Prognostic factors, morbidity and mortality in tonic-clonic status epilepticus: a review

Clinical Outcomes and Systemic Complications Related to the Severity and Etiology of Status Epilepticus Using a Common Data Model

BACKGROUND

Status epilepticus (SE) is a critical neurological emergency in patients with neurological and nonneurological diseases. Mortality rises with SE severity. However, whether brain injury or systemic organ dysfunction causes death after SE remains unclear. We studied clinical outcomes and systemic dysfunctions associated with SE using standardized data from the common data model. This model includes clinical evaluations and treatments that provide real-world evidence for standard practice.

METHODS

This retrospective cohort study used the common data model database of a single tertiary academic medical center. Patients diagnosed with SE (corresponding to G41 of the International Classification of Diseases 10 and administration of antiseizure medication) between January 1, 2001, and January 1, 2018, were enrolled. Demographics, classifications of SE severity, and outcomes were collected as operational definitions by using a common data model format. Systemic complications were defined based on the Sequential Organ Failure Assessment criteria.

RESULTS

The electronic medical records of 1,825,196 patients were transformed into a common data model, and 410 patients were enrolled. The proportion of patients classified as having nonrefractory SE was 65.4% (268/410), followed by refractory (28.5%, 117/410) and super-refractory SE (6.1%, 25/410). Patients with more severe SE had longer intensive care unit and hospital stays. Renal dysfunction and thrombocytopenia were higher in the in-hospital death group (P = 0.002 and 0.003, respectively). In multivariable analysis, the Acute Physiology and Chronic Health Evaluation II score and platelet count were significantly different in the in-hospital death group (odds ratio, 1.169, P = 0.004; and 0.989, P = 0.043).

CONCLUSIONS

Systemic complications after SE, especially low platelet counts, were linked to worse outcomes and increased mortality in a common data model. The common data model offers expandability and comprehensive analysis, making it a potentially valuable tool for SE research.

Determinants of Outcomes in Convulsive Status Epilepticus: An Observational Study at a Tertiary Care Center in North India

Objective Status epilepticus (SE) presents a critical neurological emergency associated with high morbidity and mortality rates worldwide. However, the determinants influencing outcomes in SE within specific regional contexts remain less explored, especially within North India. Understanding the factors influencing the prognosis of SE in this region is crucial for tailored therapeutic approaches and improved patient outcomes.  Materials and methods This observational study was conducted at Jawaharlal Nehru Medical College, Aligarh, India, from December 1, 2020, to November 31, 2022. Patients who presented with convulsive SE lasting more than five minutes or repetitive and discrete seizures with impaired consciousness between the interictal period for at least 30 minutes were included in the study. Their clinical and biochemical variables at presentation were assessed and correlated with the outcome. Results Out of the 110 patients included in the study, males represented 59.1% (n=65), outnumbering females, who comprised 40.9% (n=45). Favourable outcome was observed in 66.36% (n=73) of patients, and unfavourable outcome was observed in 33.63% (n=37). The mean time interval between seizure onset to the patient's arrival at the hospital was 5.30 ± 4.96 hours, and the mean time interval between seizure onset to the point of seizure control was 7.10 ± 6.38 hours. On analysing the factors associated with unfavourable outcome, the type of seizure at onset (p=0.021), Glasgow Coma Scale (GCS) of <=12 at presentation (p<0.001), presence of refractory seizure (p<0.001), presence of abnormal epileptiform discharges on electroencephalography (p=0.001), Status Epilepticus Severity Score (STESS) of >2 (p<0.001), serum lactate levels (p<0.001), duration of hospital stay (p=0.004), time interval between seizure onset to hospital arrival (p<0.001) and time interval between seizure onset to the point of seizure control (p<0.001) showed significant association. However, on analysing the independent risk factors of unfavourable outcome using multivariate logistic regression, only duration of hospital stay (p<0.001, odds ratio (OR): 1.205, 95% confidence interval (CI): 1.046-1.389), and GCS of less than or equal to 12 at presentation (p<0.001, OR: 12.354, 95% CI: 2.974-51.319) showed significant association. Conclusions Our study highlighted key clinical and time-related parameters influencing the outcome of convulsive SE. Understanding these factors is crucial for better treatment and improved patient outcomes. Further research is essential for refining interventions in this complex condition.

Excessive Use of Benzodiazepines Is a Risk Factor for Endotracheal Intubation in Children Who Present to Emergency With Prehospital Status Epilepticus

OBJECTIVES

There is lack of evidence-based information on the use and timing of endotracheal intubation (ETI) in children with prehospital status epilepticus (SE).

METHODS

The aim of this study was to investigate ETI use, timing, risk factors, and outcomes in children presenting to a single-center children's emergency (CE) with prehospital SE, over a 5-year period.

RESULTS

A total of 118 events involving children presenting to CE with ongoing prehospital SE were included, and 39% (46/118) of the events required ETI. The most common indication for ETI was respiratory depression. The median time to intubation after arrival at CE was 20.0 minutes (1-155 minutes). Risk factors associated with ETI use include the administration of more than 2 benzodiazepines (26.1% vs 4.2%, P < 0.001) and the use of second- or third-line antiepileptic therapy ( P < 0.001). The use of more than 2 doses of benzodiazepines was found in 12.7% (15/118) of the patients. In patients who received excessive benzodiazepines, 87% (13/15) of them required intubation.

CONCLUSIONS

Excessive use of benzodiazepine was found to be a main risk factor for ETI in patients with prehospital SE. Avoidance of the excessive use of benzodiazepines and adhering to clinical management guidelines may reduce the risk for ETI in the CE. The best approach to airway management in children with prehospital SE is lacking and urgently needed.

The impact of a history of status epilepticus for epilepsy surgery outcome

OBJECTIVE

Patients with focal drug resistant epilepsy are excellent candidates for epilepsy surgery. Status epilepticus (SE) and seizure clusters (SC), described in a subset of patients, have both been associated with extended epileptogenic cerebral networks within one or both hemispheres. In this retrospective study, we were interested to determine if a history of SE or SC is associated with a worse surgical outcome.

METHODS

Data of 244 patients operated between 2000 to 2018 were reviewed, with a follow-up of at least 2 years. Patients with a previous history of SE or SC were compared to operated patients without these conditions (control group, CG).

RESULTS

We identified 27 (11%) and 38 (15.5%) patients with history of SE or SC, respectively. No difference in post-operative outcome was found for SE and SC patients. Compared to the control group, patients with a history of SE were diagnosed and operated significantly at earlier age(p = 0.01), and after a shorter duration of the disease (p = 0.027), but with a similar age of onset.

SIGNIFICANCE

A history of SE or SC was not associated with a worse post-operative prognosis. Earlier referral of SE patients for surgery suggests a heightened awareness regarding serious complications of recurrent SE by the referring neurologist or neuropediatrician. While the danger of SE is evident, policies to underline the impact for SC or very frequent seizures might be an efficient approach to accelerate patient referral also for this patient group.

Risk assessment of long-term epilepsy after de novo status epilepticus with clinical and electroencephalographic biomarkers: The AFTER score

BACKGROUND

The risk of developing epilepsy after de novo status epilepticus (SE) is nonnegligible. The individualized management of patients with high risk of subsequent epilepsy could improve long-term quality of life and cognitive impairment. We aimed to ascertain potential biomarkers of subsequent epilepsy and to construct a scoring system possessing predictive value for the diagnosis of post-SE epilepsy during follow-up.

METHODS

The study data were obtained from a prospective registry of all SE episodes occurring in patients over 16 years attended in our tertiary center from February 2011 to April 2022. Clinical data, electroencephalography findings, treatment, and long-term clinical data were prospectively recorded. We selected SE patients at risk of developing epilepsy (acute symptomatic and cryptogenic etiologies with no previous history of epilepsy) and analyzed the risk of developing subsequent epilepsy.

RESULTS

We included 230 patients. Median age was 65 years ± 16.9 SD and 112/230 (48.7 %) were women. One-hundred ninety-eight patients (86.1 %) had an acute symptomatic SE, whereas 32 patients (13.9 %) presented with a cryptogenic SE. A total of 55 patients (23.9 %) developed an unprovoked remote seizure and were diagnosed with epilepsy. After adjusting for identifiable confounders in a multivariable Cox regression analysis cryptogenic etiology (HR 2.24 [1.13-4.46], p = 0.022), first-line treatment initiation ≥1 h (HR 2.12 [1.03-4.36], p = 0.041], RDA/LPD/GPD EEG patterns (HR 1.88 [1.07-3.32], p = 0.028), and super-refractoriness (HR 2.90 [1.40-5.99], p = 0.004) emerged as independent predictors of post-SE epilepsy. Based on these findings, we constructed the AFTER score (1 point for each item) with a robust capability to predict post-SE epilepsy at 5 years (AUC 74.3 %, 95 %CI 64.3-84.3 %, p < 0.001).

CONCLUSIONS

The AFTER score is a robust predictor of the development of epilepsy after new onset SE using clinical and electroencephalographic biomarkers (such as etiology, time to first-line treatment initiation, EEG pattern and super-refractoriness). Prospective studies are warranted to validate the score in other populations.

Prediction of long-term unprovoked seizures after status epilepticus

OBJECTIVE

Possible long-term consequences of status epilepticus (SE) include cognitive and behavioral impairment and the development of chronic epilepsy. However, these aspects have not been systematically studied in clinical practice. We aimed to evaluate long-term seizure recurrence after SE and the potential risk factors for their development.

METHODS

Data were obtained from a prospective registry of all SE episodes occurring in adult patients who attended our center from February 2011 to April 2022. Clinical data, electroencephalographic findings, treatment, and long-term data were prospectively recorded. We performed a cross-sectional study of consecutive SE patients without previous epilepsy diagnosis, and analyzed the development of unprovoked remote seizures.

RESULTS

A total of 849 patients were registered in the database. After excluding in-hospital mortality (198/849, 23.3%) and patients with prior epilepsy history (291/849, 44.7%), 360 patients (42.4%) with a first SE episode were included. The median age was 68 years (interquartile range [IQR] = 56-79), and 176 patients (48.9%) were women. The median time to first-line treatment initiation was 2 h (IQR = .7-7.4), and it was correlated with SE duration (R = .375, p < .001). One hundred nine patients (30.3%) presented unprovoked seizures during a median follow-up of 1.8 years (IQR = .5-4.3). After adjusting for identifiable confounders in a multivariable Cox regression analysis, progressive symptomatic etiology (hazard ratio [HR] = 1.97, 95% confidence interval [CI] = 1.17-3.33, p = .011), time to first-line treatment initiation > 1.5 h (HR = 1.89, 95% CI = 1.25-2.87, p = .003), and superrefractory SE (HR = 2.34, 95% CI = 1.26-4.33, p = .007) were independently associated with a greater risk of unprovoked seizure recurrence. In contrast, older patients (HR = .99, 95% CI = .97-.99, p = .021) and an acute symptomatic etiology (HR = .44, 95% CI .28-.68, p < .001) were at lower risk of unprovoked seizure recurrence.

SIGNIFICANCE

The etiology of SE, the delay in initiating SE treatment, and the presence of superrefractoriness have been identified as potentials factors associated with unprovoked remote seizures following a new onset SE. Therefore, prompt and appropriate management should be applied to avoid seizure recurrence.

Neurological Emergencies in the Intensive Care Unit

Neurological emergencies carry significant morbidity and mortality, and it is necessary to have a multidisciplinary approach involving the emergency physician, the neurologist, the intensivist, and the critical care nursing staff. These disorders can be broadly divided into noninfectious and infectious etiologies. In this article, we review a few of the neurological emergencies that present to the neurological intensive unit, with emphasis on convulsive status epileptics, myasthenia gravis, Guillain-Barré syndrome, meningitis, encephalitis, and brain abscess.

Predicting the progression to super-refractory status epilepticus: A machine-learning study

AIM

Super-refractory status epilepticus (SRSE) is a status epilepticus (SE) that continues or recurs ≥24 h after the onset of anesthesia. We aimed to identify the predictors of progression to SRSE and the risk of 30-day mortality in patients with SRSE by using a machine learning technique.

METHODS

We reviewed consecutive SE episodes in patients aged ≥14 years at Baggiovara Civil Hospital (Modena, Italy) from 2013 to 2021. A classification and regression tree analysis was performed to develop a predictive model of progression to SRSE in SE patients. In SRSE patients, a multivariate analysis was conducted to identify predictors of 30-day mortality.

RESULTS

We included 705 patients, 16% of whom (113/705) progressed to SRSE. Acute symptomatic hypoxic etiology and age ≤ 68.5 years predicted the highest risk (87.1%) of progression to SRSE. Etiology other than acute symptomatic hypoxic and absence of NCSE predicted the lowest risk (3.6%) of progression to SRSE. The predictive model was accurate in 96.1% of patients not evolving to SRSE and in 48.7% of those evolving to SRSE. Among patients with SRSE, 46.9% (53/113) died within 30 days compared to 25.2% (149/592) of patients without SRSE (p < 0.001). Among patients with SRSE, older age was associated with increased 30-day mortality (odds ratio 1.075; 95% confidence interval: 1.031-1.112; p = 0.001).

CONCLUSIONS

Acute symptomatic hypoxic etiology and younger age are major predictors of progression to SRSE. In patients with SRSE, older age is associated with increased risk of short-term mortality.

Machine learning validation through decision tree analysis of the Epidemiology-Based Mortality Score in Status Epilepticus

OBJECTIVE

This study was undertaken to validate the accuracy of the Epidemiology-Based Mortality Score in Status Epilepticus (EMSE) in predicting the risk of death at 30 days in a large cohort of patients with status epilepticus (SE) using a machine learning system.

METHODS

We included consecutive patients with SE admitted from 2013 to 2021 at Modena Academic Hospital. A decision tree analysis was performed using the 30-day mortality as a dependent variable and the EMSE predictors as input variables. We evaluated the accuracy of EMSE in predicting 30-day mortality using the area under the receiver operating characteristic curve (AUC ROC), with 95% confidence interval (CI). We performed a subgroup analysis on nonhypoxic SE.

RESULTS

A total of 698 patients with SE were included, with a 30-day mortality of 28.9% (202/698). The mean EMSE value in the entire population was 57.1 (SD = 36.3); it was lower in surviving compared to deceased patients (47.1, SD = 31.7 vs. 81.9, SD = 34.8; p < .001). The EMSE was accurate in predicting 30-day mortality, with an AUC ROC of .782 (95% CI = .747-.816). Etiology was the most relevant predictor, followed by age, electroencephalogram (EEG), and EMSE comorbidity group B. The decision tree analysis using EMSE variables correctly predicted the risk of mortality in 77.9% of cases; the prediction was accurate in 85.7% of surviving and in 58.9% of deceased patients within 30 days after SE. In nonhypoxic SE, the most relevant predictor was age, followed by EEG, and EMSE comorbidity group B; the prediction was correct in 78.9% of all cases (89.6% in survivors and 46.1% in nonsurvivors).

SIGNIFICANCE

This validation study using a machine learning analysis shows that the EMSE is a valuable prognostic tool, and appears particularly accurate and effective in identifying patients with 30-day survival, whereas its performance in predicting 30-day mortality is lower and needs to be further improved.

Out-of-hospital versus in-hospital status epilepticus: the role of etiology and comorbidities

Background and purpose

Our objectives were to identify differences in clinical characteristics between patients with out‐of‐hospital and in‐hospital status epilepticus (SE) onset, and to evaluate the influence of SE onset setting on 30‐day mortality and SE cessation.

Methods

We included consecutive patients with SE admitted from 2013–2021 at Modena Academic Hospital. A propensity score was obtained with clinical variables unevenly distributed between the two groups.

Results

Seven hundred eleven patients were included; 55.8% (397/711) with out‐of‐hospital and 44.2% (314/711) with in‐hospital onset. Patients with in‐hospital SE onset were older and had a higher frequency of comorbidities, acute and/or potentially fatal etiologies, impaired consciousness before treatment, and nonconvulsive or myoclonic SE. No difference was found in SE cessation between the groups. Patients with in‐hospital SE had higher 30‐day mortality (127/314, 62.9% vs. 75/397, 37.1%; p < 0.001). In‐hospital onset was an independent risk factor for 30‐day mortality (adjusted odds ratio = 1.720; 95% confidence interval = 1.107–2.674; p = 0.016). In the propensity group (n = 244), no difference was found in 30‐day mortality and SE cessation between out‐of‐hospital and in‐hospital SE onset groups (36/122, 29.5% vs. 34/122, 27.9%; p = 0.888; and 47/122, 38.5% vs. 39/122; 32%; p = 0.347, respectively).

Conclusions

In‐hospital SE is associated with higher 30‐day mortality without difference in SE cessation. The two groups differ considerably for age, acute and possibly fatal etiologies, comorbidities, and SE semiology. The patient location at SE onset is an important prognostic predictor. However, the increased mortality is probably unrelated to the setting of SE onset and reflects intrinsic prognostic predictors.

Status epilepticus: review on diagnosis, monitoring and treatment

Status epilepticus (SE) is a frequent neurological emergency associated with high morbidity and mortality. According to the new ILAE 2015 definition, SE results either from the failure of the mechanisms responsible for seizure termination or initiation, leading to abnormally prolonged seizures. The definition has different time points for convulsive, focal and absence SE. Time is brain. There are changes in synaptic receptors leading to a more proconvulsant state and increased risk of brain lesion and sequelae with long duration. Management of SE must include three pillars: stop seizures, stabilize patients to avoid secondary lesions and treat underlying causes. Convulsive SE is defined after 5 minutes and is a major emergency. Benzodiazepines are the initial treatment, and should be given fast and an adequate dose. Phenytoin/fosphenytoin, levetiracetam and valproic acid are evidence choices for second line treatment. If SE persists, anesthetic drugs are probably the best option for third line treatment, despite lack of evidence. Midazolam is usually the best initial choice and barbiturates should be considered for refractory cases. Nonconvulsive status epilepticus has a similar initial approach, with benzodiazepines and second line intravenous (IV) agents, but after that, aggressiveness should be balanced considering risk of lesion due to seizures and medical complications caused by aggressive treatment. Usually, the best approach is the use of sequential IV antiepileptic drugs (oral/tube are options if IV options are not available). EEG monitoring is crucial for diagnosis of nonconvulsive SE, after initial control of convulsive SE and treatment control. Institutional protocols are advised to improve care.

Frequency and Types of Complications Encountered in Patients With Nonconvulsive Status Epilepticus in the Neurological ICU: Impact on Outcome

Objectives. The frequency and types of complications in patients with nonconvulsive status epilepticus (NCSE) who are followed up in the intensive care unit (ICU), and the impact of these complications on outcome are not well-known. We investigated the complications and their effects on prognosis in NCSE patients. Methods. After reviewing the video-EEG monitoring (VEEGM) reports of all the consecutive patients who were followed up in our ICU between 2009 and 2019, we identified two groups of patients: 1-patients with NCSE (study group) and 2-patients who underwent VEEGM for possible NCSE but did not have ictal recordings (no-NCSE group). Electronic health records were reviewed to identify demographic and clinical data, duration of ICU care, medical and surgical complications, pharmacologic treatment, and outcome. These parameters were compared statistically between the groups. We also investigated the parameters affecting prognosis at discharge. Results. Thirty-two patients with NCSE comprised the study group. Infection developed in 84%. More than half were intubated, had tracheostomy or percutaneous endoscopic gastrostomy application. Refractory NCSE was associated with significantly more frequent complications and worse outcome. There was a higher tendency of infections in the study group (P = .059). Higher organ failure scores and prolonged stay in ICU predicted worse outcome (P < .05). Conclusion. The frequency of complications in patients with NCSE who are cared for in the ICU is considerable. Most of the complications are similar to the other patients in ICU, except for the higher frequency of infections. Increased physician awareness about modifiable parameters and timely interventions might help improve prognosis.

Characteristics and outcome in an Egyptian Cohort with status epilepticus

OBJECTIVES

Status epilepticus (SE) is an important cause of mortality worldwide. Information regarding associations of mortality outcome in Egypt is limited. The main objective of this study was to describe the clinical characteristics and factors associated with mortality of patients with SE admitted to Cairo University Hospitals.

METHODS

A prospective observational hospital-based study was conducted from January 2017 to June 2018. Patients with SE aged ≥12 years old were followed with documentation of outcome on discharge as survival versus death.

RESULTS

The study cohort included 144 SE patients. The majority of episodes (96.5%) were with prominent motor features, while nonconvulsive SE occurred in 3.5%. There was a clear semiology evolution in 22.9% of episodes, 56.3% had unchanging semiology (e.g., just convulsive or just nonconvulsive) and the semiology evolution could not be discerned in 20.8%. In relation to treatment, the majority of cases were responsive (46.5%), whereas 43.1% were refractory and only 10.4% were super-refractory SE. Apart from seven patients who were referred to other hospitals, 99 patients survived whereas 38 (26.4%) died. After regression analysis, only absence of a history of epilepsy, semiology evolution and mechanical ventilator use were associated with mortality increasing its odds by 3.7, 5, 111 times, respectively.

CONCLUSION

Absence of a history of epilepsy, SE semiology evolution, and mechanical ventilator use was found to be associated with mortality outcome among Egyptian patients with SE.

Status epilepticus without impairment of consciousness: Long-term outcomes according to duration

OBJECTIVE

The point after which non-convulsive status epilepticus (NCSE) can cause permanent damage remains to be elucidated. The aim of this study was to analyze the association between time to resolution and long-term outcomes in NCSE.

METHODS

We performed a retrospective study of all patients with focal NCSE without consciousness impairment at two tertiary care hospitals in Spain. All the data were registered prospectively and the study period was December 2014-May 2018. We collected information on demographics, SE etiology, time to administration of different lines of treatment, time to NCSE resolution, and outcomes at discharge, 1 year, and 4 years. Clinical outcome was prospectively categorized as good (return to baseline function) or poor (new disability and death).

RESULTS

Seventy-four patients with a mean (±SD) age of 63.4 ± 17.5 years and a mean follow-up time of 2.4 ± 2.2 years were studied. A poor outcome at discharge was associated with a potentially fatal etiology (p < 0.001), EMSE score (Epidemiology-based Mortality Score in Status Epilepticus) (p = 0.012), lateral periodic discharges on EEG (p = 0.034), and occurrence of major complications during hospitalization (p = 0.007). An SE duration of >100 h was clearly associated with a worse outcome (p < 0.001). In the multiple regression analysis, the only independent predictors of a poor outcome at discharge were an SE duration of >+100 hours (p = 0.001), a potentially fatal etiology (p = 0.001), and complications during hospitalization (p = 0.010). An SE duration of >100 hours retained its value as the optimal cutoff point for predicting poor outcomes at both 1 year (p = 0.037) and 4 years (p = 0.05). Other predictors of poor long-term outcomes were a potentially fatal etiology (p < 0.001) and EMSE score (p = 0.034) at 1 year, and progressive symptomatic etiology at 4 years (p = 0.025).

SIGNIFICANCE

In patients with focal NCSE without consciousness impairment, a potentially fatal etiology and an SE duration of >100 h were associated with poor short-term and long-term outcomes.

Treatment Outcomes of Pediatric Status Epilepticus in a Tertiary Pediatric Intensive Care Unit

OBJECTIVE

Status epilepticus is associated with high rates of morbidity and mortality; thus, early diagnosis and proper treatment are crucial. We aimed to study the etiology, clinical features, and treatment among pediatric patients with convulsive status epilepticus.

METHODS

The medical records of 100 patients were retrospectively obtained from pediatric intensive care unit. Etiology, clinical features, and treatment were interpreted by using Fisher exact test, χ2 test, and Spearman ρ correlation coefficient.

RESULTS

Seizures had stopped with the first-, second-, and third-line treatment in 29%, 36%, and 35% of the patients, respectively. Only phenytoin treatment was efficient; it has 32.3% rate in second-line treatment. Whereas mortality rate was 10%, morbidity rate was 14% during the follow-up. Epilepsy, hemiparesis, spastic tetraparesis, and mental retardation developed. Mortality was significantly much more in the patients with refractory seizure and cerebral palsy. Development of mental retardation was much higher in the male sex.

CONCLUSIONS

Phenytoin is still one of the most efficient antiepileptic drugs. If the duration of status epilepticus can be shortened by prompt treatment, neurological complications may be prevented.

Efficacy of Home Anticonvulsant Administration for Second-Line Status Epilepticus Treatment

OBJECTIVE

To investigate whether receiving a second-line anticonvulsant medication that is part of a patient's home regimen influences outcomes in benzodiazepine-refractory convulsive status epilepticus.

METHODS

Using the Established Status Epilepticus Treatment Trial data, allocation to a study drug included in the patient's home anticonvulsant medication regimen was compared to receipt of an alternative second-line study medication. The primary outcome was cessation of clinical seizures with improved consciousness by 60 minutes after study drug initiation. Secondary outcomes were seizure cessation adjudicated from medical records and adverse events. We performed inverse probability of treatment-weighted (IPTW) logistic regressions.

RESULTS

Of 462 patients, 232 (50%) were taking 1-2 of the 3 study medications at home. The primary outcome was observed in 39/89 (44%) patients allocated to their home medication vs 76/143 (53%) allocated to a nonhome medication (IPTW odds ratio [OR] 0.66, 95% confidence interval [CI] 0.39-1.14). The adjudicated outcome occurred in 37/89 (42%) patients vs 82/143 (57%), respectively (IPTW OR 0.52, 95% CI 0.30-0.89). There was no interaction between study levetiracetam and home levetiracetam and there were no differences in adverse events.

CONCLUSION

There was no difference in the primary outcome for patients who received a home medication vs nonhome medication. However, the retrospective evaluation suggested an association between receiving a nonhome medication and seizure cessation.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that for patients with refractory convulsive status epilepticus, use of a home second-line anticonvulsant compared to a nonhome anticonvulsant did not significantly affect the probability of stopping seizures.

Increased mortality after post-stroke epilepsy following primary intracerebral hemorrhage

OBJECTIVES

This study aimed to determine whether post-stroke epilepsy (PSE) predicts mortality, and to describe the most prominent causes of death (COD) in a long-term follow-up after primary intracerebral hemorrhage (ICH).

METHODS

We followed 3-month survivors of a population-based cohort of primary ICH patients in Northern Ostrobothnia, Finland, for a median of 8.8 years. Mortality and CODs were compared between those who developed PSE and those who did not. PSE was defined according to the ILAE guidelines. CODs were extracted from death certificates (Statistics Finland).

RESULTS

Of 961 patients, 611 survived for 3 months. 409 (66.9%) had died by the end of the follow-up. Pneumonia was the only COD that was significantly more common among the patients with PSE (56% vs. 37% of deaths). In the multivariable models, PSE (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.06-1.87), age (HR 1.07, 95% CI 1.06-1.08), male sex (HR 1.35, 95% CI 1.09-1.67), dependency at 3 months (HR 1.52, 95% CI 1.24-1.88), non-subcortical ICH location (subcortical location HR 0.78, 95% CI 0.61-0.99), diabetes (HR 1.43, 95% CI 1.07-1.90) and cancer (HR 1.45, 95% CI 1.06-1.98) predicted death in the long-term follow-up.

CONCLUSION

PSE independently predicted higher late morality of ICH in our cohort. Pneumonia-related deaths were more common among the patients with PSE.

Magnolia officinalis Reduces Inflammation and Damage Induced by Recurrent Status Epilepticus in Immature Rats

BACKGROUND

Neuroinflammation induced in response to damage caused by status epilepticus (SE) activates the interleukin (IL)1-β pathway and proinflammatory proteins that increase vulnerability to the development of spontaneous seizure activity and/or epilepsy.

OBJECTIVES

The study aimed to assess the short-term anti-inflammatory and neuroprotective effects of Magnolia officinalis (MO) on recurrent SE in immature rats.

METHODS

Sprague-Dawley rats at PN day 10 were used; n = 60 rats were divided into two control groups, SHAM and KA, and two experimental groups, MO (KA-MO) and Celecoxib (KA-Clbx). The anti-inflammatory effect of a single dose of MO was evaluated at 6 and 24 hr by Western blotting and on day 30 PN via a subchronic administration of MO to assess neuronal preservation and hippocampal gliosis by immunohistochemistry for NeunN and GFAP, respectively.

RESULTS

KA-MO caused a decrease in the expression of IL1-β and Cox-2 at 6 and 24 h post-treatment, a reduction in iNOS synthase at 6 and 24 hr post-treatment and reduced neuronal loss and gliosis at postnatal day 30, similar to Clbx.

CONCLUSION

The results indicating that Magnolia officinalis is an alternative preventive treatment for early stages of epileptogenesis are encouraging.

Seizure-Induced Oxidative Stress in Status Epilepticus: Is Antioxidant Beneficial?

Epilepsy is a common neurological disorder which affects patients physically and mentally and causes a real burden for the patient, family and society both medically and economically. Currently, more than one-third of epilepsy patients are still under unsatisfied control, even with new anticonvulsants. Other measures may be added to those with drug-resistant epilepsy. Excessive neuronal synchronization is the hallmark of epileptic activity and prolonged epileptic discharges such as in status epilepticus can lead to various cellular events and result in neuronal damage or death. Unbalanced oxidative status is one of the early cellular events and a critical factor to determine the fate of neurons in epilepsy. To counteract excessive oxidative damage through exogenous antioxidant supplements or induction of endogenous antioxidative capability may be a reasonable approach for current anticonvulsant therapy. In this article, we will introduce the critical roles of oxidative stress and further discuss the potential use of antioxidants in this devastating disease.

Neonatal Seizures and Purinergic Signalling

Neonatal seizures are one of the most common comorbidities of neonatal encephalopathy, with seizures aggravating acute injury and clinical outcomes. Current treatment can control early life seizures; however, a high level of pharmacoresistance remains among infants, with increasing evidence suggesting current anti-seizure medication potentiating brain damage. This emphasises the need to develop safer therapeutic strategies with a different mechanism of action. The purinergic system, characterised by the use of adenosine triphosphate and its metabolites as signalling molecules, consists of the membrane-bound P1 and P2 purinoreceptors and proteins to modulate extracellular purine nucleotides and nucleoside levels. Targeting this system is proving successful at treating many disorders and diseases of the central nervous system, including epilepsy. Mounting evidence demonstrates that drugs targeting the purinergic system provide both convulsive and anticonvulsive effects. With components of the purinergic signalling system being widely expressed during brain development, emerging evidence suggests that purinergic signalling contributes to neonatal seizures. In this review, we first provide an overview on neonatal seizure pathology and purinergic signalling during brain development. We then describe in detail recent evidence demonstrating a role for purinergic signalling during neonatal seizures and discuss possible purine-based avenues for seizure suppression in neonates.

Impact of predictive, preventive and precision medicine strategies in epilepsy

Over the last decade, advances in genetics, neuroimaging and EEG have enabled the aetiology of epilepsy to be identified earlier in the disease course than ever before. At the same time, progress in the study of experimental models of epilepsy has provided a better understanding of the mechanisms underlying the condition and has enabled the identification of therapies that target specific aetiologies. We are now witnessing the impact of these advances in our daily clinical practice. Thus, now is the time for a paradigm shift in epilepsy treatment from a reactive attitude, treating patients after the onset of epilepsy and the initiation of seizures, to a proactive attitude that is more broadly integrated into a 'P4 medicine' approach. This P4 approach, which is personalized, predictive, preventive and participatory, puts patients at the centre of their own care and, ultimately, aims to prevent the onset of epilepsy. This aim will be achieved by adapting epilepsy treatments not only to a given syndrome but also to a given patient and moving from the usual anti-seizure treatments to personalized treatments designed to target specific aetiologies. In this Review, we present the current state of this ongoing revolution, emphasizing the impact on clinical practice.

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.

Intramuscular Midazolam for treatment of Status Epilepticus

INTRODUCTION

Status epilepticus (SE) is a common neurological and medical emergency. It has high mortality and morbidity rates, which typically correlate with seizure semiology and duration; therefore, prompt and proper pharmacological intervention is paramount. In a pre-hospital setting, establishing venous access can be difficult, so other routes of drug administration should be considered.

AREAS COVERED

The paper summarizes the data from the literature and provides an evaluation of the efficacy and safety of intramuscular midazolam (IM MDZ) as it pertains to the management of acute seizures and SE.

EXPERT OPINION

The cascade of events involved in the genesis and sustenance of seizures, if not promptly stopped, lead to the perpetuation of the condition and may contribute to the refractoriness of pharmacological treatment. Hence, non-venous routes for drug administration were developed to allow untrained personnel to rapidly stop seizures. Among benzodiazepines (BDZs), IM MDZ is at least as effective and safe as other intravenously administered BDZs. Moreover, thanks to IM MDZ's favorable pharmacodynamic and pharmacokinetic profile, it is a promising alternative to other non-venous drugs such as intranasal-MDZ, buccal-MDZ, and rectal-diazepam in the pre-hospital management of SE cases with motor features.

Ketogenic diet treatment of children in the intensive care unit: Safety, tolerability, and effectiveness

PURPOSE

The ketogenic diet (KD) is initiated emergently in the intensive care unit (ICU) for patients with super refractory status epilepticus (SRSE) and epileptic encephalopathies (EE). However, few data are available regarding safety, effectiveness, and long-term outcomes.

METHODS

We performed a retrospective cohort study of consecutive patients with KD initiated in the ICU from 2010 to 2018 for SRSE and EE. We characterized time to ketosis, adverse effects, and seizure outcomes. Responders were defined as having ≥50 % reduction in seizure frequency compared to prior to KD initiation.

RESULTS

We identified 29 patients. KD was initiated for SRSE in 12 patients, EE in 8 patients, and EE with SRSE in 9 patients. KD was initiated after a median of 9 days. Ketosis was achieved 2 days faster in fasted patients (p < 0.0001). All patients had at least 1 KD-related adverse effect, most often hypoglycemia, constipation, or acidosis. There was ≥50 % reduction in seizure frequency compared to prior to KD initiation by 1 week in 17/28 patients, seizure-freedom by 2 weeks in 7/28 patients, and weaned off anesthetics in 11/17 patients. All KD-responders at 1 month had continued response at 6 months. Mortality at 1 year was 24 %. There was no difference in KD response or mortality between KD indication groups.

CONCLUSION

Emergent KD initiation in the ICU is feasible, safe, and often effective for SRSE and EE. Expected adverse effects were common but treatable. Morbidity and mortality in this group was high. A ≥ 50 % reduction in seizure is achieved in most responders by 1-2 weeks.

Factors affecting mortality of refractory status epilepticus

OBJECTIVE

The aim of this study was to determine the factors affecting the mortality of refractory status epilepticus (RSE) in comparison with non-refractory status epilepticus (non-RSE).

MATERIAL-METHOD

Included in this retrospective study were 109 status epilepticus cases who were hospitalized in the neurological intensive care unit Katip Celebi University. Fifty-two were RSE and 57 were non-RSE. All clinical data were gathered from the hospital archives. Factors which may cause mortality were categorized for statistical analysis.

RESULTS

While elderly age, continuous clinical seizure activity, absence of former seizure, infection, prolonged stay of ICU, anesthesia, and cardiac comorbidity were significantly related to mortality in the RSE subgroup, potentially fatal accompanying diseases were significantly related to mortality in the non-RSE subgroup. No significant relationship was found between mortality and refractoriness. Multivariate analysis revealed that a Glasgow Coma Score (GCS) at presentation of 8 or lower was the independent predictor of mortality both in the general SE population (P = .017) and in the RSE subgroup (P = .007). Intubation (P = .011) and hypotension (P = .011) were the other independent predictors of mortality in the general SE population. No independent predictor of mortality was detected in the non-RSE subgroup.

DISCUSSION/CONCLUSION

Intubation, hypotension, and a low GCS at presentation could be the main factors which could alert clinicians of an increased risk of mortality in SE patients. Although non-RSE and RSE had similar rates of mortality in the ICU, the mortality-related factors of SE vary in the RSE and the non-RSE subgroups.

Lessons from the Established Status Epilepticus Treatment Trial

Convulsive status epilepticus (SE) is a relatively common emergency condition affecting individuals of all ages. The primary goal of treatment is prompt termination of seizures. Where first-line treatment with benzodiazepine has failed to achieve this, a condition known as established SE (ESE), there is uncertainty about which agent to use next. The Established Status Epilepticus Treatment Trial (ESETT) is a 3-arm (valproate (VPA), fosphenytoin (FOS), levetiracetam (LEV)), phase III, double-blind randomized comparative effectiveness study in patients aged 2 years and above with established convulsive SE. Enrollment was completed in January 2019, and the results are expected later this year. We discuss lessons learnt during the conduct of the study in relation to the following: ethical considerations; trial design and practical implementation in emergency settings, including pediatric and adult populations; quality assurance; and outcome determination where treating emergency clinicians may lack specialist expertise. We consider that the ESETT is already informing both clinical practice and future trial design. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".

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.

Medical management of status epilepticus: Emergency room to intensive care unit

In convulsive status epilepticus (SE), achieving seizure control within the first 1-2 hours after onset is a significant determinant of outcome. Treatment is also more likely to work and be cost effective the earlier it is given. Initial first aid measures should be accompanied by establishing intravenous access if possible and administering thiamine and glucose if required. Calling for help will support efficient management, and also the potential for video-recording the events. This can be done as a best interests investigation to inform later management, provided adequate steps to protect data are taken. There is high quality evidence supporting the use of benzodiazepines for initial treatment. Midazolam (buccal, intranasal or intramuscular) has the most evidence where there is no intravenous access, with the practical advantages of administration outweighing the slightly slower onset of action. Either lorazepam or diazepam are suitable IV agents. Speed of administration and adequate initial dosing are probably more important than choice of drug. Although only phenytoin (and its prodrug fosphenytoin) and phenobarbitone are licensed for established SE, a now considerable body of evidence and international consensus supports the utility of both levetiracetam and valproate as options in established status. Both also have the advantage of being well tolerated as maintenance treatment, and possibly a lower risk of serious adverse events. Two adequately powered randomized open studies in children have recently reported, supporting the use of levetiracetam as an alterantive to phenytoin. The results of a large double blind study also including valproate are also imminent, and together likely to change practice in benzodiazepine-resistant SE.

Rates and Trends of Endotracheal Intubation in Patients With Status Epilepticus

OBJECTIVE

Among patients with status epilepticus, we sought to determine the rate of endotracheal intubation, identify the physician specialties responsible for endotracheal intubation, and characterize the trend in use of endotracheal intubation over the last 20 years.

METHODS

We performed a cross-sectional study using data from 2 sources. First, we used inpatient claims between 2009 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. Patients with status epilepticus were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes, and those who underwent endotracheal intubation were identified based on Current Procedural Terminology codes. Medical specialties of providers performing intubation were identified based on Healthcare Provider Taxonomy Codes. Second, we used claims data from the National Inpatient Sample (NIS) to estimate the annual rates and trends of endotracheal intubation and tracheostomy among patients with status epilepticus from 1995 to 2014.

RESULTS

Among 1971 Medicare beneficiaries with status epilepticus, 566 (29%) patients underwent endotracheal intubation. 375 (66%) patients were intubated on admission. The most common medical providers performing intubation in patients with status epilepticus were emergency medicine physicians (50.4%), anesthesiologists (16.4%), and pulmonary medicine physicians (10.1%). Neurologists accounted for 1.7% of all intubations. Among individuals with status epilepticus identified in the NIS, 248 681 (41.7%) were intubated. The proportion of patients intubated increased from 29.5% (95% confidence interval [CI]: 27.8%-31.3%, P = .018) in 1995 to 50.8% (95% CI: 49.6%-52%, P = .012) in 2014. The proportion of patients with status epilepticus who underwent tracheostomy increased from 2.2% (95% CI: 1.7%-2.7%, P = .005) in 1995 to 3.4% (95% CI: 3%-3.9%, P = .004) in 2014.

SIGNIFICANCE

Approximately 1 in 3 patients with status epilepticus undergo endotracheal intubation. Over the last 20 years, the proportion of patients with status epilepticus undergoing endotracheal intubation has almost doubled. Neurologists perform a small percentage of these intubations.

Change in Mortality of Generalized Convulsive Status Epilepticus in High-Income Countries Over Time: A Systematic Review and Meta-analysis

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.

Use of Newer Anticonvulsants for the Treatment of Status Epilepticus

Status epilepticus (SE) has a high mortality rate and is one of the most common neurologic emergencies. Fast progression of this neurologic emergency and lack of response to traditional antiepileptic drugs (AEDs) in most cases has challenged clinicians to use new agents. This article evaluates the efficacy and safety of AEDs released to the market after 2000 for SE, refractory status epilepticus (RSE), and super-refractory status epilepticus (SRSE). The PubMed database was searched for clinical trials published between January 2000 and July 2018 using the search terms status epilepticus, refractory status epilepticus, super refractory status epilepticus, brivaracetam, clobazam, cannabidiol, eslicarbazepine, lacosamide, perampanel, rufinamide, stiripentol, and zonisamide. Trials that evaluated these agents in adults with SE, RSE, and SRSE were included. Brivaracetam use was identified in two retrospective reviews with success rates of 27% and 57%. One unsuccessful case report of cannabidiol use in SE was found. Four clobazam studies were identified in SE and RSE with success rates ranging from 25-100%. No evidence for the use of eslicarbazepine and zonisamide was found. Using the search terms for lacosamide identified 38 articles: 1 systematic review, 5 prospective studies, 15 retrospective reviews, and 17 case reports. Success rates and dosing varied, but studies that included focal or partial types of SE showed higher success rates. Five articles were identified regarding perampanel use in this setting. Three were retrospective reviews with success rates ranging from 17-60%, and two were case reports. Only one case report regarding the use of rufinamide was found; rufinamide titrated up to 4.4 mg/day allowed discontinuation of barbiturate and clobazam. One case report and two case series of stiripentol were found with reported efficacy between 60% and 100% in SRSE. Evidence is currently insufficient to support the use of these agents in this setting.

Update in status epilepticus

Status epilepticus (SE) is a neurological emergency that requires urgent antiepileptic therapies, and a rapid treatment of its cause. In recent years, its definition has been updated to adapt it to all types of SE; this update helps to standardise the treatment. The new definition is based on two times: point t1, after which the event will not spontaneously cease, and period t2, after which neuronal damage may appear. There are three lines of treatment: first, benzodiazepines; second, antiepileptic drugs; and third, intravenous anaesthetics. The application of the different lines of treatment raises still unanswered questions, since the prognosis also depends on the aetiology, age and duration. For this reason, different prognostic scales are being developed to help us to assess its evolution and in turn, adapt the aggressiveness of the treatment to each patient.

Determinants of Outcome in Convulsive Status Epilepticus in Adults: An Ambispective Study from Central India

BACKGROUND

The determinants of the outcome in adult convulsive status epilepticus(CSE), also the implication of the value of mean arterial blood pressure (MAP), and random blood sugar at admission on the outcome are not clear.

OBJECTIVES

The objective of this study is to look for the determinants of unfavorable outcome in CSE.

MATERIALS AND METHODS

Ambispectively gathered data from 55 patients, treated consecutively with identical protocol during January 2010-December 2016, were analyzed. The demographic and clinical variables were identified and correlated with outcome in each individual.

RESULTS

There were 65.45% males and 34.55% females. Favorable outcome (conscious and discharged) was seen in 63.6%, unfavorable (death 14.5%, absent cortical functions 10.9%, and inability to wean-off anesthetic agents 10.9%). The parameters associated with unfavorable outcome were female gender (odds ratio [OR]: 1.45), MAP ≤80 mmHg (OR: 2.57), time to first medical attention >5 h (OR: 127.8), and time to control clinical seizures >3.5 h (OR: 7.87). Almost 44.2% of patients with SE severity score >2 had unfavorable outcome (sensitivity 75% and specificity 45.7%). New scoring system, the CSE outcome score (CSEOS, developed by combining the predictors associated with higher odds of poor outcome), predicted the poor outcome with the sensitivity and specificity of 90% and 54.29%, respectively.

DISCUSSION AND CONCLUSION

Low MAP and delay of >3.5 h in treatment initiation or seizure control are the key determinants of poor outcome in CSE. With the incorporation of CSEOS, we believe that our findings can be helpful in the process of clinical decision-making and prognostication of patients with CSE.

Cost of status epilepticus (SE): Effects of delayed treatment and SE duration

BACKGROUND

The health expenditure related to status epilepticus (SE) is high because of lengthy hospitalization requirements and possible sequelae. We aimed to study the factors associated with this cost including the different timings of the treatment and SE duration.

METHODS

We evaluated retrospectively all SE recorded in 2 hospitals. The factors studied included the mean cost of hospitalization, demographics, clinical data, duration of hospitalization, in-hospital/out-of-hospital debut, time from onset to treatment, duration of SE, and destination at discharge.

RESULTS

Three hundred five patients were evaluated (December/2012-July/2017), 195 with out-of hospital and 110 with in-hospital debut. The cost of SE with out-of-hospital onset was significantly lower (6559€ vs 15,174€; p = 0.0001). In out-of-hospital cases, the factors independently related to expenditure were the level of consciousness (p < 0.001), presence of complications (p = 0.005), a potentially fatal etiology (p = 0.008), and duration of the episode (p = 0.003). Duration was significantly higher in patients discharged to a convalescence center (p = 0.006); this variable was significantly related to the time SE onset-arrival to hospital, and SE onset-administration of the treatment. In the in-hospital cases, cost was related to male sex (p = 0.002), the development of complications (p = 0.003), and the etiology (p = 0.016) but was not directly related to the SE duration or to the time onset-treatment.

CONCLUSIONS

The duration of SE and the speed with which proper management is applied have a direct impact on the healthcare expenditure resulting from out-of-hospital SE. In contrast, the etiology and development of complications are the main factors responsible for expenditure related to in-hospital SE.

Adult convulsive status epileptic us: clinical, etiological, and predictors of outcome study from rural population of North India

AIM

To determine the clinical profile, etiologies and predictors of mortality in patients with convulsive status epilepticus (CSE) among rural population of North India in view of limited published data on epidemiology and etiology of status epilepticus (SE) from developing countries.

METHODS

One hundred sixty-two consecutive adult patients with CSE were evaluated from 2016 to 2018 for demographic profile, etiologies and predictors of poor outcome.

RESULTS

The mean age was 41.71 ± 19.72 years. Most of the CSE cases were acute symptomatic (48.8%) type with central nervous system (CNS) infections (24.1%) being the predominant precipitating factor. Antiepileptic drugs (AEDs) noncompliance accounted for 34.9% of the cases with pre-existing epilepsy. The median duration of CSE was 5.5 h (IQR-3-10 h). 82.1% cases responded to the first line drugs and their response was related with duration of CSE (p = .0045). Case fatality was 16.0% and the predictors of the mortality were; low Glasgow Coma Scale (GCS) (OR =9.64, 95% CI= 2.064-45.02; p = .0001), lack of response to first line drugs (OR =0.019, 95% CI= 0.003-0.11; p = .0001) and absence of past history of epilepsy (OR =0.525, 95%CI =0.104-2.66; p = .004).

CONCLUSIONS

CNS infection and AEDs noncompliance were identified to be the major cause of CSE which can be potentially preventable. Present study signifies that prompt and successful control of infections appears to be the most efficient preventive approach. Level of consciousness as a potential predictor of poor outcome can be quickly accessible to the treating clinician in optimizing treatment strategies.

Treatment gap for convulsive status epilepticus in resource-poor countries

The magnitude of the treatment gap (TG) for convulsive status epilepticus (CSE) in resource-poor countries is unknown. Hospital-based cohort studies from developing countries revealed that the management of CSE was usually suboptimal due to lack of advanced diagnostic and treatment facilities, significant delay in patient's presentation at hospital, and shortages of essential antiepileptic drugs (AEDs). However, there were no significant differences in the proportion of refractory status epilepticus, short-term mortalities, and morbidities of CSE between the developed and the developing countries. Therefore, the presence of significant TG for CSE in developing countries is still an assumption without evidence. We conducted an expert survey in Asia for potential sources of TG. Experts from 16 Asian countries responded to the questionnaire. An injectable form of diazepam was available in all 16 countries even at the primary care level, but intravenous lorazepam was available only in four countries. Second-line AEDs were widely available at tertiary care hospitals, but not at primary care hospitals. Lack of second-line AEDs at primary care hospitals, significant delay in patient transportation to the hospital, shortages of intensive care unit facilities, and absence of trained physicians were important contributing factors to TG in Asia.

The etiology and prognosis of super-refractory convulsive status epilepticus in children

BACKGROUND

Both refractory convulsive status epilepticus (SE) and super-refractory SE are medical emergencies. However, there are limited data on super-refractory SE in children. Thus, this study focuses on characterizing the demographics, outcomes, and prognostic factors for super-refractory SE in children.

METHODS

This study was a retrospective analysis of super-refractory SE treated in a tertiary referral center in Taiwan. The functional outcome was evaluated by modified Rankin scale (mRS). Significant functional decline was defined as an mRS difference (before hospital admission and at discharge) of more than 2. The variates and the follow-up mRS values were then analyzed statistically.

RESULTS

We enrolled 134 patients with 191 episodes of convulsive SE and identified 30 patients with 38 episodes of convulsive super-refractory SE. The incidence of convulsive super-refractory SE in the group with SE was 19.9%, and the age ranged from 2.5 months to 17 years. In-hospital mortality was 13.3%, which was much lower than that of adult cohorts. Newly acquired epilepsy and cognitive deficit occurred in 100% and 88.5%, respectively. Newly acquired epilepsy, as a sequel of super-refractory SE, was observed in all 18 patients (100%) who survived and had no history of epilepsy. Significant functional decline (mRS difference of more than 2) at discharge occurred in 76.7%. Poor functional outcome was associated with acute symptomatic etiology (P < 0.001) and the number of anesthetic agents (P = 0.002). The functional outcome improved after 1 year of follow-up in our population.

CONCLUSIONS

Super-refractory SE is associated with significant morbidity and mortality in children. However, the in-hospital mortality rate is much lower compared with adults. The functional outcome in children is associated with acute symptomatic etiology and the number of anesthetic agents and may improve after long-term follow-up.

Risk score predictive of mortality in status epilepticus according to a national database

Status epilepticus (SE) is a serious neurologic condition with high morbidity and mortality rates. This study aimed to develop and validate a risk score that is predictive of mortality in patients with SE using clinical factors without electrocardiography. The inclusion criteria of this study were all patients diagnosed with SE and treated between 2005 and 2015. We retrospectively searched for eligible patients using the International Classification of Diseases, Tenth Revision (ICD-10) code for SE (G41) in the national Universal Health Coverage database. The outcome was death at discharge or within 30 days after discharge. Factors-associated death was analyzed using stepwise logistic regression analysis. Risk scores were developed based on the final logistic regression model. The final model was also validated. There were 10 924 patients used for model development and 10 808 used for model validation. The formula to determine the risk score for SE mortality was 5 × shock + 4 × age over 60 years old + 3.5 × heart diseases + 3 × acute renal failure + 3 × septicemia + 2.5 × central nervous system infection + 2.5 × age 41-60 years old + 2 × cancer + 2 × chronic renal failure + 1.5 × age 21-40 years old + 1 × pneumonia + 1 × respiratory failure + 1 × anemia. The risk scores of greater than 4 indicated risk for mortality with a sensitivity of 78.20% and specificity of 75.38%. The area under the receiver-operating characteristic (ROC) curve for death in the final model was 83.59%. The area under the ROC curve for the model validation group was 83.52%. SE patients who had a risk score of 4 or more were at high risk for death. Physicians should be aware of the high mortality rate in these particular patients.

Acute Resective Surgery for the Treatment of Refractory Status Epilepticus

BACKGROUND

To identify the role of acute surgical intervention in the treatment of refractory status epilepticus (RSE).

METHODS

Retrospective review of consecutive patients who underwent epilepsy surgery from 2006 to 2015 was done to identify cases where acute surgical intervention was employed for the treatment of RSE. In addition, the adult and pediatric RSE literature was reviewed for reports of surgical treatment of RSE.

RESULTS

Nine patients, aged 20-68 years, with various etiologies were identified to have undergone acute surgical resection for the treatment of RSE, aided by electrocorticography. Patients required aggressive medical therapy with antiepileptic drugs and intravenous anesthetic drugs for 10-54 days and underwent extensive neurodiagnostic testing prior to resective surgery. Eight out of nine patients survived and five patients were seizure-free at the last follow-up. The literature revealed 13 adult and 48 pediatric cases where adequate historical detail was available for review and comparison.

CONCLUSIONS

We present the largest cohort of consecutive adult patients who underwent resective surgery in the setting of RSE. We also reveal that surgery can be efficacious in aborting status and in some can lead to long-term seizure freedom. Acute surgical intervention is a viable option in prolonged RSE and proper evaluation for such intervention should be conducted, although the timing and type of surgical intervention remain poorly defined.

Perampanel in patients with refractory and super-refractory status epilepticus in a neurological intensive care unit: A single-center audit of 30 patients

In refractory status epilepticus (SE), γ-aminobutyric acidergic drugs become less effective and glutamate plays a major role in seizure perpetuation. Data on the efficacy of perampanel (PER) in treatment of refractory SE in humans are limited. Here, we present a single-center case series of patients with refractory SE who received PER orally in an intensive care unit. We retrospectively analyzed treatment response, outcome, and adverse effects of all patients with refractory SE in our Neurological Intensive Care Unit who received add-on PER between September 2012 and February 2018. Thirty patients with refractory SE (median = 72 years, range = 18-91, 77% women) were included. In 14 patients (47%), a high-dose approach was used, with a median initial dose of 24 mg (range = 16-32). In five patients (17%), SE could be terminated after PER administration (median dose = 6 mg, range = 6-20 mg, 2/5 patients in high-dose group). Clinical response was observed after a median of 24 hours (range = 8-48 hours), whereas electroencephalogram resolved after a median of 60 hours (range = 12-72 hours). Time to treatment response tended to be shorter in patients receiving high-dose PER (median clinical response = 16 hours vs 18 hours; electroencephalographic response = 24 hours vs 72 hours), but groups were too small for statistical analysis. Continuous cardiorespiratory monitoring showed no changes in cardiorespiratory function after "standard" and "high-dose" treatment. Elevated liver enzymes without clinical symptoms were observed after a median of 6 days in seven of 30 patients (23%; 57% high dose vs 43% standard dose), of whom six also received treatment with phenytoin (PHT). Outcome was unfavorable (death, persistent vegetative state) in 13 patients (43%; 39% high dose vs 61% standard dose), and good recovery (no significant disability, moderate disability) was achieved in nine patients (56% high dose vs 44% standard dose). Oral PER in loading doses up to 32 mg were well tolerated but could terminate SE only in a few patients (5/30; 17%). Long duration of SE, route of administration, and severe underlying brain dysfunction might be responsible for the modest result. An intravenous formulation is highly desired to explore the full clinical utility in the treatment of refractory SE.

Sodium valproate compared to phenytoin in treatment of status epilepticus

BACKGROUND

Status epilepticus (SE) is a neurological emergency which can be life-threatening. Several medical regimens are used in order to control it. In this study, we intended to evaluate the clinical efficacy and tolerability of sodium valproate and intravenous phenytoin (IV PHT) in the control of SE.

METHODS

One hundred and ten consecutive patients suffering from benzodiazepine refractory SE who were referred to the emergency ward from March 2014 to March 2015 were randomly divided into two groups. The first group received intravenous sodium valproate, 30 mg/kg as loading dose and then 4-8 mg/kg every 8 hr as maintenance regimen. The second group received IV PHT 20 mg/kg as loading dose and then 1.5 mg/kg for 8 hr as maintenance therapy. All patients were monitored for vital signs every 2 hr up to 12 hr. The patients were also followed up for 7 days regarding drug response and adverse effects.

RESULTS

The administration of sodium valproate and phenytoin respectively resulted in seizure control in 43 (78.18%) and 39 (70.90%) of the patients within 7 days of drug administration (p = .428). Seven-day mortality rate was similar in both groups (12.73% vs. 12.73%; p = .612). There was no significant difference in adverse effects between two groups.

CONCLUSION

Sodium valproate is preferred to IV PHT for treatment and control of SE due to its higher tolerability and lower hemodynamic instability.

Post-treatment with the GLP-1 analogue liraglutide alleviate chronic inflammation and mitochondrial stress induced by Status epilepticus

Glucagon-like peptide-1(GLP-1) is a growth factor that has neuroprotective and anti-inflammatory properties. The protease resistant GLP-1 analogue liraglutide has been shown to be neuroprotective in previous studies in animal models of Alzheimer's disease or Parkinson's disease. Status epilepticus (SE) is a complex disorder, involving many underlying pathological processes, including excitotoxic and chronic inflammatory events. The present pilot study aims to investigate whether liraglutide alleviates the chronic inflammation response and mitochondrial stress induced by SE in the lithium-pilocarpine animal model. We found that treatment with 25nmol/kg. i.p. once-daily after the induction of SE for 7 days reduced chronic inflammation as shown by reduced numbers of activated microglia and astrocytes, and reduced levels of TNF-α and IL-1ß in the hippocampus. The mitochondrial stress marker BAX was reduced and the survival factor Bcl-2 was enhanced by liraglutide. Blood glucose levels were not affected by liraglutide. We show for the first time that liraglutide can reduce the chronic inflammation and mitochondrial stress induced by SE, and the results suggest that GLP-1 receptor agonists such as liraglutide have restorative and protective effects in the brain after SE and could serve as a potential treatment.