded to include approximately 10 anti-epileptic drugs over the course of 30 days. The status epilepticus was super refractory to sedation. She underwent ECT on day 31 with remarkable improvement in electroencephalogram (EEG) pattern and resolution of status epilepticus following a single ECT session. We reviewed PubMed and collated case reports involving the use of ECT in status epilepticus with emphasis on differences in various confounding factors esp. etiology of status and age group. CONCLUSION Our case is the first reported case of ECT for successful treatment of SRSE in pregnancy. While majority AEDs pose a significant maternal and fetal risk during pregnancy, ECT could be a potential frontline therapy for SE in pregnancy.
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Affiliation(s)
- Laveena Singla
- Department of Neurology, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Manan Shah
- Department of Neurology, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Debra Moore-Hill
- Department of Neurology, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Peter Rosenquist
- Department of Psychiatry, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Klepper Alfredo Garcia
- Department of Neurology, Medical College of Georgia at Augusta University, Augusta, GA, USA
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Stavropoulos I, Khaw JH, Valentin A. Neuromodulation in new-onset refractory status epilepticus. Front Neurol 2023; 14:1195844. [PMID: 37388544 PMCID: PMC10301751 DOI: 10.3389/fneur.2023.1195844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/17/2023] [Indexed: 07/01/2023] Open
Abstract
Background New-onset refractory status epilepticus (NORSE) and its subset of febrile infection-related epilepsy syndrome (FIRES) are devastating clinical presentations with high rates of mortality and morbidity. The recently published consensus on the treatment of these conditions includes anesthetics, antiseizure drugs, antivirals, antibiotics, and immune therapies. Despite the internationally accepted treatment, the outcome remains poor for a significant percentage of patients. Methods We conducted a systematic review of the use of neuromodulation techniques in the treatment of the acute phase of NORSE/FIRES using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results Our search strategy brought up 74 articles of which 15 met our inclusion criteria. A total of 20 patients were treated with neuromodulation. Thirteen cases represented FIRES and in 17 cases the NORSE remained cryptogenic. Ten had electroconvulsive therapy (ECT), seven had vagal nerve stimulation (VNS), and four had deep brain stimulation (DBS); one patient had initially VNS and later DBS. Eight patients were female and nine were children. In 17 out of 20 patients, the status epilepticus was resolved after neuromodulation, while three patients died. Conclusion NORSE can have a catastrophic course and the first treatment goal should be the fastest possible termination of status epilepticus. The data presented are limited by the small number of published cases and the variability of neuromodulation protocols used. However, they show some potential clinical benefits of early neuromodulation therapy, suggesting that these techniques could be considered within the course of FIRES/NORSE.
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Affiliation(s)
- Ioannis Stavropoulos
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
| | - Jin Han Khaw
- Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Antonio Valentin
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
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Mehra B, Sabharwal R, Sachdev A, Kumar P, Mehta R, Gupta N. Successful Use of Inhalational Anesthesia and Electroconvulsive Therapy in a Child with New Onset Prolonged Super-Refractory Status Epilepticus. JOURNAL OF PEDIATRIC EPILEPSY 2021. [DOI: 10.1055/s-0041-1740112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AbstractThe treatment of super-refractory status epilepticus (SRSE) and prolonged SRSE rests on urgent seizure control to minimize excitotoxic cerebral damage, other forms of neurologic damage, and multiple medical complications. To date no randomized controlled trials or clear-cut guidelines are available for the management of SRSE. We reported the case of a 10-year-old previously healthy male child patient who presented with a febrile illness and new onset prolonged SRSE that became refractory to multiple antiseizure medications (ASMs). Coma induction with anesthetic agents, 14 ASMs, ketogenic diet, immunotherapy failed to completely control the SRSE in our patient. On day 22, clinical and electroencephalographic seizure control was achieved with isoflurane inhalation anesthesia, which was continued for 3 weeks but was unable to be weaned. From day 57 onwards, electroconvulsive therapy was administered (total 14 sessions that resulted in complete control of seizures). He was discharged on the 80th day.
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Affiliation(s)
- Bharat Mehra
- Pediatric Intensive Care Unit, Institute of Child Health, Sir Ganga Ram Hospital, Delhi, India
| | - Ramakant Sabharwal
- Division of Pediatric Neurology, Institute of Child Health, Sir Ganga Ram Hospital, Delhi, India
| | - Anil Sachdev
- Pediatric Intensive Care Unit, Institute of Child Health, Sir Ganga Ram Hospital, Delhi, India
| | - Praveen Kumar
- Division of Pediatric Neurology, Institute of Child Health, Sir Ganga Ram Hospital, Delhi, India
| | - Rajiv Mehta
- Institute of Psychiatry and Behavioural Sciences, Sir Ganga Ram Hospital, Delhi, India
| | - Neeraj Gupta
- Pediatric Intensive Care Unit, Institute of Child Health, Sir Ganga Ram Hospital, Delhi, India
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Stavropoulos I, Pak HL, Valentin A. Neuromodulation in Super-refractory Status Epilepticus. J Clin Neurophysiol 2021; 38:494-502. [PMID: 34261110 DOI: 10.1097/wnp.0000000000000710] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SUMMARY Status epilepticus (SE) is a severe condition that needs immediate pharmacological treatment to tackle brain damage and related side effects. In approximately 20% of cases, the standard treatment for SE does not control seizures, and the condition evolves to refractory SE. If refractory status epilepticus lasts more than 24 hours despite the use of anesthetic treatment, the condition is redefined as super-refractory SE (srSE). sRSE is a destructive condition, potentially to cause severe brain damage. In this review, we discuss the clinical neuromodulation techniques for controlling srSE when conventional treatments have failed: electroconvulsive therapy, vagus nerve stimulation, transcranial magnetic stimulation, and deep brain stimulation. Data show that neuromodulation therapies can abort srSE in >80% of patients. However, no randomized, prospective, and controlled trials have been completed, and data are provided only by retrospective small case series and case reports with obvious inclination to publication bias. There is a need for further investigation into the use of neuromodulation techniques as an early treatment of srSE and to address whether an earlier intervention can prevent long-term complications.
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Affiliation(s)
- Ioannis Stavropoulos
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; and
| | - Ho Lim Pak
- Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Antonio Valentin
- Department of Clinical Neurophysiology, King's College Hospital, London, United Kingdom
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; and
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Status Epilepticus in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Schneegans H, Stetefeld H, Dohmen C, Onur OA, Lehnhardt FG. Successful Treatment of Super-Refractory Status Epilepticus with High-Intensity Electroconvulsive Therapy - A Case Report and Review of the Current Literature. J Epilepsy Res 2019; 9:76-82. [PMID: 31482059 PMCID: PMC6706647 DOI: 10.14581/jer.19008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 12/01/2018] [Accepted: 03/20/2019] [Indexed: 01/19/2023] Open
Abstract
Status epilepticus (SE) is a severe neurological condition in which epileptic activity is prolonged or recurring, and the likelihood of spontaneous seizure cessation decreases over time. Evidence on the appropriate treatment regimen in therapy-refractory cases is still sparse. Electroconvulsive therapy (ECT) is known as a last resort treatment for SE due its anticonvulsant properties mediated by an increase in seizure threshold during the course of a treatment series. We examined the effects of ECT in a 61-year-old male patient with new-onset super-refractory SE (SRSE), for whom previous extensive efforts to achieve seizure control had failed. To achieve reliable seizure inductions in ECT concomitantly with an extended anticonvulsant treatment, we established a high-intensity ECT protocol: bitemporal ECT was conducted at a double-dosage setting (200% stimulation energy; equivalent to a mean charge of 1,031 mC) including three seizure stimulations during each treatment session on consecutive days until SRSE termination. After the first course of ECT, temporary seizure cessation was reached but lasted for only several days. A second course of ECT was then initiated, using the identical regimen but followed by tapering sessions every other day. Again, the SRSE terminated and after regaining consciousness the patient could be transferred to an acute rehabilitation facility. SRSE cessation can successfully be achieved by means of high-intensity ECT even after six weeks of prolonged SE and exhausted anticonvulsant pharmacotherapeutic strategies. As controlled clinical trials in the area of SRSE are still lacking, the relative significance of a high-intensity ECT protocol in this clinical setting has yet to be determined.
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Affiliation(s)
- Hanna Schneegans
- Department of Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany
| | | | - Christian Dohmen
- Department of Neurology, University of Cologne, Cologne, Germany
| | - Oezguer A Onur
- Department of Neurology, University of Cologne, Cologne, Germany
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San-Juan D, Dávila-Rodríguez DO, Jiménez CR, González MS, Carranza SM, Hernández Mendoza JR, Anschel DJ. Neuromodulation techniques for status epilepticus: A review. Brain Stimul 2019; 12:835-844. [PMID: 31053521 DOI: 10.1016/j.brs.2019.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 04/05/2019] [Accepted: 04/14/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Electroconvulsive therapy (ECT), Vagal Nerve Stimulation (VNS), Transcranial Magnetic Stimulation (TMS) and Deep Brain Stimulation (DBS) are neuromodulation therapies that have been used to treat Status Epilepticus (SE). OBJECTIVE Review the literature about the efficacy and safety of neuromodulation therapies in SE in humans. METHODS We searched studies in PubMed, Scopus, Google Scholar and Science Direct (inception to June 2018). Four review authors independently selected the studies, extracted data and assessed the methodological quality of the studies using the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, PRISMA guidelines, Oxford and GRADE scales, and Murad et al., 2018 methodological quality and synthesis of case series and case reports. RESULTS We analyzed 27 articles (45 patients) with 4 different neuromodulation therapies. In ECT we found 80% rate of disruption of SE and 5% of adverse events was reported. Using iVNS 15/16 (93.7%) patients resolved the SE. All patients who underwent TMS and DBS aborted SE, however, 50% of patients with DBS had severe adverse events. CONCLUSIONS Case series and case reports suggest that neuromodulation therapies can abort SE in 80-100% of patients (Oxford scale and GRADE were level 4 and D) with a wide range of adverse effects, which claims for prospective studies on the relationship be-tween efficacy and safety.
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Affiliation(s)
- Daniel San-Juan
- Neurophysiology Department, National Institute of Neurology and Neurosurgery Manuel Velasco Suárez, Mexico City, Mexico.
| | | | - Christian Ramos Jiménez
- Faculty of Medicine, Autonomous University of State of Mexico, Toluca de Lerdo, State of Mexico, Mexico
| | | | | | - Jesús Ricardo Hernández Mendoza
- Faculty of Medicine Mexicali, Autonomous University of Baja California, Dr. Humberto Torres Sangines, Mexicali, Baja California, Mexico
| | - David J Anschel
- Comprehensive Epilepsy Center of Long Island, Port Jefferson, NY, USA
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Schotte C, Cleeren E, Goffin K, Hunyadi B, Buggenhout S, Van Laere K, Van Paesschen W. Development of temporal lobe epilepsy during maintenance electroconvulsive therapy: A case of human kindling? Epilepsia Open 2019; 4:200-205. [PMID: 30868132 PMCID: PMC6398093 DOI: 10.1002/epi4.12294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 10/05/2018] [Accepted: 10/09/2018] [Indexed: 11/09/2022] Open
Abstract
We describe a patient with new-onset temporal lobe epilepsy during prolonged maintenance electroconvulsive therapy. We suggest a possible causal relationship with maintenance electroconvulsive therapy through electrical kindling of the temporal lobe.
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Affiliation(s)
| | - Evy Cleeren
- Department of NeurologyUniversity Hospitals LeuvenLeuvenBelgium
- Laboratory for Epilepsy ResearchKU LeuvenLeuvenBelgium
| | - Karolien Goffin
- Department of Nuclear MedicineUniversity Hospital LeuvenLeuvenBelgium
- Department of Imaging and PathologyNuclear Medicine and Molecular ImagingKU LeuvenLeuvenBelgium
| | - Borbala Hunyadi
- Faculty of EEMCSTU DelftDelftThe Netherlands
- Department of Electrical Engineering (ESAT)STADIUS Center for Dynamical Systems, Signal Processing and Data AnalyticsKU LeuvenLeuvenBelgium
| | - Satya Buggenhout
- Department of PsychiatryUniversity Psychiatric Centre KU LeuvenKortenbergBelgium
| | - Koen Van Laere
- Department of Nuclear MedicineUniversity Hospital LeuvenLeuvenBelgium
- Department of Imaging and PathologyNuclear Medicine and Molecular ImagingKU LeuvenLeuvenBelgium
| | - Wim Van Paesschen
- Department of NeurologyUniversity Hospitals LeuvenLeuvenBelgium
- Laboratory for Epilepsy ResearchKU LeuvenLeuvenBelgium
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Abstract
The appropriate use of medications during Emergency Neurological Life Support (ENLS) is essential to optimize patient care. Important considerations when choosing the appropriate agent include the patient's organ function and medication allergies, potential adverse drug effects, drug interactions and critical illness and aging pathophysiologic changes. Critical medications used during ENLS include hyperosmolar therapy, anticonvulsants, antithrombotics, anticoagulant reversal and hemostatic agents, anti-shivering agents, neuromuscular blockers, antihypertensive agents, sedatives, vasopressors and inotropes, and antimicrobials. This article focuses on the important pharmacokinetic and pharmacodynamics characteristics, advantages and disadvantages and clinical pearls of these therapies, providing practitioners with essential drug information to optimize pharmacotherapy in acutely ill neurocritical care patients.
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Affiliation(s)
- Gretchen M Brophy
- Departments of Pharmacotherapy and Outcomes Science and Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA.
| | - Theresa Human
- Department of Clinical Pharmacy, Barnes-Jewish Hospital, Washington University in St. Louis, St. Louis, MO, USA
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Abstract
OBJECTIVES Super refractory status epilepticus (SRSE) is a stage beyond refractory status that requires general anesthesia as management. Electroconvulsive therapy (ECT) is recommended only as a potential treatment option beyond general anesthesia and after all other options have been exhausted. Its effect on aborting status has been minimally researched. We present the largest case series to our knowledge exploring the effect of ECT on SRSE. METHODS Eight adults hospitalized for SRSE received ECT in an attempt to abort status after other treatment modalities were exhausted. Electroconvulsive therapy consisted of a 504-mC (≈99.4 J) stimulus delivered bifrontotemporally with a constant 0.5-millisecond pulse width. Seizure activity during ECT was monitored visually and correlated to the single-channel recording provided by the apparatus. RESULTS There was neurotelemetry or clinical evidence of improvement within 24 hours after the full course of ECT treatment in 5 (63%) of the 8 cases. Cases that improved were given an average of 7.8 total ECT stimulations, eliciting an average of 4.2 total seizures. CONCLUSIONS Although it is difficult to determine the exact role of ECT in the improvement of 63% of our cases, we present a series of patients for whom pharmacotherapy, ketogenic diet, and general anesthesia otherwise did not produce an appreciable effect on status prior to implementation of ECT. These findings suggest that cases of SRSE may benefit from ECT administration.
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Williams NR, Sahlem G, Pannu J, Takacs I, Short B, Revuelta G, George MS. Neuroversion: using electroconvulsive therapy as a bridge to deep brain stimulation implantation. Neurocase 2017; 23:26-30. [PMID: 28376692 DOI: 10.1080/13554794.2016.1276605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Parkinson's disease (PD) is a movement disorder with significant neuropsychiatric comorbidities. Electroconvulsive therapy (ECT) is effective in treating these neuropsychiatric symptoms; however, clinicians are reluctant to use ECT in patients with deep brain stimulation (DBS) implantations for fear of damaging the device, as well as potential cognitive side effects. Right unilateral ultra-brief pulse (RUL UBP) ECT has a more favorable cognitive side-effect profile yet has never been reported in PD patients with DBS implants. We present a case series of three patients with a history of PD that all presented with psychiatric decompensation immediately prior to planned DBS surgery. All three patients had DBS electrode(s) in place at the time and an acute course of ECT was utilized in a novel method to "bridge" these individuals to neurosurgery. The patients all experienced symptom resolution (psychosis and/or depression and/or anxiety) without apparent cognitive side effects. This case series not only illustrates that right unilateral ultra-brief pulse can be utilized in patients with DBS electrodes but also illustrates that this intervention can be utilized as a neuromodulatory "bridge", where nonoperative surgical candidates with unstable psychiatric symptoms can be converted to operative candidates in a manner similar to electrical cardioversion.
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Affiliation(s)
- Nolan R Williams
- a Department of Psychiatry , Stanford University , Stanford , CA , USA
| | - Greg Sahlem
- b Department of Psychiatry , Medical University of South Carolina , Charleston , SC , USA
| | - Jaspreet Pannu
- a Department of Psychiatry , Stanford University , Stanford , CA , USA
| | - Istvan Takacs
- d Department of Neurosurgery , Medical University of South Carolina , Charleston , SC , USA
| | - Baron Short
- b Department of Psychiatry , Medical University of South Carolina , Charleston , SC , USA
| | - Gonzalo Revuelta
- c Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
| | - Mark S George
- b Department of Psychiatry , Medical University of South Carolina , Charleston , SC , USA.,c Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
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Affiliation(s)
- Ali A Asadi-Pooya
- Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A.,Neurosciences Research Center, Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
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14
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Abstract
The appropriate use of medications during Emergency Neurological Life Support (ENLS) is essential to optimize patient care. Important considerations when choosing the appropriate agent include the patient's organ function and medication allergies, potential adverse drug effects, drug interactions, and critical illness and aging pathophysiologic changes. Critical medications used during ENLS include hyperosmolar therapy, anticonvulsants, antithrombotics, anticoagulant reversal and hemostatic agents, anti-shivering agents, neuromuscular blockers, antihypertensive agents, sedatives, vasopressors and inotropes, and antimicrobials. This article focuses on the important pharmacokinetic and pharmacodynamics characteristics, advantages and disadvantages, and clinical pearls of these therapies, providing practitioners with essential drug information to optimize pharmacotherapy in acutely ill neurocritical care patients.
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15
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Functional Hemispherectomy for Refractory Status Epilepticus in 2 Adults. World Neurosurg 2016; 93:489.e11-6. [PMID: 27377225 DOI: 10.1016/j.wneu.2016.06.086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 06/17/2016] [Accepted: 06/20/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Status epilepticus (SE) is a medical emergency, as deleterious long-term effects are well known. Medically induced burst suppression is often required if first-line and second-line treatments fail. Surgical intervention can be considered in some patients after prolonged treatment failure of medically induced coma. Multiple surgical options for terminating SE have been demonstrated in the literature, with only 2 reports including hemispherectomy in adults. CASE DESCRIPTION We present 2 cases of adults with refractory SE who failed more conservative medical/surgical treatment but responded to functional hemispherectomy. Pertinent electroencephalography and imaging findings are discussed. In addition, all previously published pediatric and adult cases are briefly reviewed. CONCLUSIONS Functional hemispherectomy can be considered in patients, including adults, with super-refractory SE and diffuse hemispheric onset. We report acceptable outcomes and quality of life in our 2 patients.
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Bayrlee A, Ganeshalingam N, Kurczewski L, Brophy GM. Treatment of Super-Refractory Status Epilepticus. Curr Neurol Neurosci Rep 2016; 15:66. [PMID: 26299274 DOI: 10.1007/s11910-015-0589-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Super-refractory status epilepticus (SRSE) is a devastating neurological condition with limited treatment options. We conducted an extensive literature search to identify and summarize the therapeutic options for SRSE. The search mainly resulted in case reports of various pharmacologic and non-pharmacologic treatments. The success rate of each of the following agents, ketamine, inhaled anesthetics, intravenous immunoglobulin G (IVIG), IV steroids, ketogenic diet, hypothermia, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and vagal nerve stimulation (VNS), are discussed in greater detail. The choice of appropriate treatment options for a given patient is based on clinical presentation. This review focuses on evidence-based, pharmacotherapeutic strategies for patients in SRSE.
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Affiliation(s)
- Ahmad Bayrlee
- Department of Neurology, Virginia Commonwealth University, P.O. Box 980599, Richmond, VA, 23298, USA,
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Electroconvulsive therapy for refractory status epilepticus: A systematic review. Seizure 2016; 35:23-32. [DOI: 10.1016/j.seizure.2015.12.015] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 12/25/2015] [Accepted: 12/28/2015] [Indexed: 11/19/2022] Open
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Lionel KR, Hrishi AP. Seizures - just the tip of the iceberg: Critical care management of super-refractory status epilepticus. Indian J Crit Care Med 2016; 20:587-592. [PMID: 27829714 PMCID: PMC5073773 DOI: 10.4103/0972-5229.192047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is defined as status epilepticus (SE) that continues or recurs 24 h or more after the onset of anesthetic therapy, including those cases where SE recurs on the reduction or withdrawal of anesthesia. Although SRSE is a rare clinical problem, it is associated with high mortality and morbidity rates. This article reviews the treatment approaches and the systemic complications commonly encountered in patients with SRSE. As evident in our search of literature, therapy for SRSE and its complications have been based on clinical reports and expert opinions since there is a lack of controlled and randomized trials. Even though this complex condition starts as a neurological disorder, because of the associated systemic complications, it can be considered as a multisystem disorder requiring scrupulous attention and deliberate efforts to prevent, detect, and treat these systemic effects. We have critically reviewed the intensive care management for SRSE per se as well as its associated systemic complications. We believe that a good recovery can occur even after prolonged and severe SRSE as long as the systemic complications are detected early and managed appropriately.
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Affiliation(s)
- Karen Ruby Lionel
- Department of Neuroanesthesia and Neurocritical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ajay Prasad Hrishi
- Department of Neuroanesthesia and Neurocritical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Weiner RD. Introduction to Convulsive Therapy. Brain Stimul 2015. [DOI: 10.1002/9781118568323.ch5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Wang X, Jin J, Chen R. Combination drug therapy for the treatment of status epilepticus. Expert Rev Neurother 2015; 15:639-54. [DOI: 10.1586/14737175.2015.1045881] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Yang X, Wang X. Potential mechanisms and clinical applications of mild hypothermia and electroconvulsive therapy on refractory status epilepticus. Expert Rev Neurother 2014; 15:135-44. [DOI: 10.1586/14737175.2015.992415] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Williams NR, Taylor JJ, Snipes JM, Short EB, Kantor EM, George MS. Interventional psychiatry: how should psychiatric educators incorporate neuromodulation into training? ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2014; 38:168-76. [PMID: 24554501 PMCID: PMC4021584 DOI: 10.1007/s40596-014-0050-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 11/04/2013] [Indexed: 05/02/2023]
Abstract
OBJECTIVE Interventional psychiatry is an emerging subspecialty that uses a variety of procedural neuromodulation techniques in the context of an electrocircuit-based view of mental dysfunction as proximal causes for psychiatric diseases. METHODS The authors propose the development of an interventional psychiatry-training paradigm analogous to those found in cardiology and neurology. RESULTS The proposed comprehensive training in interventional psychiatry would include didactics in the theory, proposed mechanisms, and delivery of invasive and noninvasive brain stimulation. CONCLUSIONS The development and refinement of this subspecialty would facilitate safe, effective growth in the field of brain stimulation by certified and credentialed practitioners within the field of psychiatry while also potentially improving the efficacy of current treatments.
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Shoirah H, Hamoda HM. Electroconvulsive therapy in children and adolescents. Expert Rev Neurother 2014; 11:127-37. [DOI: 10.1586/ern.10.178] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Huang L, van Luijtelaar G. The effects of responsive and scheduled subicular high frequency stimulation in the intra-hippocampal kainic acid seizure model. Epilepsy Res 2013; 106:326-37. [PMID: 23899954 DOI: 10.1016/j.eplepsyres.2013.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Revised: 05/22/2013] [Accepted: 06/25/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Responsive stimulation is a promising and newly emerging treatment for refractory temporal lobe epilepsy in which current is delivered to target areas following seizure occurrence. OBJECTIVE We compared responsive and scheduled subicular high frequency stimulation (HFS) with a sham control group on acute seizures and seizure sensitivity two weeks later. We also investigated the role of status epilepticus (SE) on efficacy of both types of stimulation. METHOD Adult Wistar rats received kainic acid (KA) injections intrahippocampally until they reached Stage V (Racine scale) on Day 1. Responsive, scheduled or sham HFS (125 Hz, 100 μs) was delivered in three groups while EEG was recorded. All rats received KA injections again on Day 15 to measure the excitability of animals to KA, again with EEG monitoring. RESULTS All rats reached Stage V and 60% reached SE on Day 1. Focal seizures were suppressed in both stimulated groups (the scheduled group was slightly more effective) on both days in only non-SE rats. Similar stimulation effects were found on generalized seizures but mainly on Day 15. CONCLUSION Both types of subicular HFS suppressed focal and generalized seizures, albeit differently. Scheduled stimulation seemed a bit more effective, and the amount of stimulation might be a factor that influences the differences between the stimulated groups. Beneficial effects of HFS were restricted to non-SE rats and HFS did not suppress or even worsen seizures in SE rats.
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Affiliation(s)
- L Huang
- Department of Biological Psychology, Donders Center for Cognition, Donders Institute for Brain Cognition and Behaviour, Radboud University Nijmegen, Nijmegen, The Netherlands.
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Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ, Shutter L, Sperling MR, Treiman DM, Vespa PM. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17:3-23. [PMID: 22528274 DOI: 10.1007/s12028-012-9695-z] [Citation(s) in RCA: 998] [Impact Index Per Article: 83.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Status epilepticus (SE) treatment strategies vary substantially from one institution to another due to the lack of data to support one treatment over another. To provide guidance for the acute treatment of SE in critically ill patients, the Neurocritical Care Society organized a writing committee to evaluate the literature and develop an evidence-based and expert consensus practice guideline. Literature searches were conducted using PubMed and studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using standardized assessment methods from the American Heart Association and Grading of Recommendations Assessment, Development, and Evaluation systems, as well as expert opinion when sufficient data were lacking.
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Affiliation(s)
- Gretchen M Brophy
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Medical College of Virginia Campus, 410 N. 12th Street, P.O. Box 980533, Richmond, VA 23298-0533, USA.
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Lambrecq V, Villéga F, Marchal C, Michel V, Guehl D, Rotge JY, Burbaud P. Refractory status epilepticus: Electroconvulsive therapy as a possible therapeutic strategy. Seizure 2012; 21:661-4. [DOI: 10.1016/j.seizure.2012.07.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2012] [Revised: 07/22/2012] [Accepted: 07/24/2012] [Indexed: 10/28/2022] Open
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Centromedian thalamic nuclei deep brain stimulation in refractory status epilepticus. Brain Stimul 2012; 5:594-8. [DOI: 10.1016/j.brs.2011.10.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 09/23/2011] [Accepted: 10/05/2011] [Indexed: 11/20/2022] Open
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Abstract
Status epilepticus is among the most dramatic of clinical presentations encountered by emergency room physicians, neurologists, neurosurgeons and intensivists. While progress in its management has been aided significantly with an increasing number of effective treatment options, improved diagnostic methods and more effective monitoring, poor outcomes and diagnostic failures are still frequently encountered. Refractory cases still carry significant morbidity and mortality rates, including poor cognitive outcomes. This review discusses basic pathophysiology and management of status epilepticus, neuroimaging findings, the role of continuous electroencephalogram monitoring and nonconvulsive status epilepticusas well as recent developments in treatment options for refractory cases.
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Abstract
PURPOSE OF REVIEW Refractory status epilepticus (RSE) has a high morbidity and mortality. There are currently no definitive data to guide both the optimal choice of therapy and treatment goals. This review focuses on RSE diagnosis and outcome and discusses both commonly used and anecdotal therapies for RSE. RECENT FINDINGS The challenges in performing randomized controlled trials (RCTs) in neurocritical care and more specifically for the treatment of RSE are illustrated by the early termination of the first RCT of RSE due to low recruitment that compared propofol to barbiturates. Recent case series include the successful treatment of recurrent RSE with ketamine, intravenous lacosamide as an add-on treatment, the use of combination antiepileptics (phenytoin, levetiracetam, and pregabalin), and surgical treatments (vagal nerve and deep brain stimulation) for the control of RSE. SUMMARY A number of different therapeutic options are available for the treatment of RSE but none have been shown to be superior to others at this point.
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Abstract
There is a long history of the use of brain stimulation in the treatment of epilepsy but relatively little experience for its use in status epilepticus. Electroconvulsive therapy, transcranial magnetic stimulation, subcortical and cortical stimulation have all been tried with varying degrees of success in single cases or small case series. It remains unclear, however, which brain areas should be stimulated and the parameters that should be used. Moreover, the aim (stopping status epilepticus) is different from preventing seizures and so the brain areas and parameters that are useful in epilepsy may not directly translate to the treatment of status epilepticus.
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Affiliation(s)
- Matthew C Walker
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, Queen Square, London, United Kingdom
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Rossetti AO, Lowenstein DH. Management of refractory status epilepticus in adults: still more questions than answers. Lancet Neurol 2011; 10:922-30. [PMID: 21939901 DOI: 10.1016/s1474-4422(11)70187-9] [Citation(s) in RCA: 217] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Refractory status epilepticus (RSE) is defined as status epilepticus that continues despite treatment with benzodiazepines and one antiepileptic drug. RSE should be treated promptly to prevent morbidity and mortality; however, scarce evidence is available to support the choice of specific treatments. Major independent outcome predictors are age (not modifiable) and cause (which should be actively targeted). Recent recommendations for adults suggest that the aggressiveness of treatment for RSE should be tailored to the clinical situation. To minimise intensive care unit-related complications, focal RSE without impairment of consciousness might initially be approached conservatively; conversely, early induction of pharmacological coma is advisable in generalised convulsive forms of the disorder. At this stage, midazolam, propofol, or barbiturates are the most commonly used drugs. Several other treatments, such as additional anaesthetics, other antiepileptic or immunomodulatory compounds, or non-pharmacological approaches (eg, electroconvulsive treatment or hypothermia), have been used in protracted RSE. Treatment lasting weeks or months can sometimes result in a good outcome, as in selected patients after encephalitis or autoimmune disorders. Well designed prospective studies of RSE are urgently needed.
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Affiliation(s)
- Andrea O Rossetti
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
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Abstract
OPINION STATEMENT Status epilepticus is characterized by a prolonged, self-sustaining seizure or repeated seizures without return to baseline. The clinical manifestations of status epilepticus in children and adults range from overt generalized convulsions to more subtle behavioral manifestations, including unresponsiveness in the setting of the intensive care unit. Status epilepticus is the most common neurologic emergency of childhood. A large proportion of these episodes are the result of a prolonged febrile seizure or an acute symptomatic etiology. Fortunately, status epilepticus occurs without consequence for many children, but for others, it is correlated with long-term neurologic dysfunction or death. Treatment of status epilepticus should commence promptly upon its recognition, using predefined treatment protocols. The goal of treatment is the rapid termination of the seizure, to minimize the acute and chronic effects of this emergency and to allow for the prompt assessment and management of the underlying precipitant. Currently, the drug class of first choice in the in-hospital and out-of-hospital treatment of status epilepticus is the benzodiazepines, which may need to be quickly followed by a next-line agent, as the efficacy of the benzodiazepines is negatively correlated with seizure duration. Traditionally, these next-line agents have included phenobarbital and phenytoin, but emerging evidence supports the use of intravenous formulations of other antiepileptic drugs. If the first two agents fail, high-dose intravenous midazolam or anesthetic therapy should be rapidly initiated. This paper reviews the current treatment options and strategies for pediatric patients with status epilepticus.
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Affiliation(s)
- Tobias Loddenkemper
- Harvard Medical School, Division of Epilepsy and Clinical Neurophysiology, Fegan 9, Children's Hospital Boston, 300 Longwood Ave., Boston, MA, 02115, USA,
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Abstract
PURPOSE OF REVIEW Status epilepticus is one of the most common emergencies in neurology, and every third patient does not respond to adequate first-line treatment. Refractory status epilepticus may be associated with increased morbidity and mortality, and new treatment options are urgently required. This review critically discusses recently published data regarding the role of 'new' antiepileptic drugs, the efficacy and safety of anesthetic agents, and the overall clinical outcome that is an integral part of treatment decisions. RECENT FINDINGS In complex partial status epilepticus, levetiracetam may be administered after failure of first-line and/or second-line agents. Lacosamide may be an interesting new adjunct, but reliable data are pending. In the treatment of refractory generalized convulsive status epilepticus, propofol seems to be as efficient as barbiturates. The latter are associated with prolonged ventilation times due to redistribution kinetics, whereas the former bears the risk of propofol infusion syndrome if administered continuously. Even after prolonged treatment with anesthetics over weeks, survival with satisfactory functional outcome is possible. SUMMARY Unambiguous recommendations regarding treatment strategies for refractory status epilepticus are limited by a lack of reliable data. Therefore, randomized controlled trials or at least prospective observational studies based on strict protocols incorporating long-term outcome data are urgently required.
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Shin HW, O’Donovan CA, Boggs JG, Grefe A, Harper A, Bell WL, McCall WV, Rosenquist P. Successful ECT treatment for medically refractory nonconvulsive status epilepticus in pediatric patient. Seizure 2011; 20:433-6. [DOI: 10.1016/j.seizure.2011.01.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Accepted: 01/17/2011] [Indexed: 10/18/2022] Open
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Current World Literature. Curr Opin Neurol 2011; 24:183-90. [DOI: 10.1097/wco.0b013e32834585ec] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wachtel LE, Dhossche DM, Kellner CH. When is electroconvulsive therapy appropriate for children and adolescents? Med Hypotheses 2011; 76:395-9. [DOI: 10.1016/j.mehy.2010.11.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 11/04/2010] [Indexed: 11/29/2022]
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Schreiber JM, Gaillard WD. Treatment of Refractory Status Epilepticus in Childhood. Curr Neurol Neurosci Rep 2010; 11:195-204. [DOI: 10.1007/s11910-010-0170-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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