Guidelines for the evaluation and management of status epilepticus

Initial Management of Acute Seizures and Status Epilepticus

Status epilepticus is a time-sensitive neuro-emergency, linked to poor functional outcomes and higher mortality rates. Prompt diagnosis and treatment are crucial to reduce its morbidity and mortality. Status epilepticus is often underdiagnosed in acutely ill hospitalized patients with altered consciousness, in whom most ongoing seizures can be subtle or nonconvulsive. For unexplained, persistent altered consciousness, clinicians should use electroencephalography to confirm or exclude a diagnosis of status epilepticus. A standardized treatment protocol should include prompt and adequately dosed first benzodiazepines as line therapy. Treatment approaches for second-line and third-line management continue to evolve as new anti-seizure medications become available.

Levetiracetam dosing in continuous renal replacement therapy: A systematic review and development of a novel pharmacokinetic model to optimise dosing in critically ill patients. Do recommended doses achieve therapeutic drug concentrations?

Aim

Levetiracetam is a widely used anti-epileptic in the critical care setting that is almost exclusively (>90%) renally excreted. The altered pharmacokinetics of levetiracetam have been widely studied in intermittent haemodialysis but the evidence and guidance on dosage in continuous renal replacement therapy is varied and poorly defined. Understanding this is critical as a significant number of critically unwell patients develop renal failure requiring continuous renal replacement therapy. The aim of this systematic review is to investigate the pharmacokinetics of levetiracetam in such patients and to understand the implications on dosing strategies.

Methods

A systematic review of the available literature from 2000 to November 2022 was conducted. Seven articles were identified for inclusion from 54 records. A novel hybrid model was developed to evaluate the quality of pharmacokinetic and haemofiltration data. This data was used to develop a one-compartment model that simulated dosing strategies in 10,000 patients based on an assumed steady state of 72 hr and target trough concentrations of 12-46 mcg/mL.

Results

From the seven articles included, pharmacokinetic data was retrieved for 24 individual patients. Total clearance was 3.49-4.63 L/hr (mean 3.55, S.D. 0.52). Elimination half-life was 5.66-12.88 hr (mean 9.41, S.D. 2.86). Volume of distribution was 0.45-0.73 L/kg. The proportion of total clearance attributable to continuous renal replacement therapy was 52%-73% (mean 54.7%, S.D. 13.5). Our simulations demonstrate that more than half of patients who received twice daily doses of 750 mg or greater without a loading dose achieved therapeutic drug concentrations. The time to achievement of therapeutic drug concentrations was greatly reduced by the addition of a 60 mg/kg loading dose (up to a maximum of 4.5 g). The use of a reduced loading dose or twice daily doses of 500 mg or less without loading were more likely to result in prolonged sub-therapeutic drug concentrations.

Conclusion

Levetiracetam clearance in haemofiltration is similar to healthy adults with normal renal function (GFR > 90 mL/min). The use of reduced doses due to renal failure in critically ill patients may result in sub-therapeutic drug concentrations in a high number of patients. A twice daily dosing of 750-1000 mg with an initial loading dose of 60 mg/kg should be considered in such patients alongside therapeutic drug monitoring.

Prolonged Monitoring of Brain Electrical Activity in the Intensive Care Unit

Electroencephalography (EEG) has been used to assess brain electrical activity for over a century. More recently, technological advancements allowed EEG to be a widely available and powerful tool in the intensive care unit (ICU), where patients at risk for cerebral dysfunction and brain injury can be monitored in a continuous, real-time manner. In the last 2 decades, several organizations established guidelines for continuous EEG monitoring in the ICU, defining critical care EEG terminology and technical standards for technicians, machines, and electroencephalographers. This article provides an overview of the current role of continuous EEG monitoring in the ICU.

Late-Onset Findings During Extended EEG Monitoring Are Rare in Critically Ill Children

PURPOSE

Electrographic seizures (ES) are common in critically ill children undergoing continuous EEG (CEEG) monitoring, and previous studies have aimed to target limited CEEG resources to children at highest risk of ES. However, previous studies have relied on observational data in which the duration of CEEG was clinically determined. Thus, the incidence of late occurring ES is unknown. The authors aimed to assess the incidence of ES for 24 hours after discontinuation of clinically indicated CEEG.

METHODS

This was a single-center prospective study of nonconsecutive children with acute encephalopathy in the pediatric intensive care unit who underwent 24 hours of extended research EEG after the end of clinical CEEG. The authors assessed whether there were new findings that affected clinical management during the extended research EEG, including new-onset ES.

RESULTS

Sixty-three subjects underwent extended research EEG. The median duration of the extended research EEG was 24.3 hours (interquartile range 24.0-25.3). Three subjects (5%) had an EEG change during the extended research EEG that resulted in a change in clinical management, including an increase in ES frequency, differential diagnosis of an event, and new interictal epileptiform discharges. No subjects had new-onset ES during the extended research EEG.

CONCLUSIONS

No subjects experienced new-onset ES during the 24-hour extended research EEG period. This finding supports observational data that patients with late-onset ES are rare and suggests that ES prediction models derived from observational data are likely not substantially underrepresenting the incidence of late-onset ES after discontinuation of clinically indicated CEEG.

First Seizures, Acute Repetitive Seizures, and Status Epilepticus

OBJECTIVE

This article provides current evidence on how and when to treat unprovoked first seizures in children and adults, guides intervention with appropriate doses and types of modern and effective therapies for acute repetitive (cluster) seizures, and reviews evidence for the diagnosis and management of established, refractory and super-refractory status epilepticus.

LATEST DEVELOPMENTS

Artificial intelligence shows promise as a clinical assistant in decision making after a first seizure. For nonanoxic convulsive refractory status epilepticus third-phase treatment, equipoise exists regarding whether it is better to add a second IV nonsedating antiseizure medication given via loading dose (eg, brivaracetam, lacosamide, levetiracetam, fosphenytoin or valproic acid) or to start an anesthetizing continuous IV infusion antiseizure medication such as ketamine, midazolam, propofol or pentobarbital.

ESSENTIAL POINTS

After a first seizure, the risk of a second seizure is about 36% at 2 years and 46% after 5 years. The risk is doubled in the presence of EEG epileptiform discharges, a brain imaging abnormality, a nocturnal first seizure, or prior brain trauma. For acute repetitive seizures, providers should give a proper dose of benzodiazepines based on the patient's weight and needs. First-phase treatment for convulsive established status epilepticus is the immediate administration of full doses of benzodiazepines. Second-phase treatment for convulsive established status epilepticus is a full loading dose of IV fosphenytoin, levetiracetam, valproic acid, or if necessary, phenobarbital.

Japanese guidelines for treatment of pediatric status epilepticus - 2023

The updated definition of status epilepticus (SE) by the International League Against Epilepsy in 2015 included two critical time points (t1: at which the seizure should be regarded as an "abnormally prolonged seizure"; and t2: beyond which the ongoing seizure activity can pose risk of long-term consequences) to aid in diagnosis and management and highlights the importance of early treatment of SE more clearly than ever before. Although Japan has witnessed an increasing number of pre-hospital drug treatment as well as first- and second-line treatments, clinical issues have emerged regarding which drugs are appropriate. To address these clinical concerns, a revised version of the "Japanese Guidelines for the Treatment of Pediatric Status Epilepticus 2023" (GL2023) was published. For pre-hospital treatment, buccal midazolam is recommended. For in-hospital treatment, if an intravenous route is unobtainable, buccal midazolam is also recommended. If an intravenous route can be obtained, intravenous benzodiazepines such as midazolam, lorazepam, and diazepam are recommended. However, the rates of seizure cessation were reported to be the same among the three drugs, but respiratory depression was less frequent with lorazepam than with diazepam. For established SE, phenytoin/fosphenytoin and phenobarbital can be used for pediatric SE, and levetiracetam can be used in only adults in Japan. Coma therapy is recommended for refractory SE, with no recommended treatment for super-refractory SE. GL2023 lacks adequate recommendations for the treatment of nonconvulsive status epilepticus (NCSE). Although electrographic seizure and electrographic SE may lead to brain damages, it remains unclear whether treatment of NCSE improves outcomes in children. We plan to address this issue in an upcoming edition of the guideline.

Tenets of timing: An evidence based comprehensive review on time-lag in the management of pediatric status epilepticus and its effect on clinical outcomes

Pediatric status epilepticus (SE) is a life-threatening, time-sensitive neurological emergency. The adequate treatment of pediatric patients with SE is challenging, especially when the principles of time are considered. Various clinical trials and studies [especially one of the most important randomized controlled trials of the present time, 'ESETT (Established Status Epilepticus Treatment Trial)'] compared the effectiveness of 3 antiseizure medications (ASMs) in patients with SE, providing robust evidence for clinical practice. Meticulous analysis of care delivery is an essential component as far as optimal management of pediatric SE is concerned. We performed an evidence-based comprehensive review on documented non-compliance and deviations from standard-treatment guidelines (STGs), focusing on time-elapsed from pediatric SE onset to ASM administration and escalation to subsequent classes. We have found significant gaps in real-world clinical practice. A literature review and a pooled-analysis of 12 studies on pediatric SE showed prehospital time to SE treatment was 29.5 minutes. Time to EMS arrival and hospital admission was 23 minutes and 48 minutes, respectively. Time-elapsed from SE onset to first-line ASM administration was 25.5 minutes, compared to evidence-based guidelines recommended time of 5-10 minutes. Similar delays were also observed in second- and third-line ASM administration. We have reviewed the factors affecting time-delays and impact on clinical outcomes. This review also highlights quality-improvement avenues that may help in improvising time for SE treatment and associated outcomes in pediatrics.

Evaluating the Impact of Point-of-Care Electroencephalography on Length of Stay in the Intensive Care Unit: Subanalysis of the SAFER-EEG Trial

BACKGROUND

Electroencephalography (EEG) is needed to diagnose nonconvulsive seizures. Prolonged nonconvulsive seizures are associated with neuronal injuries and deleterious clinical outcomes. However, it is uncertain whether the rapid identification of these seizures using point-of-care EEG (POC-EEG) can have a positive impact on clinical outcomes.

METHODS

In a retrospective subanalysis of the recently completed multicenter Seizure Assessment and Forecasting with Efficient Rapid-EEG (SAFER-EEG) trial, we compared intensive care unit (ICU) length of stay (LOS), unfavorable functional outcome (modified Rankin Scale score ≥ 4), and time to EEG between adult patients receiving a US Food and Drug Administration-cleared POC-EEG (Ceribell, Inc.) and those receiving conventional EEG (conv-EEG). Patient records from January 2018 to June 2022 at three different academic centers were reviewed, focusing on EEG timing and clinical outcomes. Propensity score matching was applied using key clinical covariates to control for confounders. Medians and interquartile ranges (IQRs) were calculated for descriptive statistics. Nonparametric tests (Mann-Whitney U-test) were used for the continuous variables, and the χ2 test was used for the proportions.

RESULTS

A total of 283 ICU patients (62 conv-EEG, 221 POC-EEG) were included. The two populations were matched using demographic and clinical characteristics. We found that the ICU LOS was significantly shorter in the POC-EEG cohort compared to the conv-EEG cohort (3.9 [IQR 1.9-8.8] vs. 8.0 [IQR 3.0-16.0] days, p = 0.003). Moreover, modified Rankin Scale functional outcomes were also different between the two EEG cohorts (p = 0.047).

CONCLUSIONS

This study reveals a significant association between early POC-EEG detection of nonconvulsive seizures and decreased ICU LOS. The POC-EEG differed from conv-EEG, demonstrating better functional outcomes compared with the latter in a matched analysis. These findings corroborate previous research advocating the benefit of early diagnosis of nonconvulsive seizure. The causal relationship between the type of EEG and metrics of interest, such as ICU LOS and functional/clinical outcomes, needs to be confirmed in future prospective randomized studies.

Nursing Initiation of Rapid Electroencephalography Point-of-Care Monitoring: Lessons From the Pioneer Summit

ABSTRACT

BACKGROUND: Status epilepticus is an emergency, and applying electroencephalography (EEG) monitoring is an important part of diagnosing and treating seizure. The use of rapidly applied limited array continuous EEG (rapid EEG) has become technologically feasible in recent years. Nurse-led protocols using rapid EEG as a point-of-care monitor are increasingly being adopted. METHODS: A virtual summit meeting of nurses and physicians was convened to discuss various technological and practical aspects of rapid EEG, including the use of nurse-led protocols using rapid EEG. After oral presentations, participants responded to a survey indicating their level of agreement with key position statements. RESULTS: From the 52 participants who participated in the 2-hour summit, there was a strong agreement with the statement "Bedside nurses can start point-of-care EEG with automated seizure alert software to provide more informed care," with a median Likert score of 5 (completely agree) and an interquartile range of 4 to 5. CONCLUSION: Using rapid EEG to monitor for seizure is a valid and valuable method that falls within the nursing domain. Nurse-driven protocols may provide the opportunity to enhance patient care through early identification of seizures.

Predisposing Factors of Progression from Refractory Status Epilepticus to Super-Refractory Status Epilepticus in ICU-Admitted Patients: Multicenter Retrospective Cohort Study in a Resource-Limited Setting

BACKGROUND

Super-refractory status epilepticus (SRSE) is an extremely serious neurological emergency. Risk factors and mechanisms involved in transition from refractory status epilepticus (RSE) to SRSE are insufficiently studied.

METHODS

This was a multicenter retrospective cohort study of consecutive patients diagnosed and treated for RSE at two reference hospital over 5 years in Ecuador. A total of 140 patients were included. Potential demographic, clinical, and treatment variables that may predict progression from refractory to SRSE were analyzed.

RESULTS

Super-refractory status epilepticus was identified in 67/140 (48%) of patients. In univariate analyses, level of consciousness on hospital admission (Glasgow Coma Score < 12, odds ratio [OR] 2.9, p < 0.01), traumatic brain injury (OR 2.3, p = 0.05), acute etiology (OR 3.0, p = 0.04), higher Status Epilepticus Severity Score (STESS) (OR 1.7, p < 0.01), and new clinical or electrographic seizure within 6 h (OR 4.2, p < 0.01) of starting anesthetic infusion were important factors related to super-refractory disease. The best independents predictors of SRSE when the presence of other potential factors were considered for multivariate analysis. Two models were calculated to avoid interactions between similar variables. Glasgow Coma Score on hospital admission < 12 (OR 3.1 [95% confidence interval {CI} 1.16-8.29], p = 0.02) and new clinical or electroencephalography (EEG) seizure after first 6 h of starting anesthetic infusion (OR 3.1 [95% CI 1.36-7.09], p = 0.01) were associated with higher risk of progression to SRSE in model 1. In contrast, model 2 indicated that patients with STESS ≥ 3 points (OR 2.9 [95% CI 1.24-6.65], p = 0.01) and new clinical or EEG seizure after 6 h starting anesthetic infusion (OR 3.0 [95% CI 1.32-6.97], p = 0.01) were the factors independently related to super-refractory disease.

CONCLUSIONS

The rate of patients with RSE admitted to intensive care units developing SRSE was high. Low level of consciousness on admission, higher STESS scores, and patients who did not achieve total control of clinical or EEG seizure in the first 6 h of starting intravenous anesthetic infusion may be early indicators of SRSE.

Ketamine Versus Midazolam as the First-Line Continuous Infusion for Status Epilepticus in Children with Cardiac Disease

BACKGROUND

The treatment of status epilepticus (SE) in children with cardiac disease is challenging given their often-tenuous hemodynamic state. We aim to determine whether ketamine is safe and effective in children with cardiac disease as the first-line continuous infusion for the treatment of refractory SE (RSE) and to compare ketamine to midazolam for the treatment of RSE in this population.

METHODS

This is a single-center retrospective cohort study of pediatric patients with cardiac disease and RSE admitted to the cardiac intensive care unit at a tertiary children's hospital between January 1, 2017 and June 30, 2023. Consecutive patients < 18 years of age who had electroencephalogram-confirmed RSE treated with a continuous infusion of ketamine and/or midazolam were included. Clinical variables were extracted from the electronic medical record, and descriptive statistics were used.

RESULTS

Thirty-four patients with cardiac disease and RSE were treated with a continuous infusion: 15 were treated with ketamine first, and 19 were treated with midazolam first. An equivalent number of patients in both groups required a single infusion for seizure cessation (11 [73%] in the ketamine group and 12 [63%] in the midazolam group; p = 0.72). The median time from seizure onset to seizure cessation, time from seizure onset to initiation of a continuous infusion, time from initiation of a continuous infusion to seizure cessation, infusion duration, and recurrence of seizures during weaning of the continuous infusion were comparable between groups. There was no difference between groups in the proportion of patients who experienced potential adverse events attributable to their continuous infusion.

CONCLUSIONS

This retrospective cohort study provides evidence that ketamine may be as effective as midazolam as the first-line continuous infusion for RSE in children with cardiac disease. This study also provides preliminary evidence of safety in this population, at least in comparison to midazolam.

Intravenous push administration of anti-seizure medications

Intravenous push (IVP) administration of anti-seizure medications is becoming increasingly popular among emergency departments. IVP administration eliminates the need for compounding and preparation by the pharmacy department, as well as the need to gather infusion materials or set up a patient's tubing and pump, all of which translate to faster drug administration. This is important given the time-sensitive nature of status epilepticus treatment. This review will discuss several anti-seizure medications, including phenytoin, fosphenytoin, valproic acid, levetiracetam, brivaracetam and lacosamide, for which evidence supports the safe and efficacious use of IV push administration.

Adherence to Recommendations and Yield of Critical Care EEG Monitoring: A Prospective Multicentric Study

PURPOSE

The American Clinical Neurophysiology Society has provided a set of recommendations on the use of critical care EEG monitoring (CEEG). However, these recommendations have not been prospectively validated. We aimed to assess the adherence to the American Clinical Neurophysiology Society recommendations for obtaining CEEG for different indications and the yield of obtained CEEG according to these different indications.

METHODS

This was a multicenter prospective observational study of critically ill adult patients between April 01, 2022, and June 22, 2022, in two academic medical centers and a large teaching hospital. Indications for CEEG, according to the American Clinical Neurophysiology Society recommendations, were determined based on clinical data at the time of discharge from the intensive care unit. The use of CEEG and detection of electrographic seizures were retrieved from the EEG databases.

RESULTS

A total of 600 patients were enrolled in this study. The primary admission diagnoses were medical (49%), surgical (30%), or neurologic/neurosurgical (21%). Approximately 60% of patients had an altered mental status. A few (6%) patients had a preceding clinical seizure, and 1% had generalized convulsive status epilepticus. Indications were identified in 226 admissions. Of these patients, 88 (39%) underwent CEEG. In addition, 12 patients underwent CEEG without clear indications. Of the 100 patients, 33 (33%) had electrographic seizures. Adherence to recommendations and yields was highest for refractory status epilepticus, altered mental status after any clinical seizure, and acute brain injury. Adherence and yield varied the most and were inversely correlated in the group of patients without acute brain injury, suggesting that additional clinical factors may have contributed to patient selection.

CONCLUSIONS

Patients meeting American Clinical Neurophysiology Society indications and receiving CEEG had a high seizure risk. Emerging CEEG programs should focus on epilepsy-related and neurologic diagnosis. Although recommendations effectively identify groups of patients with a high seizure risk, additional clinical factors might further help select candidates in the low-risk group.

Anticonvulsant Effects of Synthetic N-(3-Methoxybenzyl)oleamide and N-(3-Methoxybenzyl)linoleamide Macamides: An In Silico and In Vivo Study

Epilepsy is a chronic neurological disorder that affects nearly 50 million people worldwide. Experimental evidence suggests that epileptic neurons are linked to the endocannabinoid system and that inhibition of the FAAH enzyme could have neuroprotective effects by increasing the levels of endogenous endocannabinoid anandamide. In this context, the use of macamides as therapeutic agents in neurological diseases has increased in recent years. With a similar structure to anandamide, several theories point to the FAAH-macamide interaction as a possible cause of FAAH enzymatic inhibition. In this work, we used in silico and in vivo techniques to analyze the potential therapeutic effect of three synthetic macamides in the treatment of epilepsy: N-3-methoxybenzyl-oleamide (3-MBO), N-3-methoxybenzyl-linoleamide (3-MBL), and N-3-methoxybenzyl-linolenamide (3-MBN). In the first stage, an in silico analysis was conducted to explore the energetic affinity of these macamides with rFAAH and their potential inhibitory effect. MD simulations, molecular docking, and MM/PBSA calculations were used for these purposes. Based on our results, we selected the two best macamides and performed an in vivo study to analyze their therapeutic effect in male Sprague Dawley rat models. Rats were subjected to an in vivo induction of epileptic status by the intraperitoneal injection of pilocarpine and analyzed according to the Racine scale. In silico results showed an energetic affinity of three macamides and a possible "plugging" effect of the membrane access channel to the active site as a potential cause of FAAH inhibition. On the other hand, the in vivo results showed an anticonvulsant effect of both macamides, with 3-MBL being the most active, resulting in a higher survival probability in the rats. This work represents one of the first studies on the use of macamides for the treatment of epilepsy.

Diagnostic accuracy of reduced electroencephalography montages for seizure detection: A frequentist and Bayesian meta-analysis

AIM

To evaluate the diagnostic accuracy of reduced montage electroencephalography (EEG) for seizure detection and provide evidence-based recommendations.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a diagnostic meta-analysis to assess the sensitivity and specificity of reduced EEG montages in detecting seizure activity. A hierarchical summary receiver operating characteristic curve (HSROC) model was used to estimate the area under the curve (AUC). Subgroup analyses were conducted to identify sources of heterogeneity. Bayesian estimates were used for validation.

RESULTS

Across 8 studies encompassing 3,458 reduced EEG montage samples, all studies used a reduced EEG montage with 7 to 10 electrodes. The pooled sensitivity was 0.75 (95 % CI: 0.68-0.80), and the pooled specificity was 0.97 (95 % CI: 0.95-0.98). The HSROC model had an AUC of 0.96 (95 % CI: 0.93-0.97). Variations in study results were attributed to factors such as the number of electrodes (pooled sensitivity of 0.66 for studies employing <8 leads and 0.77 for studies employing ≥8 leads) and montage design coverage (pooled sensitivity of 0.64 for studies employing subhairline montage and 0.77 for studies employing above-hairline montage). The Bayesian and frequentist findings agreed with each other and had a pooled sensitivity of 0.74 (95 % HPD: 0.65-0.83) and pooled specificity of 0.97 (95 % highest posterior density 0.95-0.98).

CONCLUSION

Reduced EEG montages with 8 or more electrodes are feasible for seizure detection, especially in emergency settings where rapid detection is crucial.

Efficacy of delivery of care with Tele-continuous EEG in critically ill patients: a multicenter randomized controlled trial (Tele-cRCT study) study

BACKGROUND

Continuous electroencephalography (cEEG) has been recommended in critically ill patients although its efficacy for improving patients' functional status remains unclear. This study aimed to compare the efficacy of Tele-cEEG with Tele-routine EEG (Tele-rEEG), in terms of seizure detection rate, mortality and functional outcomes.

METHODS

This study is a 3-year randomized, controlled, parallel, multicenter trial, conducted in eight regional hospitals across Thailand. Eligible participants were critically ill patients aged ≥ 15 years and at-risk for developing nonconvulsive seizure (NCS)/nonconvulsive status epilepticus (NCSE). Study interventions were 24-72 h Tele-cEEG versus 30-min Tele-rEEG. Study outcomes were seizure detection rate, mortality and functional outcomes (mRS), assessed at hospital discharge, ≤ 7 days, 3-, 6-, 9-months and 1 year.

RESULTS

Two hundred and fifty-four patients were randomized, 128 and 126 patients received Tele-cEEG and Tele-rEEG, respectively. NCS/NCSE were detected more commonly in the Tele-cEEG (21.88%) than Tele-rEEG arm (14.29%) but this was not statistically significant (p = 0.116). Intention-to-treat, per-protocol and as-treated analysis showed non-significant differences in mortality at all assessment periods, with corresponding mortality rates of 10.03% (Tele-cEEG) versus 10.10% (Tele-rEEG) (p = 0.894), 9.67% versus 9.06% (p = 0.833) and 10.34% versus 9.06% (p = 0.600), respectively. Functional outcome was also not significantly different in all analyses.

CONCLUSIONS

Both Tele-cEEG and Tele-rEEG are feasible, although Tele-EEG requires additional EEG specialists, budget, and computational resources. While Tele-cEEG may help detect NCS/NCSE, this study had limited power to detect its efficacy in reducing mortality or improving functional outcomes. In limited-resource settings, Tele-rEEG approximating 30 min or longer offers a feasible and potentially valuable initial screening tool for critically ill patients at-risk of seizures. However, where Tele-cEEG is readily available, it remains the recommended approach. Trial registration Thai Clinical Trials Registry (TTCTR20181022002); Registered 22 October 2018.

Treatment of convulsive status epilepticus in Brazil: a review

Status epilepticus (SE) is the most severe presentation of epilepsy. Currently, SE is defined according to 2 sequential time frames: time 1, after which it is unlikely that the seizure will resolve spontaneously, therefore requiring the initiation of therapy; and time 2, when long-term consequences become more likely. For convulsive SE, these time frames are well defined: 5 minutes for time 1 and 30 minutes for time 2. "Time is brain" in the treatment of SE, as delays in diagnosis and treatment are associated with worse outcomes. After clinical stabilization, the first step is the administration of intravenous (IV) benzodiazepines. Rapid initiation of treatment and use of appropriate dosing are more important than the selection of a specific benzodiazepine. Following this, treatment continues with the use of an IV antiseizure medication (ASM). In Brazil, the recommended options available are phenytoin and levetiracetam. Status epilepticus is considered refractory to treatment if seizures persist after the administration of benzodiazepines and IV ASM. The cornerstone of this stage is the induction of therapeutic coma using IV anesthetic drugs (IVADs), although evidence is limited regarding the choice among midazolam, propofol, or barbiturates. Super-refractory SE is defined when seizures persist despite continuous infusion of IVADs or recur after these drugs are tapered. There is very limited data regarding the treatment of super-refractory SE. In the absence of randomized controlled trials, treatment should be guided by the physician's experience, clinical judgment, and established therapeutic options from previous reports.

Using artificial intelligence to optimize anti-seizure treatment and EEG-guided decisions in severe brain injury

Electroencephalography (EEG) is invaluable in the management of acute neurological emergencies. Characteristic EEG changes have been identified in diverse neurologic conditions including stroke, trauma, and anoxia, and the increased utilization of continuous EEG (cEEG) has identified potentially harmful activity even in patients without overt clinical signs or neurologic diagnoses. Manual annotation by expert neurophysiologists is a major resource limitation in investigating the prognostic and therapeutic implications of these EEG patterns and in expanding EEG use to a broader set of patients who are likely to benefit. Artificial intelligence (AI) has already demonstrated clinical success in guiding cEEG allocation for patients at risk for seizures, and its potential uses in neurocritical care are expanding alongside improvements in AI itself. We review both current clinical uses of AI for EEG-guided management as well as ongoing research directions in automated seizure and ischemia detection, neurologic prognostication, and guidance of medical and surgical treatment.

Effectiveness of Highly Purified Cannabidiol in Refractory and Super-Refractory Status Epilepticus: A Case Series

INTRODUCTION

Refractory and super-refractory status epilepticus are medical emergencies that must be promptly treated in consideration of their high mortality and morbidity rate. Nevertheless, the available evidence of effective treatment for these conditions is scarce. Among novel antiseizure medications (ASMs), highly purified cannabidiol (hpCBD) has shown noteworthy efficacy in reducing seizures in Lennox-Gastaut syndrome, Dravet syndrome, and Tuberous Sclerosis Complex.

CASE PRESENTATION

Here, we present two cases of effective use of hpCBD in both refractory and super- refractory status epilepticus. The administration of the nasogastric tube permitted the resolution of status epilepticus without adverse events. At 6-month follow-up, both patients were on hpCBD treatment, which continued to be efficacious for treating seizures.

CONCLUSION

According to our experience, hpCBD should be taken into consideration as an add-on therapy of RSE and SRSE while also considering the possibility of maintaining this treatment during the follow-up of patients. However, more studies and real-world experiences are needed to better understand its effectiveness in this setting and the interaction with other ASMs.

Electrographic Seizure Characteristics and Electrographic Status Epilepticus Prediction

PURPOSE

We aimed to characterize electrographic seizures (ES) and electrographic status epilepticus (ESE) and determine whether a model predicting ESE exclusively could effectively guide continuous EEG monitoring (CEEG) utilization in critically ill children.

METHODS

This was a prospective observational study of consecutive critically ill children with encephalopathy who underwent CEEG. We used descriptive statistics to characterize ES and ESE, and we developed a model for ESE prediction.

RESULTS

ES occurred in 25% of 1,399 subjects. Among subjects with ES, 23% had ESE, including 37% with continuous seizures lasting >30 minutes and 63% with recurrent seizures totaling 30 minutes within a 1-hour epoch. The median onset of ES and ESE occurred 1.8 and 0.18 hours after CEEG initiation, respectively. The optimal model for ESE prediction yielded an area under the receiver operating characteristic curves of 0.81. A cutoff selected to emphasize sensitivity (91%) yielded specificity of 56%. Given the 6% ESE incidence, positive predictive value was 11% and negative predictive value was 99%. If the model were applied to our cohort, then 53% of patients would not undergo CEEG and 8% of patients experiencing ESE would not be identified.

CONCLUSIONS

ESE was common, but most patients with ESE had recurrent brief seizures rather than long individual seizures. A model predicting ESE might only slightly improve CEEG utilization over models aiming to identify patients at risk for ES but would fail to identify some patients with ESE. Models identifying ES might be more advantageous for preventing ES from evolving into ESE.

Association of early general anesthesia with outcome in adults with status epilepticus: A propensity-matched observational study

General anesthesia (GA) earlier than recommended (as first- or second-line treatment) was recently described to improve status epilepticus (SE) outcome. We aimed to assess the impact of early GA on outcome in matched groups. Data from a multicenter, prospective cohort of 1179 SE episodes in 1049 adults were retrospectively analyzed. Incident SE episodes were categorized as "early anesthesia" (eGA; GA as first- or second-line treatment) or "non-early anesthesia" (neGA; GA after second-line treatment or not at all). Using propensity score matching, eGA episodes were paired 1:4 with neGA episodes. We assessed survival, functional outcomes at discharge (good: modified Rankin Scale = 0-2 or no worsening), SE cessation rate, SE duration, and hospital stay. Among 1049 SE episodes, 55 (5.2%) received eGA, and 994 constituted the neGA group; 220 represented the matched controls. Patients receiving eGA were younger (median = 63, interquartile range [IQR] = 56-76 vs. median = 70, IQR = 54-80 years, p = .004), had deeper consciousness impairment (80% vs. 40% stuporous/comatose, p < .001), and had more severe SE forms (89% vs. 54% generalized convulsive SE/nonconvulsive SE in coma, p < .001). Mortality, functional outcome, SE cessation rate, and duration of SE and hospital stay were similar between the eGA group and matched controls. We conclude that early anesthesia for SE treatment did not influence prognosis.

The value of hypothermia as a neuroprotective and antiepileptic strategy in patients with status epilepticus: an update of the literature

INTRODUCTION

Status epilepticus represents a significant neurological emergency, with high morbidity and mortality rates. In addition to standard care, the identification of adjuvant strategies is essential to improve the outcome.

AREAS COVERED

The authors conducted a narrative review to provide an update on the value of hypothermia as an antiseizure and neuroprotective treatment in status epilepticus.

EXPERT OPINION

The use of targeted temperature management in the treatment of hypothermia in patients with status epilepticus represents a potentially promising adjuvant strategy, supported by a substantial body of experimental evidence. However, further clinical data demonstrating its efficacy are necessary before it can be recommended for routine use in targeted patient populations, such as those with refractory or super-refractory status epilepticus.

Can the large language model ChatGPT-4omni predict outcomes in adult patients with status epilepticus?

OBJECTIVE

Large language models (LLMs) have recently gained attention for clinical decision-making and diagnosis. This study evaluates the performance of the recently updated LLM (ChatGPT-4o) in predicting clinical outcomes in patients with status epilepticus and compares its prognostic performance to the Status Epilepticus Severity Score (STESS).

METHODS

This retrospective single-center cohort study was performed at the University Hospital Basel (tertiary academic medical center) from January 2005 to December 2022. It included consecutive adult patients (≥18 years of age) with a diagnosis of status epilepticus. The primary outcome was survival at hospital discharge, and the secondary outcome was return to premorbid neurological function at hospital discharge. The performance characteristics of ChatGPT4-o (sensitivity, specificity, Youden Index) were evaluated and compared to those of the STESS.

RESULTS

Of 760 patients, 689 patients (90.7%) survived to discharge, and 317 survivors (41.7%) regained their premorbid neurological function at discharge. ChatGPT-4o predicted survival in 567 of 760 patients (74.6%), of which 45 died. ChatGPT-4o predicted death in 193 of 760 patients (25.4%), of which 167 survived, resulting in a sensitivity of 75.8% and a specificity of 36.6% (Youden Index 0.12, 95% confidence interval [CI] 0-.28) for predicting survival. ChatGPT-4o predicted return to premorbid neurologic function in 249 of 760 patients (32.8%), of which 112 did not return to their premorbid neurological function. ChatGPT-4o predicted no return to premorbid function in 511 of 760 patients (67.2%), of which 180 returned to their premorbid function, resulting in a sensitivity of 43.2% and a specificity of 74.7% (Youden Index .12, 95% CI .08-.28) for predicting return to premorbid neurological function. There was no difference in the prognostic performance of ChatGPT-4o and the STESS. A second round of prompting did not increase the predictive performance of ChatGPT-4o.

SIGNIFICANCE

ChatGPT-4o unreliably predicts outcomes in patients with status epilepticus. Clinicians should refrain from using ChatGPT-4o for prognostication in these patients.

Consensus Guideline for Care of Patients in the Prehospital and Aerospace Settings with Exposures to Hydrazine and Hydrazine Derivatives

OBJECTIVES

Hydrazine (HZ) and Hydrazine Derivative (HZ-D) exposures pose health risks to people in industrial and aerospace settings. Several recent systematic reviews and case series have highlighted common clinical presentations and management strategies. Given the low frequency at which HZ and HZ-D exposures occur, a strong evidence base on which to develop an evidence-based guideline does not exist at this time. Therefore, the aim of this project is to establish a consensus guideline for prehospital care of patients with exposures to HZ and HZ-Ds.

METHODS

A modified Delphi technique was used to develop clinical questions, obtain expert panel opinions, develop initial patient care recommendations, and revise the draft into a final consensus guideline. First, individuals (Emergency Medical Services (EMS) physicians and hazardous materials technicians) with experience in management of HZ and HZ-Ds identified relevant clinical questions. An expert panel was then convened to make clinical recommendations. In the first round, the panel voted on clinical care recommendations. These recommendations were drafted into a guideline that expert panel members reviewed. After review, additional unanswered questions were discussed electronically by expert panel members, and electronic votes were cast. Ultimately, patient care recommendations were condensed into a concise, consensus guideline.

RESULTS

Eight clinical questions regarding treatment of patients with HZ and HZ-D exposures were identified. These questions were reviewed by the expert panel which included 2 representatives from: aerospace medicine, military medicine, EMS medicine, paramedicine, pharmacy, and toxicology. Draft patient care recommendations generated three additional questions which were discussed electronically and voted on. These recommendations were then formatted into a guideline outlining recommendations for care prior to decontamination, during decontamination, and after decontamination.

CONCLUSIONS

The consensus guideline for clinical care of patients with exposure to HZ/HZ-Ds is as follows: Prior to decontamination, use appropriate personal protective equipment, and when necessary, support ventilation using a bag-valve-mask and administer midazolam intramuscularly for seizures. After decontamination, provide supplemental oxygen; consider selective advanced airway management when indicated; administer inhaled beta-agonists for wheezing; and, for seizures unresponsive to multiple doses of benzodiazepines that occur during pre-planned, high-hazard activities, such as spacecraft recovery, consider intravenous or intraosseous pyridoxine.

2024 American Heart Association and American Red Cross Guidelines for First Aid

Codeveloped by the American Heart Association and the American Red Cross, these guidelines represent the first comprehensive update of first aid treatment recommendations since 2010. Incorporating the results of structured evidence reviews from the International Liaison Committee on Resuscitation, these guidelines cover first aid treatment for critical and common medical, traumatic, environmental, and toxicological conditions. This update emphasizes the continuous evolution of evidence evaluation and the necessity of adapting educational strategies to local needs and diverse community demographics. Existing guidelines remain relevant unless specifically updated in this publication. Key topics that are new, are substantially revised, or have significant new literature include opioid overdose, bleeding control, open chest wounds, spinal motion restriction, hypothermia, frostbite, presyncope, anaphylaxis, snakebite, oxygen administration, and the use of pulse oximetry in first aid, with the inclusion of pediatric-specific guidance as warranted.

A roadmap to closing the evidence-to-practice gap in status epilepticus

Status epilepticus (SE) is a time-sensitive, potentially life-threatening neuro-emergency associated with poor functional outcomes and increased hospital resource utilization especially when it progresses to refractory or super-refractory forms. Timely recognition & treatment improves outcomes, however gaps between recommended and implemented care are common and pervasive. This review provides a roadmap for incorporating the relatively new field of Implementation Science in promoting the systematic uptake of evidence-based practices into the real-world care of patients with SE. A multifaceted approach - including better integration of real-world implementation and research infrastructure, an emphasis on standardizing and harmonization clinical data, re-examining funding priorities, regulatory reform, and the formation of transdisciplinary teams and learning collaboratives - has the potential to advance the care of patients in SE from its current status quo. This topic was presented at the 9th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in April 2024.

Progression to refractory status epilepticus: A machine learning analysis by means of classification and regression tree analysis

BACKGROUND AND OBJECTIVES

to identify predictors of progression to refractory status epilepticus (RSE) using a machine learning technique.

METHODS

Consecutive patients aged ≥ 14 years with SE registered in a 9-years period at Modena Academic Hospital were included in the analysis. We evaluated the risk of progression to RSE using logistic regression and a machine learning analysis by means of classification and regression tree analysis (CART) to develop a predictive model of progression to RSE.

RESULTS

705 patients with SE were included in the study; of those, 33 % (233/705) evolved to RSE. The progression to RSE was an independent risk factor for 30-day mortality, with an OR adjusted for previously identified possible univariate confounders of 4.086 (CI 95 % 2.390-6.985; p < 0.001). According to CART the most important variable predicting evolution to RSE was the impaired consciousness before treatment, followed by acute symptomatic hypoxic etiology and periodic EEG patterns. The decision tree identified 14 nodes with a risk of evolution to RSE ranging from 1.5 % to 90.8 %. The overall percentage of success in classifying patients of the decision tree was 79.4 %; the percentage of accurate prediction was high, 94.1 %, for those patients not progressing to RSE and moderate, 49.8 %, for patients evolving to RSE.

CONCLUSIONS

Decision-tree analysis provided a meaningful risk stratification based on few variables that are easily obtained at SE first evaluation: consciousness before treatment, etiology, and severe EEG patterns. CART models must be viewed as potential new method for the stratification RSE at single subject level deserving further exploration and validation.

Lack of association of first and second-line medication dosing and progression to refractory status epilepticus in children

PURPOSE

Evaluate the relationship between first and second-line medication dosing and progression to refractory status epilepticus (RSE) in children.

METHODS

This is a retrospective analysis of prospectively collected data from September 2014 to February 2020 of children with status epilepticus (SE) who received at least two antiseizure medications (ASMs). We evaluated the risk of developing RSE after receiving a low total benzodiazepine dose (lower than 100 % of the minimum recommended dose for each benzodiazepine dose administered within 10 min) and a low first non-benzodiazepine ASM dose (lower than 100 % of the minimum recommended dose of non-benzodiazepine ASM given as the first single-dose) using a logistic regression model, adjusting for confounders such as time to ASMs. The proportion of patients receiving low first non-benzodiazepine ASM doses was calculated and a logistic regression model was used to evaluate risk factors for low dosing of the first non-benzodiazepine ASM.

RESULTS

Among 320 children, 170 (53.1 %) developed RSE, and 150 (46.9 %) responded to the first non-benzodiazepine ASM dose (non-RSE). One hundred thirty-seven (42.8 %) received a low total benzodiazepine dose, and 128 (40 %) received a low first non-benzodiazepine ASM dose. The odds of developing RSE were not higher after a low total benzodiazepine dose (OR=0.76, 95 %CI 0.47-1.23, p = 0.27) or low first non-benzodiazepine ASM dose (OR=0.85, 95 %CI 0.42-1.71, p = 0.65). Receiving a low first non-benzodiazepine ASM dose was independently associated with having received a low total benzodiazepine dose (OR=1.65, 95 %CI 1.01-2.70, p = 0.04).

CONCLUSION

For most patients, dosing variability in first and second-line medications for SE was not the sole clinical feature predicting progression to RSE in this cohort of benzodiazepine-resistant patients. Identification of additional modifiable clinical biomarkers that predict progression to RSE is needed. Though lower ASM doses did not predict RSE in this model, the administration of ASMs at doses likely to prevent RSE remains crucial in SE treatment.

Long-Term Safety and Efficacy of Lacosamide Combined with NOACs in Post-Stroke Epilepsy and Atrial Fibrillation: A Prospective Longitudinal Study

Background and Aims: Stroke is the leading cause of seizures and epilepsy in adults; however, current guidelines lack robust recommendations for treating post-stroke seizures (PSSs) and epilepsy (PSE). This study aims to demonstrate the long-term safety and efficacy of lacosamide combined with non-vitamin K antagonist oral anticoagulants (NOACs) in patients with PSE and atrial fibrillation (AF). Methods: In this prospective longitudinal single-center study, 53 patients with concomitant PSE and AF, admitted between 2022 and 2023, received NOACs for AF management and lacosamide for seizure control. A control group of 53 patients with cardioembolic stroke, receiving NOACs (but without PSE), was matched by age, sex, and NIHSS scores to ensure comparability. Results: Over 24 months, 16 patients in the study group and 15 in the control group experienced new embolic events, with no significant difference between groups (p = 0.82). Seizure control improved significantly in the study group, with reduced frequency and severity. No severe adverse events from lacosamide were observed. Conclusions: The combination of NOACs and lacosamide is a safe and effective treatment for patients with AF and PSE and does not increase the risk of recurrent ischemic or hemorrhagic events. Further studies with larger sample sizes and longer follow-ups are needed to confirm these findings and optimize treatment protocols.

Intravenous push lacosamide: Successful implementation and patient outcomes across a health system

PURPOSE

Intravenous administration of the antiseizure medication lacosamide can be delayed given operational challenges related to short beyond-use-dating and controlled substance requirements. The purpose of this study was to describe the steps required to successfully transition from intravenous piggyback administration to intravenous push administration and demonstrate that workflow changes improved time to administration without compromising patient safety.

METHODS

This multicenter study had 2 components; the first portion was a prospective description of the implementation and operationalization process, while the second was a retrospective cohort analysis comparing patients who received intravenous piggyback and intravenous push lacosamide. After the transition, the default administration route for adult patients for lacosamide doses of 400 mg or less was intravenous push. While the primary objective was to describe the implementation process, secondary objectives included comparison of time to administration and safety, using a composite and incidence of PR prolongation.

RESULTS

Success in implementation and operationalization across a large health system was achieved by following a 6-month timeline. A total of 102 patients were included in the cohort study, with 869 individual administrations analyzed (519 intravenous piggyback and 350 intravenous push). Time from verification to administration was significantly decreased when comparing intravenous piggyback (median, 159 minutes) to intravenous push (median, 88 minutes) administrations (P = 0.008). No significant difference was found in the safety composite or PR prolongation.

CONCLUSION

Transitioning intravenous lacosamide administration from piggyback to push administration is feasible and decreases time from verification to administration without increased incidence of adverse effects.

A novel nomogram for predicting the prognosis of critically ill patients with EEG patterns exhibiting stimulus-induced rhythmic, periodic, or ictal discharges

OBJECTIVES

To explore the factors associated with poor prognosis in critically ill patients with Electroencephalogram (EEG) patterns exhibiting stimulus-induced rhythmic, periodic, or ictal discharges (SIRPIDs), and to construct a prognostic prediction model.

METHODS

This study included a total of 53 critically ill patients with EEG patterns exhibiting SIRPIDs who were admitted to the First Affiliated Hospital of Chongqing Medical University from May 2023 to March 2024. Patients were divided into two groups based on their Modified Rankin Scale (mRS) scores at discharge: good prognosis group (0-3 points) and poor prognosis group (4-6 points). Retrospective analyses were performed on the clinical and EEG parameters of patients in both groups. Logistic regression analysis was applied to identify the risk factors related to poor prognosis in critically ill patients with EEG patterns exhibiting SIRPIDs; a risk prediction model for poor prognosis was constructed, along with an individualized predictive nomogram model, and the predictive performance and consistency of the model were evaluated.

RESULTS

Multivariate logistic regression analysis revealed that APACHE II score (OR=1.217, 95 %CI=1.030∼1.438), slow frequency bands or no obvious brain electrical activity (OR=8.720, 95 %CI=1.220∼62.313), and no sleep waveforms (OR=9.813, 95 %CI=1.371∼70.223) were independent risk factors for poor prognosis in patients. A regression model established based on multivariate logistic regression analysis had an area under the curve of 0.902. The model's accuracy was 90.60 %, with a sensitivity of 92.86 % and a specificity of 89.70 %. The nomogram model, after internal validation, showed a concordance index of 0.904.

CONCLUSIONS

A high APACHE II score, EEG patterns with slow frequency bands or no obvious brain electrical activity, and no sleep waveforms were independent risk factors for poor prognosis in patients with SIRPIDs. The nomogram model constructed based on these factors had a favorably high level of accuracy in predicting the risk of poor prognosis and held certain reference and application value for clinical neurofunctional assessment and prognostic determination.

Evaluation of levetiracetam loading dose in adult patients with benzodiazepine-refractory status epilepticus

BACKGROUND

Status epilepticus (SE) is a neurologic emergency defined as continued seizure activity greater than five minutes or recurrent seizure activity without return to baseline. Benzodiazepine-refractory SE is continuous seizure activity despite treatment with a benzodiazepine. Treatment of benzodiazepine-refractory SE includes levetiracetam with loading doses ranging from 20 mg/kg to 60 mg/kg up to a maximum dose of 4500 mg. While levetiracetam has minimal adverse effects, there is currently a lack of studies directly comparing the safety and efficacy of various loading doses of levetiracetam.

OBJECTIVE

The objective of this study was to evaluate the safety and efficacy of three loading doses of levetiracetam in the setting of benzodiazepine-refractory SE.

METHODS

This was a single center, retrospective cohort study of adult patients with benzodiazepine-refractory SE who were treated with levetiracetam from April 1, 2016, to August 31, 2023. Patients with documented hypersensitivity to levetiracetam, those who were pregnant or incarcerated and patients who received an alternative antiepileptic drug (AED) prior to levetiracetam were excluded. Patients with other identifiable causes of SE including hyperglycemia, hypoglycemia, hyponatremia or who were post cardiac arrest were also excluded. Patients were divided into three arms based on loading dose of levetiracetam administered (≤20 mg/kg [LEVlow], 21--39 mg/kg [LEVmed] or ≥40 mg/kg [LEVhigh]). The primary endpoint was the rate of seizure termination, defined as the lack of need for an additional AED within 60 min following levetiracetam administration. Secondary outcomes included the rate of intubation, and recurrent seizure activity 60 min to 24 h post seizure termination as defined by positive EEG results or need for an additional AED. Subgroup analyses were performed to assess the influence of adequate loading doses of benzodiazepines, and outpatient levetiracetam use.

RESULTS

Overall, 740 patients were screened for inclusion, with 218 patients being included in the primary analysis. Patients were divided into three groups with an average levetiracetam loading dose of 14.5 mg/kg in the LEVlow group, 28.8 mg/kg in the LEVmed group, and 48.8 mg/kg in the LEVhigh group. There was no difference in rates of seizure termination at 60 min (92.9% LEVlow vs 89.3% LEVmed vs 84.7% LEVhigh; p = 0.377). Additionally, no difference was found in rates of recurrent seizure activity between 60 min and 24 h post levetiracetam loading dose (32.1% LEVlow vs 32.0% LEVmed vs 28.8% LEVhigh; p = 0.899). However, the LEVhigh group did have a higher rate of intubation (45.8%) compared to the LEVmed (28.2%) and LEVlow (26.8%) group (p = 0.040).

CONCLUSION

The loading of levetiracetam did not result in a statistically significant difference in rate of seizure termination at 60 min nor did it appear to impact the rate of recurrent seizures at 24 h. However, we did find higher rates of intubation in patients who received levetiracetam >40 mg/kg. Further research is warranted to determine the optimal loading dose of levetiracetam in benzodiazepine-refractory SE.

Population Pharmacokinetics and Loading Dose Optimization of Intravenous Valproic Acid in Hospitalized Thai Patients

Our goal is to create a population pharmacokinetic (PK) model and identify the best loading dose (LD) of intravenous valproic acid for hospitalized Thai patients. Data from patients who received intravenous valproic acid and underwent measurement of serum valproic acid concentrations during hospitalization were collected retrospectively. A nonlinear mixed-effects modeling approach was conducted to estimate the PK parameters of valproic acid. Covariates affecting the PK parameters of valproic acid were examined and ranked based on their impact on the model's performance. Monte Carlo simulations of 1000 patients were conducted to estimate the optimal LD of valproic acid. A total of 120 hospitalized patients (51.7% male) with 167 valproic acid concentrations were included in the study. A linear one-compartment model with constant residual error was the best base model. An age-covariate model was the best predictor of valproic acid clearance (CL). The typical values of CL and volume of distribution for valproic acid were 0.77 L/h and 14.56 L, respectively. The LD of 1000-1200 mg intravenous was identified as the pragmatic option as an empirical regimen for hospitalized Thai patients. The recommended time to initiate maintenance dose (MD) is 4-8 h following the LD. The population PK model and optimal LD of valproic acid in hospitalized Thai patients has been established, and it may be advisable to initiate the MD at a later time for the elderly.

Ketamine plus midazolam compared to midazolam infusion for the management of refractory status epilepticus

BACKGROUND

Data for the use of ketamine (Ket) in treatment of refractory and super-refractory status epilepticus (RSE, SRSE) is lacking despite its widespread growing use. We examined the efficacy of ketamine plus midazolam (MDZ) infusions for treating RSE versus midazolam alone. We hypothesized that ketamine initiation would result in earlier seizure termination.

METHODS

Data was obtained from electronic health records (EHR) of adult patients who received intravenous anesthetic agents for RSE in our neurointensive care unit. Two cohorts were identified. The MDZ cohort received midazolam as the only intravenous anesthetic agent for RSE. The Ket+MDZ cohort received midazolam infusion followed by ketamine infusion. The primary outcomes were time from midazolam infusion start to SE end in both cohorts, and time from ketamine infusion start (Ket Start) to SE end in the Ket+MDZ cohort versus midazolam infusion start (MDZ start) to SE end in the MDZ cohort.

RESULTS

73 patients were included (MDZ cohort n=17, Ket + MDZ cohort n=56). Cohorts did not differ significantly in age, sex, race, RSE etiology, or GCS on admission. Mean APACHE II score was higher in the Ket +MDZ cohort (26 ± 7.32 SD) versus the MDZ cohort (22 ± 5.89 SD)(P=.015). In survival analyses, cohorts did not differ significantly in time from midazolam start to SE end (HR=0.965, 95 % CI=0.556-1.673, P=.899; median [IQR]: MDZ: 25 h [4.5-58]; Ket+MDZ: 21.5 h [IQR 13.5-49]). Time from Ket start (Ket+MDZ group) versus time from MDZ start (MDZ group) to SE end was significantly shorter in the Ket+MDZ cohort (HR=1.895, 95 % CI=1.083-3.314, P=.025). The pattern of results was similar when including APACHE II and MDZ maximum dosage as covariates.

CONCLUSION

Time to SE end was significantly shorter after addition of ketamine infusion to midazolam infusion, versus after initiation of midazolam infusion monotherapy. Patients with higher disease severity favored Ket+MDZ. Randomized controlled trials are warranted in determining optimal anesthetics in RSE and SRSE.

ICU-Electroencephalogram Unit Improves Outcome in Status Epilepticus Patients: A Retrospective Before-After Study

OBJECTIVES

Continuous electroencephalogram (cEEG) monitoring is recommended for status epilepticus (SE) management in ICU but is still underused due to resource limitations and inconclusive evidence regarding its impact on outcome. Furthermore, the term "continuous monitoring" often implies continuous recording with variable intermittent review. The establishment of a dedicated ICU-electroencephalogram unit may fill this gap, allowing cEEG with nearly real-time review and multidisciplinary management collaboration. This study aimed to evaluate the effect of ICU-electroencephalogram unit establishing on SE outcome and management.

DESIGN

Single-center retrospective before-after study.

SETTING

Neuro-ICU of a Swiss academic tertiary medical care center.

PATIENTS

Adult patients treated for nonhypoxic SE between November 1, 2015, and December 31, 2023.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Data from all SE patients were assessed, comparing those treated before and after ICU-electroencephalogram unit introduction. Primary outcomes were return to premorbid neurologic function, ICU mortality, SE duration, and ICU SE management. Secondary outcomes were SE type and etiology. Two hundred seven SE patients were included, 149 (72%) before and 58 (38%) after ICU-electroencephalogram unit establishment. ICU-electroencephalogram unit introduction was associated with increased detection of nonconvulsive SE ( p = 0.003) and SE due to acute symptomatic etiology ( p = 0.019). Regression analysis considering age, comorbidities, SE etiology, and SE semeiology revealed a higher chance of returning to premorbid neurologic function ( p = 0.002), reduced SE duration ( p = 0.024), and a shift in SE management with increased use of antiseizure medications ( p = 0.007) after ICU-electroencephalogram unit introduction.

CONCLUSIONS

Integrating neurology expertise in the ICU setting through the establishment of an ICU-electroencephalogram unit with nearly real-time cEEG review, shortened SE duration, and increased likelihood of returning to premorbid neurologic function, with an increased number of antiseizure medications used. Further studies are warranted to validate these findings and assess long-term prognosis.

Ketamine reduces seizure and interictal continuum activity in refractory status epilepticus: a multicenter in-person and teleneurocritical care study

BACKGROUND

There is not a preferred medication for treating refractory status epilepticus (RSE) and intravenous ketamine is increasingly used. Ketamine efficacy, safety, dosage, and influence of other variables on seizure cessation while on ketamine infusions are not well studied. We aimed to characterize ketamine effect on RSE, including interictal activity on electroencephalogram (EEG) and when done by Teleneurocritical care (TNCC).

METHODS

We conducted a multicenter, retrospective study from August 2017 to October 2022. Patients 18 years or older who had RSE and received ketamine were included. The primary outcome was effect of ketamine on RSE including interictal activity; secondary outcomes were effect of other variables on RSE, care by TNCC, ketamine infusion dynamics, adverse events, and discharge outcomes. Logistic regression was used.

RESULTS

Fifty-one patients from five hospitals met inclusion criteria; 30 patients had RSE and interictal activity on EEG. Median age was 56.8 years (IQR 18.2) and 26% had previously diagnosed epilepsy. Sixteen (31%) patients were treated virtually by TNCC. In those with RSE on EEG, ketamine was added as the fourth antiseizure medication (mean 4.4, SD 1.6). An initial bolus of ketamine was used in 24% of patients (95 mg, IQR 47.5), the median infusion rate was 30.8 mcg/kg/min (IQR 40.4), and median infusion duration was 40 h (IQR 37). Ketamine was associated with 50% cessation of RSE and interictal activity at 24 h in 84% of patients, and complete seizure cessation in 43% of patients. In linear regression, ASMs prior to ketamine were associated with seizure cessation (OR 2.6, 95% CI 0.9-6.9, p = 0.05), while the inverse was seen with propofol infusions (OR 0.02, 95% CI 0.001-0.43, p = 0.01). RSE management by in-person NCC versus virtual by TNCC did not affect rates of seizure cessation.

CONCLUSIONS

Ketamine infusions for RSE were associated with reduced seizure burden at 24 h, with 84% of patients having 50% seizure reduction. Similar efficacy and safety was observed irrespective of underlying RSE etiology or when done via TNCC vs in-person NCC.

Spectral properties of bursts in therapeutic burst suppression predict successful treatment of refractory status epilepticus

Burst suppression (BS) on EEG induced by intravenous anesthesia (IVAT) is standard therapy for refractory status epilepticus (RSE). If BS has any independent therapeutic effect on RSE is disputed. We aimed to define EEG characteristics of BS predicting termination or recurrence of status after weaning. All RSE patients treated with IVAT while undergoing continuous EEG monitoring on the neurological intensive care unit between 2014 and 2019 were screened for inclusion. A one hour-period of visually preselected BS-EEG was analyzed. Bursts were segmented by a special thresholding technique and underwent power spectral analysis. Out of 48 enrolled patients, 25 (52.1 %) did not develop seizure recurrence (group Non SE) after weaning from IVAT; in 23 patients (47.9 %), SE reestablished (group SE). In group Non SE, bursts contained higher amounts of EEG delta power (91.59 % vs 80.53 %, p < 0.0001), while faster frequencies were more pronounced in bursts in group SE (theta: 11.38 % vs 5.41 %, p = 0.0008; alpha: 4.89 % vs 1.82 %, p < 0.0001; beta: 3.23 % vs 1.21 %, p = 0.0002). Spectral profiles of individual bursts closely resembled preceding seizure patterns in group SE but not in group Non SE. Accordingly, persistence of spectral composition of initial ictal patterns in bursts, suggests ongoing SE, merely interrupted but not altered by BS. Fast oscillations in bursts indicate a high risk of status recurrence after weaning from IVAT. EEG guided individualized sedation regimes might therefore be superior to standardized anesthesia protocols.

Evaluating the effectiveness of the maximum permitted dose of midazolam in seizure termination: Insights from New South Wales, Australia

OBJECTIVE

Out-of-hospital seizures demand rapid management. Midazolam plays a key role in stopping seizures. At times the first dose of midazolam proves insufficient, necessitating additional doses. Within the New South Wales Ambulance (NSWA) service, the upper limit for midazolam administration is set at 15 mg. However, the outcomes and safety of using midazolam at this maximum dosage have not been thoroughly investigated.

METHODS

A retrospective analysis of out of hospital electronic health records from New South Wales, Australia, over the year 2022, was conducted. The study manually reviewed cases where adult patients received the maximum dose of midazolam for seizure management by paramedics. It focused on seizure cessation success rates and the incidence of adverse effects to evaluate the clinical implications of high-dose midazolam administration.

RESULTS

Of 818 790 individual attendances by NSWA clinicians, a total of 11 392 (1.4%) adults had seizures noted, of which midazolam was administered in 2565 (22.5%). An algorithm shows that in 2352 (91.7%) instances the midazolam was associated with the apparent termination of seizures. Analysis revealed that 176 (1.5%) proportion of all adult's seizure patients required the maximum dose of midazolam for seizure control. These higher doses successfully terminate seizures in about half of the instances. AEs following the maximum dose of midazolam included hypoxia in 26.7% of patients and respiratory depression in 9.7%, indicating significant side effects at higher dosages.

CONCLUSION

In New South Wales, Australia, administering the maximum dose of midazolam to seizure patients is rare but proves effective in approximately half of the refractory seizure cases. Therefore, assessing the potential for additional doses of midazolam or the use of a second-line agent is advisable.

Efficacy and Tolerability of Intranasal Midazolam Administration for Antiseizure Treatment in Adults: A Systematic Review

OBJECTIVE

The objective of this study was to assess the efficacy and tolerability of intranasal midazolam (in-MDZ) administration for antiseizure treatment in adults.

METHODS

Embase and Medline literature databases were searched. We included randomized trials and cohort studies (excluding case series) of adult patients (≥ 18 years of age) examining in-MDZ administration for epilepsy, epileptic seizures, or status epilepticus published in English between 1985 and 2022. Studies were screened for eligibility based on predefined criteria. The primary outcome was the efficacy of in-MDZ administration, and the secondary outcome was its tolerability. Extracted data included study design, patient characteristics, intervention details, and outcomes. Risk of bias was assessed using the Cochrane Risk of Bias Tool.

RESULTS

A total of 12 studies with 929 individuals treated with in-MDZ were included. Most studies were retrospective, with their number increasing over time. Administered in-MDZ doses ranged from 2.5 to 20 mg per single dose. The mean proportion of successful seizure termination after first in-MDZ administration was 72.7% (standard deviation [SD] 18%), and the proportion of seizure recurrence or persistent seizures ranged from 61 to 75%. Most frequent adverse reactions to in-MDZ were dizziness (mean 23.5% [SD 38.6%]), confusion (one study; 17.4%), local irritation (mean 16.6% [SD 9.6%]), and sedation (mean 12.7% [SD 9.7%]).

CONCLUSIONS

Administration of in-MDZ seems promising for the treatment of prolonged epileptic seizures and seizure clusters in adults. Limited evidence suggests that intranasal administration is safe. Further research is warranted because of the heterogeneity of cohorts, the variation in dosages, and the lack of uniformity in defining successful seizure termination.

Efficiency and safety of high-dose undiluted intravenous push levetiracetam loading doses compared to intravenous infusion in seizing patients: A retrospective cohort study

OBJECTIVE

Intravenous (IV) push (IVP) is an alternative administration method for levetiracetam, but evidence evaluating it compared to IV piggyback (IVPB) for loading doses in acutely seizing patients is limited, particularly in patients with status epilepticus (SE). This study aimed to compare the efficiency and safety of IVP versus IVPB levetiracetam loading doses.

METHODS

This was a single-center sequential retrospective study conducted in adult (≥18 years) patients who received an IV levetiracetam loading dose (>2000 mg or ≥20 mg/kg) for acute or suspected seizure. The primary outcome was time to administration, compared between doses given as IVP versus IVPB. Secondary outcomes included rates of adverse events (AEs), rescue benzodiazepine or antiseizure medication administration, intubation, and intensive care unit (ICU) admission between groups.

RESULTS

A total of 246 patients were included; 116 received IVP and 130 received IVPB loading doses. Median age was 56 years; most patients were male (62%) and White (60%) and had witnessed seizures (67%). Doses were administered for SE in 32 (27.5%) and 46 (35.4%) patients in the IVP and IVPB arms, respectively. Median time to administration was shorter in the IVP group (12 vs. 38 min, p < .001). Bradycardia (1.7% vs. 2.3%, p = .99), hypotension (7.8% vs. 12%, p = .30), sedation (6% vs. 12.3%, p = .09), intubation (10% vs. 8%, p = .37), ICU admission (32% vs. 39%, p = .31), and rescue medication administration (8.6% vs. 14.6% p = .10) were similar between groups. In SE patients, IVP was associated with shorter time to administration (12 vs. 44 min, p = .003) and lower odds of ICU admission after adjustment for age, dose, Status Epilepticus Severity Score, and seizure history (adjusted odds ratio = .23, 95% confidence interval = .06-.81).

SIGNIFICANCE

IVP reduced time to levetiracetam administration versus IVPB and was not associated with more AEs. Rescue agent use, intubation, and ICU admission were similar between arms, but IVP may reduce ICU admissions in SE patients. Prospective studies should assess the effectiveness of IVP versus IVPB.

Ketamine for Super-Refractory Status Epilepticus in Palliative Care. A Case Report and Review of the Literature

We report a case of super refractory status epilepticus uncontrolled by multiple anti-seizure medications in an individual with acute liver failure due to hepatic cirrhosis and an obstructive ileocecal mass plus multiple bilateral lung lesions presumed to be metastatic. A ketamine infusion was initiated late in his hospitalization which eliminated the convulsive seizures in less than an hour. The abatement of convulsive seizures allowed his grieving wife to return to her husband's bedside to witness the withdrawal of life sustaining treatment and be present during the final 24 hours of his life. We review the medical literature on the role of Intravenous (IV) Ketamine in the treatment of super refractory status epilepticus.

Status epilepticus in tuberculous meningitis

OBJECTIVE

There is paucity of information about status epilepticus (SE) in tuberculous meningitis (TBM). In this communication, we report SE semiology, response to antiseizure medication (ASM) and outcome of the TBM patients with SE.

METHODS

The diagnosis of TBM was based on clinical, cerebrospinal fluid and MRI findings. The clinical details, severity of meningitis, and MRI and electroencephalography findings were noted. The type of SE, onset from the meningitis symptoms, number of ASMs required to control SE and outcomes were noted.

RESULTS

During study period from august 2015 to march 2023, 143 TBM patients were admitted and 10 (6.9 %) had SE, whose age ranged between 12 and 45 years. MRI revealed exudates in six, hydrocephalus in three, infarctions in seven and tuberculoma in six patients. Median (interquartile range) duration of SE after meningitis symptoms was 65 (43.7-100.5) days. Three had generalized convulsive SE, three epileptia partialis continua (EPC), three focal convulsive SE with bilateral convulsion, and one had non-convulsive SE. Two (20 %) patients responded to two ASMs, six (60 %) had refractory SE whose seizure continued after benzodiazepine and one ASM, and two (20 %) had super-refractory SE having seizures for ≥ 24 h despite use of intravenous anesthetic agent. Four (40 %) patients died; uncontrolled SE resulted death in one, and the remaining patients died due to primary disease. Only 2 (20 %) patients had good recovery and 4 (40 %) had poor recovery at 6 months.

CONCLUSION

Status epilepticus in TBM is uncommon and can be refractory or super-refractory resulting in poor outcome.

A Comprehensive Review of Recent Trends in Surgical Approaches for Epilepsy Management

Epilepsy is a neurological disorder that affects millions of people worldwide, with a significant proportion of patients experiencing drug-resistant epilepsy, where seizures remain uncontrolled despite medical treatment. This review evaluates the latest surgical techniques for managing epilepsy, focusing on their effectiveness, safety, and the ongoing challenges that hinder their broader adoption. We explored various databases including PubMed, Google Scholar, and Cochrane Library to look for relevant literature using the following keywords: Epilepsy, Resective Surgery, Corpus Collectumy, and Antiepileptic Drugs. A total of 54 relevant articles were found and thoroughly explored. Recent advancements in surgical interventions include resective procedures such as anterior temporal lobectomy, corpus callosotomy, and hemispherectomy, which have been particularly effective in reducing seizures for specific types of epilepsy. Minimally invasive techniques, including laser interstitial thermal therapy and focused ultrasound, are increasingly being used, offering promising outcomes for certain patient groups. Additionally, neuromodulation methods such as deep brain stimulation, vagus nerve stimulation, and responsive neurostimulation provide alternative treatment options, especially for patients who are not suitable candidates for resective surgery. Despite these advancements, the full potential of epilepsy surgery is often underutilized due to various challenges. Inconsistent referral practices, a lack of standardized surgical protocols, and significant socioeconomic barriers continue to limit access to these procedures. Addressing these issues through improved referral processes, better education for healthcare providers and patients, and ensuring equitable access to advanced surgical treatments is crucial for optimizing patient outcomes. Future research should focus on overcoming these barriers and assessing long-term outcomes to further enhance the care of patients with epilepsy.

Effects of steroids on super-refractory status epilepticus in tick-borne meningoencephalitis

We report a unique case of super-refractory status epilepticus (SRSE) secondary to tick-borne encephalitis (TBE) to evaluate the therapeutic challenges and potential benefits of steroid treatment in this context. A previously healthy 31-year-old woman was admitted to the hospital with fever, headache, vertigo, and meningismus, ultimately diagnosed with TBE. Despite empirical antimicrobial treatment, the patient's condition deteriorated, leading to coma and SRSE. Various antiseizure medications and sedatives were administered without sustained success. Steroid treatment was initiated due to elevated intracranial pressure and persistent seizure activity. Following the administration of dexamethasone, electrographic status epilepticus resolved, though the patient developed clinical signs of increased intracranial pressure necessitating decompressive craniectomy. The patient's condition stabilized with a combination of antiseizure medicazions. Despite cessation of SRSE, the patient remained in a minimally conscious state at discharge, showing only gradual improvement over time. The use of steroids in TBE is controversial, with limited reports of potential benefits. In this case, steroid administration coincided with the cessation of SRSE, and authors explore its potential benefit considering its immunomodulatory effects.

A Simulation-Based Assessment of Levetiracetam Concentrations Following Fixed and Weight-Based Loading Doses: A Meta-Regression and Pharmacokinetic Modeling Analysis

Current recommendations for refractory status epilepticus (SE) unresponsive to benzodiazepines suggest a loading dose of levetiracetam (LEV) of 60 mg/kg to a maximum of 4500 mg. LEV therapeutic drug monitoring can help guide therapy and is garnering increasing attention. The objective of this study is to simulate the probability of target attainment (PTA) of fixed dose and weight-based loading doses of LEV with respect to established therapeutic target concentrations. Meta-regression of the current literature was performed to evaluate the relationship between intravenous LEV loading dose and seizure cessation in refractory SE patients. A previously published pharmacokinetic model was used to simulate the PTA capacity of competing single intravenous dosing schemes (fixed vs weight-based dosing) to achieve maximum (Cpeak) and 12-h (C12h) plasma concentrations that exceed 12 mg/L. The meta-regression indicated that dosage was not a statistically significant modulator of seizure control at dosages between 20 and 60 mg/kg. Stochastic simulations showed all dosing schemes achieved plasma Cpeak >12 mg/L, but C12h levels were <12 mg/L in subjects over 60 kg with a fixed dose ≤2000 mg or in subjects <60 kg with a weight-based dose <30 mg/kg. Dosages of 40 and 60 mg/kg provided ≥90% PTAs across all weights. Using a weight-based loading dose of 40 mg/kg, up to a suggested maximum of 4500 mg, improves the likelihood of achieving a sustained therapeutic drug concentration after the initial LEV dose, whereas fixed <3000 mg may not achieve the desired concentration before maintenance dosing.

Improving Quality of Care for Status Epilepticus: Putting Protocols into Practice

PURPOSE OF REVIEW

Timely treatment of status epilepticus (SE) improves outcomes, however gaps between recommended and implemented care are common. This review analyzes obstacles and explores interventions to optimize effective, evidence-based treatment of SE.

RECENT FINDINGS

Seizure action plans, rescue medications, and noninvasive wearables with seizure detection capabilities can facilitate early intervention for prolonged seizures in the home and school. In the field, standardized EMS protocols, EMS education, and screening tools can address variability in SE definitions and treatment, particularly benzodiazepine dosing. In the emergency room and hospital, provider education, SE order sets and alerts, and rapid EEG technologies, can shorten time to first-line therapy, second-line therapy, and EEG initiation. Widespread, sustained improvement in SE care remains challenging. A multipronged approach including emphasis on pre-hospital intervention, treatment protocols adapted to local contexts, and SE databases to systematically collect process and outcome metrics have the potential to transform SE treatment and outcomes.

Intranasal Versus Buccal Versus Intramuscular Midazolam for the Home and Emergency Treatment of Acute Seizures in Pediatric Patients: A Randomized Controlled Trial

BACKGROUND

Benzodiazepines are the recommended first-line treatment of acute seizures. We wished to compare the efficacy, side effects, and satisfaction after midazolam administration by the buccal, intranasal, or intramuscular route in the treatment of acute seizures in children at homes and in emergency room (ER).

METHODS

A prospective, randomized, controlled trial was performed in children aged one month to 17 years with acute seizures lasting longer than five minutes. The primary end point was seizure cessation within 10 minutes of drug administration and no seizure recurrence within 30 minutes.

RESULTS

In the home group, 67 patients received midazolam via buccal route, 60 via intranasal route, and 69 via intramuscular route, whereas in the ER group, 37 patients received buccal, 34 received intranasal, and 34 received intramuscular midazolam. The primary end point was achieved in 94.2% and 85.3% after intramuscular midazolam in the home and ER groups, respectively. The intranasal midazolam was successful in stopping seizures in 93.3% in the home group and 88.2% in the ER group. The buccal route was effective in 91% in the home group and 78.4% in the ER group. There were no significant differences in efficacy between all groups (P = 0.763 and P = 0.509) among the home and ER groups, respectively. There were no significant cardiorespiratory events in all groups.

CONCLUSIONS

Intramuscular, intranasal, and buccal doses of midazolam resolved most seizures in prehospital and emergency settings. Our results indicate that there is no statistically significant difference detected between different routes of midazolam. Intranasal route showed the highest satisfaction rate among caregivers.

Morbidity Associated with Deviation from Pediatric Status Epilepticus Guidelines

Treatment guidelines for the management of pediatric status epilepticus (PSE) are often institution-specific. We aim to characterize deviation from our hospital-based PSE treatment guidelines, the total dosage of benzodiazepines administered, and the need for intubation. The study population included all patients with an ICD -10 code for PSE who required admission to the Pediatric Intensive Care Unit (PICU) from April 2019 to April 2022. There were 66 PICU admissions. All patients with concern for PSE and altered mental status are admitted to the PICU. The cohort was divided between those treated according to the PSE protocol (benzodiazepine dose (0.05 mg/kg- 0.2 mg/kg) versus those who had low dose (≤0.05 mg/kg) and high-dose benzodiazepine (> 0.2 mg/kg) totals. The dosage was calculated as the total dose of benzodiazepines received pre-hospital and in the ED before intubation or transport. Forty-one (62 %) of patients received high-dose benzodiazepines (median 0.34 mg/kg [IQR 0.29-0.56], 19 (29 %) received recommended-dose benzodiazepines (median 0.13 mg/kg [IQR 0.09,0.15] and 6 (9 %) received low-dose (median 0.05 mg/kg [IQR 0.03,0.05]. The high-dose group was 15.9 (95 % CI = 3.7, 99.9) times more likely to be intubated controlling for the location of care (tertiary versus community hospital), and the age of the patient. The recommended-dose and low-dose groups required intubation with much less frequency.