Status epilepticus. Causes, clinical features and consequences in 98 patients

Recurrent cerebellar ischemic infarctions and stereotyped peri-ictal sympathetic responses in a near-SUDEP patient with cardiovascular risk factors

We report a 60-year-old woman who presented to the emergency department after experiencing a witnessed unknown onset bilateral tonic clonic seizure (GTCS) that culminated in cardiac arrest. A neurology consultant uncovered a years-long history of frequent episodic staring followed by confusion and expressive aphasia, which strongly suggested that she suffered from epilepsy. Thus, her cardiac arrest and subsequent resuscitation met criteria for a near-sudden unexpected death in epilepsy (SUDEP) diagnosis. Serial bloodwork demonstrated transient troponin I elevations and leukocytoses, while a brain MRI revealed global cerebral anoxic injury and a small acute right cerebellar ischemic infarction. A review of her medical record uncovered a hospitalization sixteen months earlier for a likely GTCS whose workup showed similar troponin I elevations and leukocytoses, and surprisingly, a different small acute right cerebellar ischemic infarction in the same vascular territory. To our knowledge, this is the first report of subcortical ischemic infarctions occurring concurrently with GTCSs in a near-SUDEP patient. Aside from illustrating the key role of inpatient neurologists in the diagnosis of near-SUDEP, this manuscript discusses the potential significance of postictal ischemic infarctions, transient asymptomatic troponin elevations, and transient non-infectious leukocytoses in epilepsy patients with cardiovascular risk factors.

The Anti-Seizure Effect of Liraglutide on Ptz-Induced Convulsions Through its Anti-Oxidant and Anti-Inflammatory Properties

Epilepsy is a prevalent and frequently devastating neurological disorder defined by recurring spontaneous seizures caused by aberrant electrical activity in the brain. Over ten million people worldwide suffer from drug-resistant epilepsy. This severe condition requires novel treatment approaches. Both oxidative and nitrosative stress are thought to have a role in the etiology of epilepsy. Liraglutide is a glucagon-like peptide-1 (GLP-1) analogue that is used to treat type-2 diabetes mellitus. According to recent studies, Liraglutide also shows neuroprotective properties, improving memory retention and total hippocampus pyramidal neuronal population in mice. The purpose of this investigation was to determine the anti-seizure and anti-oxidative effects of liraglutide in a pentylenetetrazole (PTZ)-induced rat model of epilepsy. 48 rats were randomly assigned to two groups: those who had electroencephalography (EEG) recordings and those who underwent behavioral assessment. Rats received either intraperitoneal (IP) liraglutide at two different dosages (3-6 mg/kg) or a placebo, followed by pentylenetetrazole (IP). To determine if liraglutide has anti-seizure characteristics, we examined seizure activity in rats using EEG, the Racine convulsion scale (RCS), the time of first myoclonic jerk (FMJ), and MDA, SOD, TNF-α, IL-1β and GAD-67 levels. The mean EEG spike wave percentage score was reduced from 75.8% (placebo) to 59.4% (lower-dose) and 41.5% (higher-dose). FMJ had increased from a mean of 70.6 s (placebo) to 181.2 s (lower-dose) and 205.2 s (higher-dose). RCS was reduced from a mean of 5.5 (placebo) to 2.7 (lower-dose) and 2.4 (higher-dose). Liraglutide (3 and 6 mg/kg i.p.) successfully decreased the spike percentages and RCS associated with PTZ induced epilepsy, as well as considerably decreased MDA, TNF-α, IL-1β and elevated SOD, GAD-67 levels in rat brain. Liraglutide significantly decreased seizure activity at both dosages when compared to control, most likely due to its anti-oxidant and anti-inflammatory properties. The potential clinical role of liraglutide as an anti-seizure medication should be further explored.

Epidemiology and Risk Factors of Convulsive Status Epilepticus Patients Admitted in the Emergency Department of Tertiary Hospital in Mogadishu, Somalia

INTRODUCTION

Status epilepticus (SE) is one of the most common neurologic emergencies and is associated with significant morbidity and mortality. The underlying cause of SE varies between patients with epilepsy and those presenting without. The aim of this study was to evaluate the epidemiology, risk factors and outcomes of patients presenting with convulsive SE in the emergency department (ED) of a tertiary hospital in Mogadishu.

METHODS

This was a cross-sectional study conducted between July 2021 and June 2022. The study included both patients with epilepsy and those without epilepsy presenting to the ED with SE. Risk factors and underlying etiologies were evaluated in the patients in both the pediatric group (0-18 years) and adult group (18 years and above). Clinical history, neurologic examinations, neuroimaging, electroencephalography findings, and laboratory investigations were all evaluated.

RESULTS

The mean age for pediatric patients was 6 (SD±4.7), while the mean age for adult patients was 38 (SD±10.4). About 33 (36%) of the subjects had previous history of epilepsy, while 59 (64%) presented to the ED with their first seizure. About 80 (87%) had generalized seizure while 12 (13%) had focal seizure. Poor antiepileptic compliance was the most common risk factor for SE 20 (21.7%), followed by CNS infections 14 (15%), and prolonged febrile seizures 7 (7.6%). Poor antiepileptic drug compliance, cerebrovascular disorders, electrolyte imbalance, metabolic conditions, and drug abuse were the most common underlying etiologies of SE in patients older than 18 years. Prolonged febrile seizure, meningitis, encephalitis, systemic infections, and structural brain abnormalities were the most common underlying etiologies of SE in patients younger than 18 years.

CONCLUSION

CNS infections, CVDs, metabolic disturbances, electrolyte imbalances, and systemic infections are major etiological risk factors of SE in patients without prior history of epilepsy. Medication adherence was the major etiological risk factor for SE identified in patients with epilepsy.

Seizures in adults with suspected central nervous system infection

Background

Seizures can be part of the clinical presentation of central nervous system (CNS) infections. We describe patients suspected of a neurological infection who present with a seizure and study diagnostic accuracy of clinical and laboratory features predictive of CNS infection in this population.

Methods

We analyzed all consecutive patients presenting with a seizure from two prospective Dutch cohort studies, in which patients were included who underwent cerebrospinal fluid (CSF) examination because of the suspicion of a CNS infection.

Results

Of 900 episodes of suspected CNS infection, 124 (14%) presented with a seizure. The median age in these 124 episodes was 60 years (IQR 45–71) and 53% of patients was female. CSF examination showed a leukocyte count ≥ 5/mm³ in 41% of episodes. A CNS infection was diagnosed in 27 of 124 episodes (22%), a CNS inflammatory disorder in 8 (6%) episodes, a systemic infection in 10 (8%), other neurological disease in 77 (62%) and in 2 (2%) episodes another systemic disease was diagnosed. Diagnostic accuracy of clinical and laboratory characteristics for the diagnosis of CNS infection in this population was low. CSF leukocyte count was the best predictor for CNS infection in patients with suspected CNS infection presenting with a seizure (area under the curve 0.94, [95% CI 0.88 – 1.00]).

Conclusions

Clinical and laboratory features fail to distinguish CNS infections from other causes of seizures in patients with a suspected CNS infection. CSF leukocyte count is the best predictor for the diagnosis of CNS infection in this population.

Hiding in plain sight? A review of post-convulsive leukocyte elevations

During physiological stress responses such as vigorous exercise, emotional states of fear and rage, and asphyxia, the nervous system induces a massive release of systemic catecholamines that prepares the body for survival by increasing cardiac output and redirecting blood flow from non-essential organs into the cardiopulmonary circulation. A curious byproduct of this vital response is a sudden, transient, and redistributive leukocytosis provoked mostly by the resultant shear forces exerted by rapid blood flow on marginated leukocytes. Generalized convulsive seizures, too, result in catecholamine surges accompanied by similar leukocytoses, the magnitude of which appears to be rooted in semiological factors such as convulsive duration and intensity. This manuscript reviews the history, kinetics, physiology, and clinical significance of post-convulsive leukocyte elevations and discusses their clinical utility, including a proposed role in the scientific investigation of sudden unexpected death in epilepsy (SUDEP).

Predictors of high functional disability and mortality at 3 months in patients with status epilepticus

PURPOSE

There are differences in epidemiology, etiology, and outcome in status epilepticus (SE) between developing and developed countries, which limits generalizability. We evaluated factors related to outcome at 3 months in SE patients in a developing country- Ecuador.

METHODS

Retrospective analysis of a prospectively collected dataset of patients treated for SE at a single hospital over 4 years, recording on 107 patients and 109 episodes, including clinical, demographic, and prognosis assessments.

RESULTS

Hospital mortality was 33%, and 38% at 3 months. Glasgow Coma Scale score pretreatment ≤12 (odds ratio = 7.7), Charlson Index of comorbidities ≥3 (odds ratio = 5.6) and brain lesion (odds ratio = 6.4) predicted high disability. History of epilepsy was associated with favorable outcome in general, and showed a positive impact on survival rates (odds ratio = 0.3), while Glasgow Coma Scale scores pretreatment ≤12 (odds ratio = 4.1) and refractory SE (odds ratio = 2.1) were associated with reduced survival rates. Acute symptomatic etiology was the most common cause of SE (58%). Etiologies with structural brain lesion showed a significantly lower survival rate (Log ranks = 0.04 and 0.003) compared to other groups.

CONCLUSION

Mortality rate at 3 months for SE patients was high. Glasgow Coma Scale, Charlson Index, and brain lesions were associated with unfavorable outcome, including mortality. Overall, the results were similar to those reported in more developed countries, but some differences, including overall higher mortality, prevalence of nonconvulsive SE, and lack of association of age with outcome were evident.

Management of Status Epilepticus and Indications for Inpatient Electroencephalography Monitoring

Status epilepticus (SE) is a neurologic emergency requiring immediate time-sensitive treatment to minimize neuronal injury and systemic complications. Minimizing time to administration of first- and second-line therapy is necessary to optimize the chances of successful seizure termination in generalized convulsive SE (GCSE). The approach to refractory and superrefractory GCSE is less well defined. Multiple agents with differing complementary actions that facilitate seizure termination are recommended. Nonconvulsive SE (NCSE) has a wide range of presentations and approaches to treatment. Continuous electroencephalography is critical to the management of both GCSE and NCSE, while its use for patients without seizure continues to expand.

Effects of Pregabalin, Nimodipine, and Their Combination in the Inhibition of Status Epilepticus and the Prevention of Death in Mice

Objectives

The current study aims to evaluate the combined antiepileptic effects of pregabalin (PGB) and nimodipine (NMD) in an acute seizure model of epilepsy in mice.

Materials and Methods

This study assessed the combined antiepileptic effects of PGB with NMD on death protection in mice. Pentylenetetrazole was used to induce seizures. Both drugs were used singly and in combination to judge anticonvulsant effects on an acute seizure model of epilepsy in mice. Diazepam (DZ) and valproate (VPT) were used as standard antiepileptic drugs.

Results

The death protection in mice by both these drugs was observed in percentage and deliberated as marked change when the outcome of the tested drug was equal to ED₅₀ of PGB and measured highly marked when the result was more than ED₅₀ for PGB. Treatment with pregabalin and nimodipine combination revealed substantial mortality protection at 30+2.5 mg/kg dose and highly marked at doses from 35+5 mg/kg to 55+15 mg/kg, these effects were superior to individual effects of PGB, showing synergism, however lesser then classic drugs valproate and diazepam.

Conclusion

NMD showed synergistic anticonvulsant effect with PGB. However, clinical studies are required to establish the effectiveness of this combination in humans.

Diagnostic utility of cerebrospinal fluid (CSF) findings in seizures and epilepsy with and without autoimmune-associated disease

Patients with seizures and epilepsy routinely undergo multiple diagnostic tests, which may include cerebrospinal fluid (CSF) analysis. This review aims to outline different CSF parameters and their alterations in seizures or epilepsy. We then discuss the utility of CSF analysis in seizure patients in different clinical settings in depth. Some routine CSF parameters are frequently altered after seizures, but are not specific such as CSF protein and lactate. Pleocytosis and CSF specific oligoclonal bands are rare and should be considered as signs of infectious or immune mediated seizures and epilepsy. Markers of neuronal damage show conflicting results, and are as yet not established in clinical practice. Parameters of neuronal degeneration and more specific immune parameters are less well studied, and are areas of further research. CSF analysis in new-onset seizures or status epilepticus serves well in the differential diagnosis of seizure etiology. Here, considerations should include autoimmune-associated seizures. CSF findings in these disorders are a special focus of this review and are summarized in a comprehensive overview. Until now, CSF analysis has not yielded clinically helpful biomarkers for refractory epilepsy or for assessment of neuronal damage which is a subject of further studies.

Occurrence of status epilepticus in persons with epilepsy is determined by sex, epilepsy classification, and etiology: a single center cohort study

Background

Status epilepticus (SE) can occur in persons with or without epilepsy and is associated with high morbidity and mortality.

Methods

This survey aimed to record self-reported frequency of SE in persons with epilepsy, its association with clinical characteristics and patient level of information on SE and rescue medication. 251 persons with epilepsy at a tertiary epilepsy center were included in the study.

Results

87 (35%) had a history of SE defined as seizure duration of more than 5 min. These patients were less likely to be seizure-free, and had a higher number of present and past anti-seizure medication. Female sex, cognitive disability, younger age at epilepsy onset, defined epilepsy etiology, and focal epilepsy were associated with a history of SE. On Cox regression analysis, female sex, defined etiology and focal classification remained significant. 67% stated that they had information about prolonged seizures, and 75% knew about rescue medication. 85% found it desirable to receive information about SE at the time of initial diagnosis of epilepsy, but only 16% had been offered such information at the time.

Conclusion

SE is frequent among persons with epilepsy and there remain unmet needs regarding patient education.

Cerebrospinal Fluid Pleocytosis Not Attributable to Status Epilepticus in First 24 Hours

BACKGROUND

Status epilepticus (SE) has traditionally been thought to cause cerebrospinal fluid (CSF) pleocytosis. However, attributing CSF pleocytosis solely to SE without addressing the underlying etiology may lead to poor outcomes. Leukocyte recruitment to CSF has been shown to peak around 24 hours after prolonged seizures in animal studies, suggesting that CSF pleocytosis within the first 24 hours of SE onset may be due to underlying causes. The goal of this study is to assess if SE is associated with CSF pleocytosis, independent of other causes within the first 24 hours of onset.

METHODS

We completed a historical cohort study of adult patients with SE admitted to the intensive care unit of Vancouver General Hospital between March 2010 and May 2019.

RESULTS

Of the 441 patients admitted with SE during the study period, 107 met our inclusion criteria leading to 111 lumbar punctures (LPs), with 4 patients receiving two LPs. CSF pleocytosis was seen in 12 of 72 patients who underwent an LP within the first 24 hours of SE onset. In all 12 patients, a secondary etiology for the pleocytosis was observed aside from SE. Of the six CSF samples collected after 24 hours of onset that demonstrated pleocytosis, four had no cause for pleocytosis other than SE.

CONCLUSIONS

In all 12 patients with CSF pleocytosis in the first 24 hours of onset of SE, an underlying etiology was identified. Therefore, any pleocytosis noticed within the first 24 hours of onset of refractory SE should not be attributed solely to SE.

Association of systemic secondary brain insults and outcome in patients with convulsive status epilepticus: A post hoc study of a randomized controlled trial

OBJECTIVE

To evaluate the association between systemic factors (mean arterial blood pressure, arterial partial pressures of carbon dioxide and oxygen, body temperature, natremia, and glycemia) on day 1 and neurologic outcomes 90 days after convulsive status epilepticus.

METHODS

This was a post hoc analysis of the Evaluation of Therapeutic Hypothermia in Convulsive Status Epilepticus in Adults in Intensive Care (HYBERNATUS) multicenter open-label controlled trial, which randomized 270 critically ill patients with convulsive status epilepticus requiring mechanical ventilation to therapeutic hypothermia (32°C-34°C for 24 hours) plus standard care or standard care alone between March 2011 and January 2015. The primary endpoint was a Glasgow Outcome Scale score of 5, defining a favorable outcome, 90 days after convulsive status epilepticus.

RESULTS

The 172 men and 93 women had a median age of 57 years (45-68 years). Among them, 130 (49%) had a history of epilepsy, and 59 (29%) had a primary brain insult. Convulsive status epilepticus was refractory in 86 (32%) patients, and total seizure duration was 67 minutes (35-120 minutes). The 90-day outcome was unfavorable in 126 (48%) patients. In multivariate analysis, none of the systemic secondary brain insults were associated with outcome; achieving an unfavorable outcome was associated with age >65 years (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.20-3.85; p = 0.01), refractory convulsive status epilepticus (OR 2.00, 95% CI 1.04-3.85; p = 0.04), primary brain insult (OR 2.00, 95% CI 1.02-4.00; p = 0.047), and no bystander-witnessed seizure onset (OR 2.49, 95% CI 1.05-5.59; p = 0.04).

CONCLUSIONS

In our population, systemic secondary brain insults were not associated with outcome in critically ill patients with convulsive status epilepticus.

CLINICALTRIALSGOV IDENTIFIER

NCT01359332.

Markers in Status Epilepticus Prognosis

Status epilepticus (SE) is a neurologic emergency with high morbidity and mortality. The assessment of a patient's prognosis is crucial in making treatment decisions. In this review, we discuss various markers that have been used to prognosticate SE in terms of recurrence, mortality, and functional outcome. These markers include demographic, clinical, electrophysiological, biochemical, and structural data. The heterogeneity of SE etiology and semiology renders development of prognostic markers challenging. Currently, prognostication in SE is limited to a few clinical scores. Future research should integrate clinical, genetic and epigenetic, metabolic, inflammatory, and structural biomarkers into prognostication models to approach "personalized medicine" in prognostication of outcomes after SE.

The Role of Secondary Brain Insults in Status Epilepticus: A Systematic Review

(1) Background: Little is known about the impact of pathophysiological mechanisms that underlie the enhancement of excitotoxicity and the neuronal consequences of status epilepticus (SE), as well as the clinical consequences of secondary brain insults (SBI) in patients with SE on outcome; (2) Methods: Electronic searches were conducted in May 2020 using Medline via PubMed, Embase, and Google Scholar (#CRD42019139092). Experimental studies of animals or randomized, observational, controlled trials of patients with SE in indexed journals were included. There were no language or date restrictions for the published literature included in this review. Information was extracted on study design, sample size, SBI characteristics, and primary and secondary outcomes, including the timing of evaluation; (3) Results: Among the 2209 articles responding to our inclusion criteria, 56 were included in this systematic review. There are numerous experimental data reporting the deleterious effects associated with each of the SBI in animals exposed to SE. In humans, only the effect of target temperature management in hypothermia (32-34 °C) has been explored. (4) Conclusions: There is little experimental evidence that favors the control of secondary brain insult after SE. Further studies are required to assess the neuroprotective interest of secondary brain insult control after SE in humans.

Recommandations Formalisées d’Experts SRLF/SFMU : Prise en charge des états de mal épileptiques en préhospitalier, en structure d’urgence et en réanimation dans les 48 premières heures (A l’exclusion du nouveau-né et du nourrisson)

La Société de réanimation de langue française et la Société française de médecine d’urgence ont décidé d’élaborer de nouvelles recommandations sur la prise en charge de l’état mal épileptique (EME) avec l’ambition de répondre le plus possible aux nombreuses questions pratiques que soulèvent les EME : diagnostic, enquête étiologique, traitement non spécifique et spécifique. Vingt-cinq experts ont analysé la littérature scientifique et formulé des recommandations selon la méthodologie GRADE. Les experts se sont accordés sur 96 recommandations. Les recommandations avec le niveau de preuve le plus fort ne concernent que l’EME tonico-clonique généralisé (EMTCG) : l’usage des benzodiazépines en première ligne (clonazépam en intraveineux direct ou midazolam en intramusculaire) est recommandé, répété 5 min après la première injection (à l’exception du midazolam) en cas de persistance clinique. En cas de persistance 5 min après cette seconde injection, il est proposé d’administrer la seconde ligne thérapeutique : valproate de sodium, (fos-)phénytoïne, phénobarbital ou lévétiracétam. La persistance avérée de convulsions 30 min après le début de l’administration du traitement de deuxième ligne signe l’EMETCG réfractaire. Il est alors proposé de recourir à un coma thérapeutique au moyen d’un agent anesthésique intraveineux de type midazolam ou propofol. Des recommandations spécifiques à l’enfant et aux autres EME sont aussi énoncées.

Etiological assessment of status epilepticus

Status epilepticus (SE) is a potentially serious condition that can affect vital and functional prognosis and requires urgent treatment. Etiology is a determining factor in the patient's functional outcome and in almost half of all cases justifies specific treatment to stop progression. Therefore, identifying and addressing the cause of SE is a key priority in SE management. However, the etiology can be difficult to identify among acute and remote causes, which can also be multiple and interrelated. The most common etiologies are the discontinuation of antiepileptic medication in patients with a prior history of epilepsy, and acute brain aggression in cases of new onset SE (cerebrovascular pathologies are the most common). The list of remaining possible etiologies includes heterogeneous pathological contexts. Refractory SE and especially New-Onset Refractory Status Epilepticus (NORSE) lead to an extension of the etiological assessment in the search for encephalitis of autoimmune or infectious origin in adults and in children, as well as a genetic pathology in children in particular. This is an overview of current knowledge of SE etiologies and a pragmatic approach for carrying out an etiological assessment based on the following steps: - Which etiological orientation is identified according to the field and clinical presentation?; - Which etiologies to look for in an inaugural SE?; - Which first-line assessment should be carried out? The place of the biological, EEG and imaging assessment is discussed; - Which etiologies to look for in case of refractory SE?

Predisposing factors and prognosis of status epilepticus in patients with autoimmune encephalitis

The aim of this study was to study the predisposing factors and prognosis of status epilepticus (SE) in patients with autoimmune encephalitis (AE).A total of 227 cases of AE were collected from the inpatient department of West China Hospital of Sichuan University from January 2010 to May 2018. All patients met the 2015 criteria for the diagnosis of AE. The binary logistic regression model was used to multivariate and retrospective chart analysis the predisposition factors for SE and its prognostic factors.Of the 227 patients with AE, 50 (22.03%) had SE during hospitalization, and 19 patients with SE had a poor prognosis (modified Rankin score MRS = 3-6), and 7 patients with no SE had a poor prognosis. In the logistic regression model, electroencephalograms (EEGs) abnormalities (P = .000) and head magnetic resonance imaging (MRI) abnormalities (P = .003) were associated with a predisposition to SE, while Glasgow scores <8 (P = .027), abnormal EEG (P = .046), delayed immunotherapy (P = .012), and SE duration at admission lasting >30 minutes (P = .023) were risk factors for a poor prognosis of SE.SE is a common complication in patients with AE. EEG and MRI abnormalities may be predisposing factors for SE. Glasgow scores <8 points, abnormal EEG, delayed immunotherapy, and SE duration lasting >30 minutes at admission are risk factors for a poor prognosis in patients with SE.

The Magnitude of Postconvulsive Leukocytosis Mirrors the Severity of Periconvulsive Respiratory Compromise: A Single Center Retrospective Study

Background: Generalized epileptic convulsions frequently exhibit transient respiratory symptoms and non-infectious leukocytosis. While these peri-ictal effects appear to arise independently from one another, the possibility that they stem from a common ictal pathophysiological response has yet to be explored. We aimed to investigate whether peri-ictal respiratory symptoms and postictal leukocytosis coexist.

Methods: We performed a single center retrospective chart review of 446 patients brought to our emergency department between January 1, 2017 and August 23, 2018 for the care of generalized epileptic convulsions with or without status epilepticus. We included 152 patients who were stratified based on the presence (PeCRC+) or absence (PeCRC–) of overt periconvulsive respiratory compromise (PeCRC). In addition, patients were stratified based on the presence or absence of postconvulsive leukocytosis (PoCL), defined as an initial postconvulsive white blood cell (WBC) count ≥ 11,000 cells/mm³. Triage vital signs, and chest x ray (CXR) abnormalities were also examined.

Results: Overt PeCRC was observed in 31.6% of patients, 43% of whom required emergent endotracheal intubations. PoCL was observed in 37.5% of patients, and was more likely to occur in PeCRC+ than in PeCRC– patients (79.2 vs. 18.2%; OR = 17.0; 95% CI = 7.2–40.9; p < 0.001). Notably, the magnitude of PoCL was proportional to the severity of PeCRC, as the postconvulsive WBC count demonstrated a negative correlation with triage hemoglobin oxygen saturation (R = −0.22; p < 0.01; CI = −0.48 to −0.07). Moreover, a receiver operating characteristic analysis of the WBC count's performance as predictor of endotracheal intubation reached a significant area under the curve value of 0.81 (95% CI = 0.71–0.90; p < 0.001). Finally, PeCRC+ patients demonstrated frequent CXR abnormalities, and their postconvulsive WBC counts correlated directly with triage heart rate (R = 0.53; p < 0.001).

Conclusion: Our data support the existence of an ictal pathophysiological response, which induces proportional degrees of PoCL and PeCRC. We suggest this response is at least partially propelled by systemic catecholamines.

Predictors of mortality at one year after generalized convulsive status epilepticus

BACKGROUND

Status epilepticus (SE) is a life-threatening neurologic emergency, which requires prompt medical treatment. Little is known of the long-term survival of SE. The aim of this study was to investigate which factors influence 90 days and 1-year mortality after SE.

MATERIALS AND METHODS

This retrospective study includes all consecutive adult (>16 years) patients (N = 70) diagnosed with generalized convulsive SE (GCSE) in Helsinki University Central Hospital (HUCH) emergency department (ED) over 2 years. We defined specific factors including patient demographics, GCSE characteristics, treatment, complications, delays in treatment, and outcome at hospital discharge and determined their relation to 90 days and 1-year mortality after GCSE by using logistic regression models. Survival analyses at 1 year after GCSE were performed with Cox proportional hazards regression analysis.

RESULTS

In-hospital mortality was 7.1%. Mortality rate was 14.3% at 90 days and 24.3% at 1 year after GCSE. In the univariate logistic regression analysis, Status Epilepticus Severity Score > 4 (STESS) (ODDS = 7.30, p = 0.012), worse-than-baseline condition at hospital discharge (ODDS = 3.5, p = 0.006), long delays in attaining seizure freedom (ODDS = 2.2, p = 0.041), and consciousness (ODDS = 3.4, p = 0.014) were risk factors for mortality at 90 days whereas epilepsy (ODDS = 0.2, p = 0.014) and Glasgow Outcome Scale (GOS) >3 at hospital discharge (ODDS = 0.05, p = 0.006) were protective factors. Risk factors for mortality at 1 year were STESS >4 (ODDS = 5.1, p = 0.028), use of vasopressors (ODDS = 8.2, p = 0.049), and worse-than-baseline condition at discharge (ODDS = 7.8, p = 0.010) while GOS >3 (ODDS = 0.2, p = 0.005) was protective. The univariate survival analysis at 1 year confirmed the significant findings regarding parameters STESS >4 (Hazard ratio (HR) = 4.1, p = 0.009), worse-than-baseline condition (HR = 6.2, p = 0.015), GOS >3 (HR = 0.2, p = 0.004) at hospital discharge and epilepsy (HR = 0.4, p = 0.044). Additionally, diagnostic delay over 6 h (HR = 3.8, p = 0.022) and Complication Burden Index (CBI) as an ordinal variable (0-2, 3-6, >6) (HR = 2.7, p = 0.027) were predictive for mortality. In the multivariate survival analysis, STESS > 4 (HR = 5.1, p = 0.007), CBI (HR = 3.2, p = 0.025, ordinal variable), diagnostic delay over 6 h (HR = 7.2, p = 0.003), and worse-than-baseline condition at hospital discharge (HR = 5.8, p = 0.027) were all independent risk factors for mortality at 1 year.

CONCLUSIONS

Severe form of SE, delayed recognition of GCSE, high number of complications during treatment period, and poor condition at hospital discharge are all independent predictors of long-term mortality. Most of these factors are also associated with mortality at 90 days, though at that point, delays in treatment seem to have a greater impact on prognosis than at 1 year. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures.

Thermoregulation in epilepsy

Several aspects of thermoregulation play a role in epilepsy. Circuitries involved in thermoregulation are affected by seizures and epilepsy, hyperthermia may be both cause and result of seizures, and hypothermia may prevent or abort seizures. Autonomic manifestations of seizures including thermoregulatory disturbances are common in a variety of clinical epilepsy syndromes. Experimental hyperthermia has been studied extensively, predominantly to investigate febrile seizures of childhood. In particular prolonged or complex febrile seizures have been associated with the later development of epilepsy in adulthood and the pathophysiology of how febrile seizures cause epilepsy is of tremendous interest. Febrile seizures represent an opportunity to potentially intervene early in life in susceptible individuals and affect epileptogenesis. The pathophysiologic underpinnings of how hyperthermia induces seizures and how this in turn results in epilepsy are controversial, but likely involve multiple factors. Both glutamatergic and GABAergic neurotransmission is affected, and numerous mutations in genes encoding ion channels have been identified. Cytokines such as interleukin-1β have been implicated in febrile seizures as well as susceptibility to provoked seizures later in life. Hyperthermia is a common feature of generalized convulsive status epilepticus, but may also be seen with nonconvulsive seizures, indicating involvement of thermoregulatory centers.

Chronic Skull Base Erosion from Temporomandibular Joint Disease Causes Generalized Seizure and Profound Lactic Acidosis

This report displays a rare presentation of lactic acidosis in the setting of status epilepticus (SE). The differential diagnosis of lactic acidosis is broad and typically originates from states of shock; however, this report highlights an alternative and rare etiology, SE, due to chronic skull base erosion from temporomandibular joint (TMJ) disease. Lactic acidosis is defined by a pH below 7.35 in the setting of lactate values greater than 5 mmol/L. Two broad classifications of lactic acidosis exist: a type A lactic acidosis which stems from global or localized tissue hypoxia or a type B lactic acidosis which occurs once mitochondrial oxidative capacity is unable to match glucose metabolism. SE is an example of a type A lactic acidosis in which oxygen delivery is unable to meet increased cellular energy requirements. This report is consistent with a prior case series that consists of five patients experiencing generalized tonic-clonic (GTC) seizures and lactic acidosis. These patients presented with a pH range of 6.8-7.41 and lactate range of 3.8-22.4 mmol/L. Although severe lactic acidosis following GTC has been described, this is the first report in the literature of chronic skull base erosion from TMJ disease causing SE.

Pathophysiology of convulsive status epilepticus

PURPOSE

To summarize the pathophysiology of convulsive status epilepticus (SE) with a focus on practical implications for treatment.

METHOD

Narrative review of the medical literature on the pathophysiology of convulsive SE. We considered both animal models of SE and clinical studies.

RESULTS

Convulsive SE is an emergency in which prolonged convulsive seizures are associated with cardiorespiratory instability, hypoxia, hypoglycemia, and hyperthermia. Supportive treatment helps correct these physiological imbalances. When treatment is delayed, the ability of first line seizure suppressing medications to terminate the seizure can be reduced. Animal studies have suggested that GABA_A receptor trafficking may contribute to the failure of the first line therapies and that NMDA receptor antagonists such as ketamine may become more effective as seizures last longer. Potential strategies to take advantage of these changes in pathophysiology include a rapid escalation from benzodiazepines to non-benzodiazepine antiepileptic drugs (AEDs), early polytherapy and use of NMDA antagonists such as ketamine for refractory convulsive SE. Despite the importance of a timely treatment of convulsive SE, major treatment delays are frequent in clinical practice. Policies to improve time to treatment, especially in convulsive SE that starts outside the hospital, may improve response to treatment and convulsive SE outcomes.

CONCLUSIONS

Convulsive SE is a time-sensitive emergency in which the underlying pathophysiology may provide targets for improving treatment strategies. A timely transition from benzodiazepines to other AEDs may help reduce treatment resistance in convulsive SE.

Cognitive dysfunction after generalized tonic-clonic status epilepticus in adults

OBJECTIVES

Generalized tonic-clonic status epilepticus (GTC-SE) is considered a risk for cognitive impairment. Research with standardized tools is scarce and non-conclusive. We systematically assessed short-term and long-term cognitive function after GTC-SE.

MATERIALS AND METHODS

Thirty-three patients were tested after the clinical post-ictal phase of GTC-SE (timepoint 1) and again after 1 year (timepoint 2). Twenty controls were examined with the same tests. Tests from Cambridge Neuropsychological Test Automated Battery were used. Motor screening test (MOT) assessed motor speed, delayed matching to sample (DMS) and paired associates learning (PAL) assessed memory, and Stockings of Cambridge (SOC) assessed executive function. Estimated premorbid IQ and radiologically visible brain lesions were controlled for in adjusted results. Outcome measures were z-scores, the number of standard deviations a score deviates from the mean of a norm population.

RESULTS

At timepoint 1, unadjusted patient results were significantly below both norm and control group performances on all subtests. Patient mean was 1.9 z-scores below controls (P < .001) on PAL total errors. Results remained significant for PAL and DMS after adjustments. Patient results improved at timepoint 2, but memory tests remained lower than norms and for controls. An executive dysfunction emerged on the most complex SOC stage (z-score difference -0.83; P = .008, adjusted difference -0.94; P = .02).

CONCLUSIONS

Memory and learning impairment in the early phase after SE and late developing executive dysfunction remained significant after adjusting for estimated premorbid IQ and pre-SE brain lesions. Results suggest that GTC-SE poses a risk for cognitive impairment.

Clinical Risk Factors for Early Seizure Recurrence in Dogs Hospitalized for Seizure Evaluation

BACKGROUND

Epileptic seizures are a common cause for neurological evaluations in dogs.

HYPOTHESIS/OBJECTIVES

To determine the timing, frequency, and risk factors for early seizure recurrence (ESR) among dogs admitted to the hospital for seizure evaluation and to facilitate rapid decision making about whether dogs should be placed in the intensive care unit (ICU) or day ward.

ANIMALS

Nine-hundred twenty-two dogs referred for seizure investigation; 214 patients were included.

METHODS

Retrospective study. Medical records between 2000 and 2017 were reviewed to determine risk factors for ESR. Findings were compared among dogs diagnosed with idiopathic epilepsy (IE), structural epilepsy (StE) and reactive seizures (RS), as well as in all selected cases together.

RESULTS

Fifty percent of dogs had a seizure while hospitalized. In the group 53.1 and 52.2% in the StE group, whereas in the RS 40.44% had ESR. The average time to ESR was 7 hours. In IE group, abnormal postictal neurological examination with prosencephalon signs predicted ESR. In StE group, a single generalized or focal seizure 72 hours before hospital admission and abnormal neurologic examination predicted ESR. In the RS group, ERS was predicted by long-term antiepileptic monotheraphy. When all dogs were analyzed together, abnormal neurological examination, the occurrence of cluster seizures, status epilepticus, or combination of them 72 hours before presentation predicted ESR.

CONCLUSIONS AND CLINICAL IMPORTANCE

Epileptic seizures recurred in 50% of patients within a mean time of 7 hours. In general, when cluster seizures, status epilepticus or both occurred 72 hours before presentation and neurological examination was abnormal upon presentation, the dog should be placed in ICU for observation.

Status Epilepticus as an Unusual Manifestation of Heat Stroke

Heat stroke (HS) is a medical emergency and life threatening condition, characterized by body temperature over 40°C. This can lead to dysfunction of multiple organs such as the heart, liver, kidneys, lungs, blood coagulation system, and central nervous system. Neurological complications include change in consciousness, cerebellar dysfunction, convulsions, aphasia, muscular weakness, and parkinsonism. Cerebellar syndrome is the most common neurological finding in HS. We report a case of HS presenting with status epilepticus, without any other neurological manifestations. A 42 year old man, previously diagnosed with bipolar disorder, was admitted to the emergency room with high fever and repetitive generalized tonic-clonic seizures. He had been found unconscious after 4 hours of heavy physical work under extremely hot weather conditions. He was diagnosed with HS accompanied by status epilepticus, and treated with emergency body cooling and antiepileptics. Five days after admission, he regained consciousness and the laboratory parameters that were initially abnormal returned to normal values. On day 14, he was discharged without any neurological complications.

Acute Systemic Complications of Convulsive Status Epilepticus-A Systematic Review

OBJECTIVES

Status epilepticus is a neurologic emergency with high morbidity and mortality requiring neurointensive care and treatment of systemic complications. This systematic review compiles the current literature on acute systemic complications of generalized convulsive status epilepticus in adults and their immediate clinical impact along with recommendations for optimal neurointensive care.

DATA SOURCES

We searched PubMed, Medline, Embase, and the Cochrane library for articles published between 1960 and 2016 and reporting on systemic complications of convulsive status epilepticus.

STUDY SELECTION

All identified studies were screened for eligibility by two independent reviewers.

DATA EXTRACTION

Key data were extracted using standardized data collection forms.

DATA SYNTHESIS

Thirty-two of 3,046 screened articles were included. Acute manifestations and complications reported in association with generalized convulsive status epilepticus can affect all organ systems fueling complex cascades and multiple organ interactions. Most reported complications result from generalized excessive muscle contractions that increase body temperature and serum potassium levels and may interfere with proper and coordinated function of respiratory muscles followed by hypoxia and respiratory acidosis. Increased plasma catecholamines can cause a decay of skeletal muscle cells and cardiac function, including stress cardiomyopathy. Systemic complications are often underestimated or misinterpreted as they may mimic underlying causes of generalized convulsive status epilepticus or treatment-related adverse events.

CONCLUSIONS

Management of generalized convulsive status epilepticus should center on the administration of antiseizure drugs, treatment of the underlying causes, and the attendant systemic consequences to prevent secondary seizure-related injuries. Heightened awareness, systematic clinical assessment, and diagnostic workup and management based on the proposed algorithm are advocated as they are keys to optimal outcome.

Management of Status Epilepticus

Status epilepticus is due to a range of insults to the central nervous system and results in significant mortality rates, especially in the elderly. We review the current management of this disorder in light of the latest developments from recent trials and guidelines. Important principles in management includes early recognition of status epilepticus, identification of the underlying cause and prompt treatment to terminate seizures and reduce complications. The differentiation diagnosis, role of electroencephalographic monitoring and different treatment regimes are examined.

Cognitive function after status epilepticus versus after multiple generalized tonic-clonic seizures

OBJECTIVES

Status epilepticus (SE) is considered a risk for cognitive impairment. Studies have indicated that SE cause more cognitive decline than multiple lifetime generalized tonic clonic (GTC) seizures. The aim of the study was to investigate whether patients suffering from SE or from multiple lifetime GTC seizures have cognitive dysfunction, and if the disabilities differ between these groups.

MATERIALS AND METHODS

Patients suffering from SE were evaluated shortly after the clinical post-ictal phase and again after one year. Their follow-up results were compared to results from patients with ≥10 GTC seizures and a group of control subjects. Tests from Cambridge Neuropsychological Test Automated Battery (CANTAB) were used. Motor Screening Test (MOT) assessed motor speed, Delayed Matching to Sample (DMS) and Paired Associates Learning (PAL) assessed memory, and Stockings of Cambridge (SOC) assessed executive function. Estimated premorbid IQ and radiologically visible brain lesions were controlled for in adjusted results. Outcome measures were z-scores, the number of standard deviations a score deviates from the mean of a norm population. Negative z-scores indicate poor performance.

RESULTS

After the clinical post-ictal phase, performances of SE patients were poor on all domains (n = 46). Mean z-scores with 95% confidence intervals were below zero for tests of psychomotor speed, executive thinking times and memory. Both SE patients at follow-up (n = 39) and patients with multiple GTC seizures (n = 24) performed poorer than controls (n = 20) on tests of memory. These group differences remained significant after covariate adjustments. SE patients at follow-up scored below patients with multiple GTC seizures on tests of psychomotor speed (mean difference -0.59, P = 0.020), but after adjusting for covariates this difference was no longer significant.

CONCLUSIONS

Our data do not allow a firm conclusion as to whether SE is a more pronounced risk factor for cognitive dysfunction than repeated generalized tonic clonic seizures. In both patient groups, memory and learning dysfunction remained significant after adjusting for estimated premorbid IQ and structural brain lesions.

Synergistic anticonvulsant effects of pregabalin and amlodipine on acute seizure model of epilepsy in mice

Status epilepticus is a life threatening neurological medical emergency. It may cause serious damage to the brain and even death in many cases if not treated properly. There is limited choice of drugs for the short term and long term management of status epilepticus and the dugs recommended for status epilepticus possess various side effects. The present study was designed to investigate synergistic anticonvulsant effects of pregabalin with amlodipine on acute seizure model of epilepsy in mice. Pentylenetetrazole was used to induce acute seizures which mimic status epilepticus. Pregabalin and amlodipine were used in combination to evaluate synergistic anti-seizure effects on acute seizure model of epilepsy in mice. Diazepam and valproate were used as reference dugs. The acute anti-convulsive activity of pregabalin with amlodipine was evaluated in vivo by the chemical induced seizures and their anti-seizure effects were compared with pentylenetetrazole, reference drugs and to their individual effects. The anti-seizure effects of tested drugs were recorded in seconds on seizure characteristics such as latency of onset of threshold seizures, rearing and fallings and Hind limbs tonic extensions. The seizure protection and mortality to the animals exhibited by the drugs were recorded in percentage. Combination regimen of pregabalin with amlodipine exhibited dose dependent significant synergistic anticonvulsant effects on acute seizures which were superior to their individual effects and equivalent to reference drugs.

Status epilepticus in dogs and cats, part 1: etiopathogenesis, epidemiology, and diagnosis

OBJECTIVE

To review current knowledge of the etiopathogenesis, diagnosis, and consequences of status epilepticus (SE) in veterinary patients.

DATA SOURCES

Human and veterinary literature, including clinical and laboratory research and reviews.

ETIOPATHOGENESIS

Status epilepticus is a common emergency in dogs and cats, and may be the first manifestation of a seizure disorder. It results from the failure of termination of an isolated seizure. Multiple factors are involved in SE, including initiation and maintenance of neuronal excitability, neuronal network synchronization, and brain microenvironmental contributions to ictogenesis. Underlying etiologies of epilepsy and SE in dogs and cats are generally classified as genetic (idiopathic), structural-metabolic, or unknown.

DIAGNOSIS

Diagnosis of convulsive SE is usually made based on historical information and the nature of the seizures. Patient specific variables, such as the history, age of seizure onset, and physical and interictal neurological examination findings can help hone the rule out list, and are used to guide selection and prioritization of diagnostic tests. Electroencephalographic monitoring is routinely used in people to diagnose SE and guide patient care decisions, but is infrequently performed in veterinary medicine. Nonconvulsive status epilepticus has been recognized in veterinary patients; routine electroencephalography would aid in the diagnosis of this phenomenon in dogs and cats.

CLINICAL SEQUELAE

Status epilepticus is a medical emergency that can result in life-threatening complications involving the brain and systemic organs. Status epilepticus often requires comprehensive diagnostic testing, treatment with multiple anticonvulsant agents, and intensive supportive care.

Cerebrospinal Fluid Pleocytosis in Critical Care Patients With Seizures

OBJECTIVES

To assess the etiology of cerebrospinal fluid (CSF) pleocytosis in critical care patients with seizure(s) or status epilepticus (SE). Many previous studies, some performed decades ago, concluded that CSF pleocytosis may be entirely attributable to seizure activity.

METHODS

We undertook a retrospective chart review of adult patients with an admitting or acquired diagnosis of seizure(s) or SE in critical care units at the Winnipeg Health Sciences Centre between 2009 and 2012. Patients were identified through a critical care information database at a tertiary care center. We limited our study to patients who had lumbar punctures at our center within 5 days of seizure(s) or SE.

RESULTS

Of 426 patients with seizures in critical care units, 51 met the inclusion criteria. Seizure subtypes included focal seizures (5 or 10%), generalized seizures (14 or 27%), and SE (32 or 63%). Twelve (seven with SE) of the 51 (24%) were found to have CSF pleocytosis. A probable etiological cause for the CSF pleocytosis was identified in all 12 cases.

CONCLUSIONS

We conclude that seizures do not directly induce a CSF pleocytosis. Instead, the CSF pleocytosis more likely reflects the underlying acute or chronic brain process responsible for the seizure(s). This was not readily apparent in early studies without magnetic resonance imaging (MRI) of the brain and currently available laboratory investigations. An etiological cause of CSF pleocytosis must always be sought when patients present with seizures and it should never be assumed that seizures are the cause.

Cerebrospinal fluid analysis after unprovoked first seizure

The aim of this study was to determine cerebrospinal fluid (CSF) characteristics after an unprovoked first seizure (UFS). We reviewed the medical records of 71 patients with UFS who underwent lumbar puncture, and examined the CSF parameters. Each CSF parameter was evaluated separately for potential correlations with the other study variables. We observed an overall frequency of CSF abnormalities of 35.2%. CSF protein was the most common abnormal parameter (31%) and showed significant positive correlations with male gender (p=0.037) and older age (p=0.007). Only seven patients (9.9%) had an abnormal cell count (5-40 cells/μl). Higher CSF cell counts were found to predict a longer hospitalization period (p=0.005). No relationship with abnormal EEG findings could be established (p=0.169). This study is one of the few to evaluate postictal CSF parameters in a clinical setting, and to our knowledge the first to investigate these parameters specifically in the emergency department. The development of a rapid, easy-to-use test that does not require extensive laboratory equipment to differentiate UFS from other conditions could be of great value in everyday clinical practice.

Management of status epilepticus

Status epilepticus is a neurologic and medical emergency manifested by prolonged seizure activity or multiple seizures without return to baseline. It is associated with substantial medical cost, morbidity, and mortality. There is a spectrum of severity dependent on the type of seizure, underlying pathology, comorbidities, and appropriate and timely medical management. This chapter discusses the evolving definitions of status epilepticus and multiple patient and clinical factors which influence outcome. The pathophysiology of status epilepticus is reviewed to provide a better understanding of the mechanisms which contribute to status epilepticus, as well as the potential long-term effects. The clinical presentations of different types of status epilepticus in adults are discussed, with emphasis on the hospital course and management of the most dangerous type, generalized convulsive status epilepticus. Strategies for the evaluation and management of status epilepticus are provided based on available evidence from clinical trials and recommendations from the Neurocritical Care Society and the European Federation of Neurological Societies.

Acceptance of disease and lifestyle modification after diagnosis among young adults with epilepsy

AIM

Assessment of factors affecting the degree of illness acceptance in patients with epilepsy and determination of whether the diagnosis of epilepsy influenced the functioning of this population group.

MATERIALS AND METHODS

The Acceptance of Illness Scale (AIS) and authors' own questionnaire were used in this study. The study included 264 patients with epilepsy aged 20-40 years. The study was carried out during the period from June 2015 to June 2016. Participants were recruited through multiple channels, including online websites, a forum for people suffering from epilepsy, and from a neurological outpatient clinic in Warsaw.

RESULTS

The mean value for overall rates of illness acceptance for all patients was 25.05±5.23, which indicated a mean level of illness acceptance of the patients. A significant correlation was observed between the results on AIS and the marital status of patients (P=0.04541). However, statistical analysis did not support the significant association between the illness acceptance and other socio-demographic factors and clinical aspects (P>0.05 in all cases). An analysis of the correlation between the level of illness acceptance and taking life decisions by the patients showed that the only statistically significant difference was the influence of an illness on the decision about marriage (P=0.032383).

CONCLUSION

The problem of illness acceptance is often addressed in scientific research. It seems to be difficult to attain the state of full illness acceptance, especially in a situation when a number of changes have to be made in a patient's current life and everyday functioning. It can be argued that illness acceptance has a positive meaning because it entails benefits resulting from better mental and physical comfort of a patient. The time needed for the attainment of full illness acceptance is individual for every patient and also depends on many factors.

Aliocha Dostoevski’s death during an epileptic seizure

ABSTRACT Mortality due to epilepsy is of great concern worldwide. Individuals with epilepsy have a two- or three-fold risk of death when compared to the general population. Based on biographical data and Anna Grigoriévna Dostoevskaia’s memories, the authors concluded that a prolonged episode of status epilepticus was the culprit in the death of young Aliocha, youngest son of Fyodor Mikhailovich and Anna Dostoevski. At the time of Aliocha’s death, very limited knowledge about epilepsy or therapeutic resources was available. Despite all the progress, epilepsies remain potentially fatal conditions. The suffering generated by Aliocha’s death and other similar cases remains as a challenge for epileptologists who assemble efforts to fight against such conditions.

Neuroserpin Differentiates Between Forms of Tissue Type Plasminogen Activator via pH Dependent Deacylation

Tissue-type plasminogen activator (t-PA), initially characterized for its critical role in fibrinolysis, also has key functions in both physiologic and pathologic processes in the CNS. Neuroserpin (NSP) is a t-PA specific serine protease inhibitor (serpin) found almost exclusively in the CNS that regulates t-PA's proteolytic activity and protects against t-PA mediated seizure propagation and blood-brain barrier disruption. This report demonstrates that NSP inhibition of t-PA varies profoundly as a function of pH within the biologically relevant pH range for the CNS, and reflects the stability, rather than the formation of NSP: t-PA acyl-enzyme complexes. Moreover, NSP differentiates between the zymogen-like single chain form (single chain t-PA, sct-PA) and the mature protease form (two chain t-PA, tct-PA) of t-PA, demonstrating different pH profiles for protease inhibition, different pH ranges over which catalytic deacylation occurs, and different pH dependent profiles of deacylation rates for each form of t-PA. NSP's pH dependent inhibition of t-PA is not accounted for by differential acylation, and is specific for the NSP-t-PA serpin-protease pair. These results demonstrate a novel mechanism for the differential regulation of the two forms of t-PA in the CNS, and suggest a potential specific regulatory role for CNS pH in controlling t-PA proteolytic activity.

Managing Status Epilepticus in the Older Adult

The aim of this systematic review was to describe particularities in epidemiology, outcome, and management modalities in the older adult population with status epilepticus. There is a higher incidence of status epilepticus in the older adult population, and it commonly has a nonconvulsive presentation. Diagnosis in this population may be difficult and requires an unrestricted use of EEG. Short and long term associated-mortality are high, and age over 60 years is an independent factor associated with poor outcome. Stroke (acute or remote symptomatic), miscellaneous metabolic causes, dementia, infections hypoxemia, and brain injury are among the main causes of status epilepticus occurrence in this age category. The use of anticonvulsive agents can be problematic as well. Thus, it is important to take into account the specific aspects related to the pharmacokinetic and pharmacodynamic changes in older critically-ill adults. Beyond these precautions, the management may be identical to that of the younger adult, including prompt initiation of symptomatic and anticonvulsant therapies, and a broad and thorough etiological investigation. Such management strategies may improve the vital and functional prognosis of these patients, while maintaining a high overall quality of care.