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Albin CSW, Cunha CB, Glaser TP, Schachter M, Snow JW, Oto B. The Approach to Altered Mental Status in the Intensive Care Unit. Semin Neurol 2024. [PMID: 39137901 DOI: 10.1055/s-0044-1788894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
Altered mental status (AMS) is a syndrome posing substantial burden to patients in the intensive care unit (ICU) in both prevalence and intensity. Unfortunately, ICU patients are often diagnosed merely with syndromic labels, particularly the duo of toxic-metabolic encephalopathy (TME) and delirium. Before applying a nonspecific diagnostic label, every patient with AMS should be evaluated for specific, treatable diseases affecting the central nervous system. This review offers a structured approach to increase the probability of identifying specific causal etiologies of AMS in the critically ill. We provide tips for bedside assessment in the challenging ICU environment and review the role and yield of common neurodiagnostic procedures, including specialized bedside modalities of diagnostic utility in unstable patients. We briefly review two common etiologies of TME (uremic and septic encephalopathies), and then review a selection of high-yield toxicologic, neurologic, and infectious causes of AMS in the ICU, with an emphasis on those that require deliberate consideration as they elude routine screening. The final section lays out an approach to the various etiologies of AMS in the critically ill.
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Affiliation(s)
| | - Cheston B Cunha
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Rhode Island Hospital, Providence, Rhode Island
| | - Timlin P Glaser
- University of Arizona College of Medicine, Phoenix, Arizona
- Banner University Medical Center, Phoenix, Arizona
| | | | - Jerry W Snow
- University of Arizona College of Medicine, Phoenix, Arizona
- Banner University Medical Center, Phoenix, Arizona
| | - Brandon Oto
- sBridgeport Hospital, Yale New Haven Health, Bridgeport, Connecticut
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2
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Yuan F, Damien C, Gaspard N. Prognostic scores in status epilepticus: A systematic review and meta-analysis. Epilepsia 2023; 64:17-28. [PMID: 36271624 DOI: 10.1111/epi.17442] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 01/21/2023]
Abstract
The performance of prognostic scores of status epilepticus (SE) has been reported in very heterogeneous cohorts. We aimed to provide a summary of the available evidence on their respective performance. PubMed and EMBASE were searched for relevant articles. Studies were reviewed for eligibility for meta-analysis of the area under the receiver-operating characteristic curve (AUC) and for meta-analysis of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in predicting in-hospital mortality with scores in which at least two external evaluations had been published. This study was registered with PROSPERO (international prospective register of systematic reviews) (CRD42022325766). Study quality was assessed using Prediction model Risk Of Bias ASsessment Tool (PROBAST). In the meta-analysis of AUC, 21 studies were pooled for STESS (Status Epilepticus Severity Score), five for EMSE-EAC (Epidemiology-based Mortality Score in Status Epilepticus - Etiology, Age, level of Consciousness), five for EMSE-EACE (EMSE - Etiology, Age, level of Consciousness, EEG), and two for ENDIT (Encephalitis, nonconvulsive status epilepticus, Diazepam resistance, Imaging abnormalities, Tracheal intubation). The pooled AUC of STESS, EMSE-EAC, EMSE-EACE, and ENDIT was 0.74 (95% CI: 0.71-0.78), 0.68 (95% CI 0.63-0.72), 0.77 (95% CI: 0.72-0.81), and 0.78 (95% CI: 0.70-0.87), respectively. The pooled sensitivity of STESS-3, STESS-4, EMSE-EACE-64, and ENDIT-4 was 0.83 (95% CI: 0.80-0.86), 0.60 (95% CI: 0.55-0.65), 0.76 (95% CI: 0.67-0.83), and 0.70 (95% CI: 0.55-0.82), respectively. Their pooled specificity was 0.50 (95% CI: 0.48-0.52), 0.74 (95% CI: 0.72-0.76), 0.63 (95% CI: 0.59-0.67), and 0.65 (95% CI: 0.61-0.70), respectively. Their pooled PPV was 0.27 (95% CI: 0.24-0.30), 0.35 (95% CI: 0.29-0.41), 0.33 (95% CI: 0.24-0.43), and 0.20 (95% CI: 0.13-0.27). Their pooled NPV was 0.94 (95% CI: 0.93-0.96), 0.90 (95% CI: 0.89-0.92), 0.89 (95% CI: 0.80-0.98), and 0.95 (95% CI: 0.92-0.98). Variations in performance were observed in patients' subgroups, such as critically ill patients and refractory cases. Investigated scores only have acceptable AUC, sensitivity, and specificity for predicting in-hospital mortality, with the EMSE-EAC having a lower discriminative power. STESS-3 has the highest sensitivity, and STESS-4 the highest specificity, but neither combines acceptable sensitivity and specificity. All these scores had high NPV but very low PPV. Caution should be exercised in their clinical use. Further studies are required to develop more accurate scores.
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Affiliation(s)
- Fang Yuan
- Neurology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.,Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Charlotte Damien
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium.,Neurology Department, Yale University School of Medicine, New Haven, Connecticut, USA
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3
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Wickstrom R, Taraschenko O, Dilena R, Payne ET, Specchio N, Nabbout R, Koh S, Gaspard N, Hirsch LJ. International consensus recommendations for management of New Onset Refractory Status Epilepticus (NORSE) incl. Febrile Infection-Related Epilepsy Syndrome (FIRES): Statements and Supporting Evidence. Epilepsia 2022; 63:2840-2864. [PMID: 35997591 PMCID: PMC9828002 DOI: 10.1111/epi.17397] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/14/2022] [Accepted: 08/18/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To develop consensus-based recommendations for the management of adult and paediatric patients with NORSE/FIRES based on best evidence and experience. METHODS The Delphi methodology was followed. A facilitator group of 9 experts was established, who defined the scope, users and suggestions for recommendations. Following a review of the current literature, recommendation statements concerning diagnosis, treatment and research directions were generated which were then voted on a scale of 1 (strongly disagree) to 9 (strongly agree) by a panel of 48 experts in the field. Consensus that a statement was appropriate was reached if the median score was greater or equal to 7, and inappropriate if the median score was less than or equal to 3. The analysis of evidence was mapped to the results of each statement included in the Delphi survey. RESULTS Overall, 85 recommendation statements achieved consensus. The recommendations are divided into five sections: 1) disease characteristics, 2) diagnostic testing and sampling, 3) acute treatment, 4) treatment in the post-acute phase, and 5) research, registries and future directions in NORSE/FIRES. The detailed results and discussion of all 85 statements are outlined herein. A corresponding summary of findings and practical flowsheets are presented in a companion article. SIGNIFICANCE This detailed analysis offers insight into the supporting evidence and the current gaps in the literature that are associated with expert consensus statements related to NORSE/FIRES. The recommendations generated by this consensus can be used as a guide for the diagnosis, evaluation, and management of patients with NORSE/FIRES, and for planning of future research.
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Affiliation(s)
- Ronny Wickstrom
- Neuropaediatric UnitDepartment of Women's and Children's HealthKarolinska Institutet and Karolinska University HospitalStockholmSweden
| | - Olga Taraschenko
- Department of Neurological SciencesUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | - Robertino Dilena
- Neuropathophysiology UnitFoundation IRCCS Ca' Granda Ospedale Maggiore PoliclinicoMilanItaly
| | - Eric T. Payne
- Department of Pediatrics, Section of NeurologyAlberta Children's HospitalCalgaryAlbertaCanada
| | - Nicola Specchio
- Rare and Complex Epilepsy Unit, Department of NeurosciencesBambino Gesù Children's Hospital, IRCCS, Full Member of European Reference Network EpiCARERomeItaly
| | - Rima Nabbout
- Department of Pediatric Neurology, APHP, Member of EPICARE ERN, Centre de Reference Epilepsies RaresUniversite de Paris, Institut Imagine, INSERM 1163ParisFrance
| | - Sookyong Koh
- Department of Pediatrics, Children's Hospital and Medical CenterUniversity of NebraskaOmahaNebraskaUSA
| | | | - Lawrence J. Hirsch
- Department of Neurology, Comprehensive Epilepsy CenterYale UniversityNew HavenConnecticutUSA
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Busl KM, Bleck TP, Varelas PN. Neurocritical Care Outcomes, Research, and Technology: A Review. JAMA Neurol 2020; 76:612-618. [PMID: 30667464 DOI: 10.1001/jamaneurol.2018.4407] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Neurocritical care has grown into an organized specialty that may have consequences for patient care, outcomes, research, and neurointensive care (neuroICU) technology. Observations Neurocritical care improves care and outcomes of the patients who are neurocritically ill, and neuroICUs positively affect the financial state of health care systems. The development of neurocritical care as a recognized subspecialty has fostered multidisciplinary research, neuromonitoring, and neurocritical care information technology, with advances and innovations in practice and progress. Conclusions and Relevance Neurocritical care has become an important part of health systems and an established subspecialty of neurology. Understanding its structure, scope of practice, consequences for care, and research are important.
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Affiliation(s)
- Katharina Maria Busl
- NeuroIntensive Care Unit, University of Florida Health Shands Hospital, Gainesville.,Department of Neurology, Division of Neurocritical Care, College of Medicine, University of Florida, Gainesville
| | - Thomas P Bleck
- Rush University Medical Center, Rush Medical College, Chicago, Illinois
| | - Panayiotis N Varelas
- Neurosciences Critical Care Services, Neuro-Intensive Care Unit, Henry Ford Hospital, Wayne State University, Detroit, Michigan
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Neligan A, Noyce AJ, Gosavi TD, Shorvon SD, Köhler S, Walker MC. Change in Mortality of Generalized Convulsive Status Epilepticus in High-Income Countries Over Time: A Systematic Review and Meta-analysis. JAMA Neurol 2019; 76:897-905. [PMID: 31135807 DOI: 10.1001/jamaneurol.2019.1268] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Status epilepticus (SE) is associated with significant morbidity and mortality. Since the late 1990s, a more aggressive management of prolonged convulsive seizures lasting longer than 5 minutes has been advocated. Objective To determine if convulsive SE mortality has decreased during a time of increasing advocacy for out-of-hospital treatment and escalating and earlier treatment protocols for prolonged seizures and SE. Data Source This systemic review and meta-analysis on studies focused on the mortality of convulsive status epilepticus was conducted by searching MEDLINE, Embase, PsychINFO, CINAHL Plus, and the Cochrane Database of Systematic Reviews between January 1, 1990, and June 30, 2017. Study Selection Studies were excluded if they had fewer than 30 participants (<20 for refractory SE), were limited to SE of single specific etiology or an evaluation of a single treatment modality, or were studies of nonconvulsive SE. Data Extraction and Synthesis Data were abstracted and their quality was assessed via a modified Newcastle-Ottawa scale independently by 2 reviewers (A.N. and T.D.G.) using the Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines. Data were pooled using a random-effects model. Main Outcomes and Measures The main outcome measure was in-hospital mortality or 30-day case fatality expressed as proportional mortality. Results Sixty-one studies were included in the analysis. The pooled mortality ratios were 15.9% (95% CI, 12.7-19.2) for adult studies, 13.0% (95% CI, 7.2-19.0) for all-age population studies, 3.6% (95% CI, 2.0%-5.2%) for pediatric studies, and 17.3% (95% CI, 9.8-24.7) for refractory SE studies, with very high between-study heterogeneity. We found no evidence of a change in prognosis over time nor by the definition of SE used. Conclusions and Relevance The mortality of convulsive SE is higher in adults than in children and there was no evidence for improved survival over time. Although there are many explanations for these findings, they can be explained by aetiology of SE being the major determinant of mortality. However, there are potential confounders, including differences in case ascertainment and study heterogeneity. This meta-analysis highlights the need for strict international guidelines for the study of this condition.
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Affiliation(s)
- Aidan Neligan
- Homerton University Hospital NHS Foundation Trust, Homerton Row, London, England.,University College London Queen Square Institute of Neurology, Queen Square, London, England.,Preventive Neurology Unit, Wolfson Institute of Preventative Medicine, Queen Mary University of London, London, England
| | - Alastair John Noyce
- University College London Queen Square Institute of Neurology, Queen Square, London, England.,Preventive Neurology Unit, Wolfson Institute of Preventative Medicine, Queen Mary University of London, London, England
| | | | - Simon D Shorvon
- University College London Queen Square Institute of Neurology, Queen Square, London, England
| | - Sebastian Köhler
- Maastricht University Medical Centre, School for Mental Health and Neuroscience, Alzheimer Centre Limburg, Maastricht, the Netherlands
| | - Matthew C Walker
- University College London Queen Square Institute of Neurology, Queen Square, London, England
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Building a Case for a Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.036] [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]
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Semmlack S, Kaplan PW, Spiegel R, De Marchis GM, Hunziker S, Tisljar K, Rüegg S, Marsch S, Sutter R. Illness severity scoring in status epilepticus—When
STESS
meets
APACHE II
,
SAPS II
, and
SOFA. Epilepsia 2018; 60:189-200. [DOI: 10.1111/epi.14623] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 11/24/2018] [Accepted: 11/25/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Saskia Semmlack
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
| | - Peter W. Kaplan
- Department of Neurology Johns Hopkins Bayview Medical Center Baltimore Maryland
| | - Rainer Spiegel
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
| | | | - Sabina Hunziker
- Medical Communication and Psychosomatic Medicine University Hospital Basel Basel Switzerland
- Medical Faculty of the University of Basel Basel Switzerland
| | - Kai Tisljar
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
| | - Stephan Rüegg
- Department of Neurology University Hospital Basel Basel Switzerland
| | - Stephan Marsch
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
- Medical Faculty of the University of Basel Basel Switzerland
| | - Raoul Sutter
- Clinic for Intensive Care Medicine University Hospital Basel Basel Switzerland
- Department of Neurology University Hospital Basel Basel Switzerland
- Medical Faculty of the University of Basel Basel Switzerland
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Continuous Electroencephalography in the Critically Ill: Clinical and Continuous Electroencephalography Markers for Targeted Monitoring. J Clin Neurophysiol 2018; 35:325-331. [PMID: 29677014 DOI: 10.1097/wnp.0000000000000475] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Electrographic seizures detected by continuous electroencephalography (CEEG) in critically ill patients with altered mental status is becoming increasingly recognized. Data guiding the appropriate selection of patients to be monitored on CEEG are lacking. The aims of this article were to study the incidence of seizures in the critical care setting and to evaluate for clinical predictors to improve the efficiency of CEEG monitoring. METHODS Retrospective review of the CEEG and clinical data on 1,123 consecutive patients who had continuous video EEG over a 24-month period. RESULTS Seizures were recorded in 215 patients on CEEG monitoring (19.1%). In total, 89.3% of these seizures occurred without clinical signs. Patients who were in a coma were more likely to have EEG seizures (odds ratio, 3.64; 95% confidence interval, 2.23-5.95) compared with those awake. The incidence of seizures was overrepresented in patients with extra-axial tumors (41.9%), multiple sclerosis (35.7%), and intra-axial tumors (33.0%). Lateralized periodic discharges were predictive (odds ratio, 8.27; 95% confidence interval, 5.52-12.46) of seizure occurrence compared with those with no epileptiform patterns. Only generalized periodic discharges with triphasic morphology had no increased odds of seizure (odds ratio, 1.02; 95% confidence interval, 0.24-3.03). When present, electroencephalography seizures were detected within 24 hours in 92% of monitored patients. CONCLUSIONS Continuous electroencephalography monitoring in the critical care setting demonstrates a linear increase in seizure incidence with declining mental status. Recognizing clinical conditions and electroencephalography markings may help in the appropriate selection of critically ill patients for CEEG monitoring.
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Alvarez V, Lee JW, Westover MB, Drislane FW, Novy J, Faouzi M, Marchi NA, Dworetzky BA, Rossetti AO. Therapeutic coma for status epilepticus: Differing practices in a prospective multicenter study. Neurology 2016; 87:1650-1659. [PMID: 27664985 DOI: 10.1212/wnl.0000000000003224] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 05/20/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Our aim was to analyze and compare the use of therapeutic coma (TC) for refractory status epilepticus (SE) across different centers and its effect on outcome. METHODS Clinical data for all consecutive adults (>16 years) with SE of all etiologies (except postanoxic) admitted to 4 tertiary care centers belonging to Harvard Affiliated Hospitals (HAH) and the Centre Hospitalier Universitaire Vaudois (CHUV) were prospectively collected and analyzed for TC details, mortality, and duration of hospitalization. RESULTS Two hundred thirty-six SE episodes in the CHUV and 126 in the HAH were identified. Both groups were homogeneous in demographics, comorbidities, SE characteristics, and Status Epilepticus Severity Score (STESS); TC was used in 25.4% of cases in HAH vs 9.75% in CHUV. After adjustment, TC use was associated with younger age, lower Charlson Comorbidity Index, increasing SE severity, refractory SE, and center (odds ratio 11.3 for HAH vs CHUV, 95% confidence interval 2.47-51.7). Mortality was associated with increasing Charlson Comorbidity Index and STESS, etiology, and refractory SE. Length of stay correlated with STESS, etiology, refractory SE, and use of TC (incidence rate ratio 1.6, 95% confidence interval 1.22-2.11). CONCLUSIONS Use of TC for SE treatment seems markedly different between centers from the United States and Europe, and did not affect mortality considering the whole cohort. However, TC may increase length of hospital stay and related costs. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for patients with SE, TC does not significantly affect mortality. The study lacked the precision to exclude an important effect of TC on mortality.
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Affiliation(s)
- Vincent Alvarez
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland.
| | - Jong Woo Lee
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - M Brandon Westover
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - Frank W Drislane
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - Jan Novy
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - Mohamed Faouzi
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - Nicola A Marchi
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - Barbara A Dworetzky
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
| | - Andrea O Rossetti
- From the Department of Neurology (V.A.), Hôpital du Valais, Sion; Department of Clinical Neurosciences (V.A., J.N., N.A.M., A.O.R.) and Institute of Social and Preventive Medicine (M.F.), CHUV and University of Lausanne, Switzerland; Department of Neurology, Brigham and Women's Hospital (V.A., J.W.L., B.A.D.), Department of Neurology, Massachusetts General Hospital (M.B.W.), and Department of Neurology, Beth Israel Deaconess Medical Center (F.W.D.), Harvard Medical School, Boston, MA; and Department of Clinical Neurosciences (N.A.M.), Geneva University Hospitals, Switzerland
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Radic JAE, Chou SHY, Du R, Lee JW. Levetiracetam versus phenytoin: a comparison of efficacy of seizure prophylaxis and adverse event risk following acute or subacute subdural hematoma diagnosis. Neurocrit Care 2014; 21:228-37. [PMID: 24549935 PMCID: PMC10627505 DOI: 10.1007/s12028-013-9951-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although both levetiracetam and phenytoin are used for seizure prophylaxis in subdural hematomas (SDHs), there is little data on their comparative efficacies. We compared the efficacy and risk of using levetiracetam versus phenytoin for seizure prophylaxis following acute or subacute SDH diagnosis. METHODS In this retrospective cohort study, the clinical data registry at a tertiary care hospital was searched for all cases of acute or subacute SDHs that were admitted to hospital in 2002, 2003, or 2011. Risk of clinical and/or electrographic seizures, and risk of adverse drug events were compared between the two exposure arms. RESULTS 124 subjects in the phenytoin arm and 164 subjects in the levetiracetam arm were included. There was no significant difference in clinical and/or electrographic seizure risk, though there was a decreased risk of adverse events in the levetiracetam arm (p < 0.001). In subjects with midline shift >0 mm, levetiracetam was associated with an increased risk of electrographic seizures during hospitalization (p = 0.028) and a decreased risk of adverse drug effects (p = 0.001), compared with phenytoin use. CONCLUSIONS Levetiracetam generally appears to have a similar efficacy to phenytoin in preventing clinical and/or electrographic seizures following acute/subacute SDH diagnosis, though patients with midline shift >0 mm may have associated with a higher risk of electrographic seizures on levetiracetam compared with patients on phenytoin. Levetiracetam is associated with a lower risk of adverse drug effects. A prospective, randomized study would more definitively determine any difference in efficacy and risk between phenytoin and levetiracetam.
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Affiliation(s)
- Julia Anne Elisabeth Radic
- The Edward B. Bromfield Epilepsy Program, Department of Neurology, Brigham and Women's Hospital, 75 Francis Street, 02115, Boston, MA, USA,
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Bhalla A, Das B, Som R, Prabhakar S, Kharbanda PS. Status epilepticus: Our experience in a tertiary care centre in Northwestern India. J Emerg Trauma Shock 2014; 7:9-13. [PMID: 24550623 PMCID: PMC3912660 DOI: 10.4103/0974-2700.125632] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 11/06/2013] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Status epilepticus (SE) is a medical emergency. Aim of this study was to examine the etiology and outcome of adult patients in status epilepticus presenting to our center. PATIENTS AND METHODS A prospective study was conducted from January 2009 to December 2010. Newly diagnosed patients as well as known case of seizure disorder presenting with status epilepticus were included. Detailed history, clinical examination, baseline investigation, neuroimaging electroencephalogram findings were recorded. Patients were treated using a standard protocol and were followed-up for 2 weeks after discharge. Quantification of precipitating factors was done using proportion, mean and standard deviation. RESULTS 80 consecutive patients were studied. Mean age was 38.43 ± 16.56 years (range 13 to 78 years). Male to female ratio was 4:1. 57.5% were known cases of seizure disorders. Generalized tonic-clonic seizure was commonest presentation in 91.30%. Majority (97.5%) had convulsive SE. Poor drug compliance was found to be the commonest precipitant (50% patients), followed by central nervous system infection (20% patients. Alcohol intake contributed in 12.5% cases, whereas, precipitating factor couldn't be traced in 7.5% patients'. In 55% patients, SE was controlled with no recurrence or complication and in 25% there was recurrence after control of SE. 15% patients ended up with persistent sequel (cognitive and psychosomatic dysfunction, neurological deficit etc.) lasting for 2 weeks or more. The mortality was 5%. CONCLUSION Poor compliance with drugs (in established cases of seizure disorders) and central nervous systems infections/structural lesions (in new onset cases) were commonest causes of SE in our study group. Conventional first line antiepileptics were able to control seizures in only 55% patients.
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Affiliation(s)
- Ashish Bhalla
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Biplab Das
- Department of Neurology and Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rimi Som
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandeep Prabhakar
- Department of Neurology and Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Parampreet S Kharbanda
- Department of Neurology and Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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