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Baysal L, Ludolph AC, Wagner J. Clinical and paraclinical features of first unprovoked seizures in the elderly. Epilepsy Behav 2024; 158:109926. [PMID: 38959742 DOI: 10.1016/j.yebeh.2024.109926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 06/26/2024] [Accepted: 06/27/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE The prevalence of unprovoked seizures and epilepsy rises significantly in later life stages. This study examines various factors in elderly patients (over 65 years) with their first unprovoked seizures, comparing findings with younger patients. METHODS We analyzed electronic medical records of individuals with first unprovoked seizures retrospectively. Diagnosis was based on patient history and witness accounts, and exclusion of other potential causes. Data included demographics, physical examination, seizure characteristics, neuroimaging, EEG findings, laboratory markers, potential causes, prescribed anti-seizure medications (ASMs) at diagnosis and follow-up, seizure-related injuries and hospital stay length. RESULTS We enrolled 391 patients (mean age 73.02 ± 16.5, 219 females). Most had late-onset (≥65 years) seizures (n = 295, 75.5 %). Status epilepticus was diagnosed in 10.2 %, more in the late-onset group. Elderly patients most often had focal seizures with impaired consciousness, while younger patients had focal to bilateral tonic-clonic seizures. (55.9 % vs 36.5 %). Late-onset seizures were linked to cerebrovascular diseases, small vessel disease, and cerebral atrophy, while early-onset cases were associated with brain tumors or unknown causes. Brain imaging revealed potentially epileptogenic abnormalities in 59.1 %. Positive paraneoplastic or autoimmune antibodies were found in 0.8 %. Abnormal EEGs were present in 25.9 %, more in the late-onset group. Most patients were discharged with levetiracetam (LEV) or lamotrigine (LTG) monotherapy. Nine patients with late-onset seizures died during in-hospital follow-up. CONCLUSION Our findings can contribute to the improved identification and characterization of patients with late-onset seizures, facilitating targeted diagnostics and appropriate treatment in this challenging patient population.
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Affiliation(s)
- Leyla Baysal
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany.
| | - Albert C Ludolph
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany
| | - Jan Wagner
- Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany; Epilepsy Center Ulm, Department of Neurology, University of Ulm, Oberer Eselsberg 45, Ulm 89081, Germany
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Tedrus GMAS. NCSE-coma in older adults: Clinical data, initial EEG, and hospital outcome. Epilepsy Behav 2024; 158:109929. [PMID: 39002275 DOI: 10.1016/j.yebeh.2024.109929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 06/03/2024] [Accepted: 06/27/2024] [Indexed: 07/15/2024]
Abstract
INTRODUCTION The clinical-EEG profile and prognosis in nonconvulsive status epilepticus (NCSE-coma) - with preceding SE and without preceding SE - have not been fully established yet. OBJECTIVE To evaluate the initial EEG, clinical characteristics, and hospital outcome of older adults with NCSE-coma. METHODOLOGY Clinical variables, immediate prognosis, initial EEG data, and scores on the Status Epilepticus Severity Score (STESS) and the SACE score were evaluated according to the type of NCSE-coma (with and without preceding seizure/SE) in 51 older adult patients treated in the emergency department. RESULTS The mean age of the participants was 72.2 years. In 23 cases, the diagnosis was NCSE-coma with preceding seizure/SE, and in 28 cases the diagnosis was NCSE-coma without preceding seizure/SE. Previous history of seizures/epilepsy occurred in 11 cases (21.5 %), and was more frequent in NCSE-coma with preceding seizure/SE. The most common etiology was acute. Death within 30 days occurred in 21 cases (41.1 %), but there was no difference between types of NCSE-coma. The predominant EEG finding was the presence of epileptiform discharges/rhythmic delta activity showing morphological/spatial/temporal evolution (classified as A2 in the Salzburg Consensus Criteria [SCC]). There was a significant difference in EEG findings according to the type of NCSE-coma. Total SACE scores averaged 0.9 ± 0.8; on the STESS, it was 4.7 ± 0.4. In the SACE score, the highest total score and a more significant occurrence of scores ≥ 3 (indicating a better prognosis) were observed in NCSE-coma with preceding seizure/SE. CONCLUSION In older adults, the types of NCSE-coma presented different clinical aspects and patterns on initial EEG. The mortality rates were elevated. The most prevalent EEG findings encompass criteria A2 of the SCC. A history of previous seizures/epilepsy and a more favorable prognosis in the SACE score occurred in NCSE-coma with preceding seizure/SE.
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Affiliation(s)
- Gloria M A S Tedrus
- Faculdade de Medicina, Pós-graduação em Ciências da Saúde, Brazil; Pontifícia Universidade Católica de Campinas, Campinas, SP, Brazil.
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Huang YT, Huang TH, Chen YS, Li YJ, Huang CW. Role of α-amino-3‑hydroxy-5-methyl-4-isoxazolepropionic acid receptors and the antagonist perampanel in geriatric epilepsy and status epilepticus. Arch Gerontol Geriatr 2024; 128:105605. [PMID: 39213748 DOI: 10.1016/j.archger.2024.105605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 07/30/2024] [Accepted: 08/22/2024] [Indexed: 09/04/2024]
Abstract
The α-amino-3‑hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR) is an ionotropic glutamate receptor recognized for its active involvement in epilepsy. Through AMPAR functional alterations, multiple factors contribute to the increased susceptibility to seizures in the geriatric population. These factors include changes in the hippocampus, neuroinflammation, ischemic insults, amyloid deposition, previous seizures, alterations in the microenvironment, and neurovascular unit dysfunction. Perampanel, a noncompetitive AMPAR antagonist, has been approved for the treatment of focal and generalized epilepsy. However, a complete understanding of AMPAR's role in epileptogenesis and the pharmacotherapy of perampanel in the geriatric population remains elusive. To address this gap, we conducted a comprehensive literature review, screening 1557 articles and ultimately selecting 94 relevant ones. We provided insights into AMPAR functionality changes and perampanel's role in treating geriatric epilepsy. Various clinical trials and retrospective studies have demonstrated that the safety and efficacy of perampanel in the older population are comparable to those in the younger population, with overall good tolerability. It is also effective for treating focal and generalized onset seizures and possibly for managing status epilepticus. In conclusion, the existing body of evidence supports the safety and efficacy of perampanel in the geriatric population, indicating its potential as a valuable therapeutic option for focal and generalized epilepsy. Additional research is warranted to deepen our understanding of AMPAR's involvement in epileptogenesis and to refine the pharmacotherapeutic nuances in this specific demographic.
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Affiliation(s)
- Yi-Te Huang
- Department of Geriatrics and Gerontology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Tzu-Hsin Huang
- Zhengxin Neurology & Rehabilitation Center, Tainan, Taiwan
| | - Yu-Shiue Chen
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng-Li Rd, Tainan 70428, Taiwan
| | - Ya-Jhen Li
- Kun-Yen Medical Library, National Cheng Kung University, Tainan, Taiwan
| | - Chin-Wei Huang
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng-Li Rd, Tainan 70428, Taiwan.
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Liu Q, Zhao Q, Ji Q, Lv X, Huang X, Xu X, Zhan Y. Trends of mortality from epilepsy in the United States, 1979-2021. Seizure 2024; 120:83-88. [PMID: 38908145 DOI: 10.1016/j.seizure.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 06/17/2024] [Accepted: 06/19/2024] [Indexed: 06/24/2024] Open
Abstract
PURPOSE The analysis of long-term trends of mortality from epilepsy has not been conducted, which is crucial for estimating the future burden of epilepsy. We therefore aimed to investigate the long-term trends of mortality from epilepsy in the United States from 1979 to 2021. METHODS The cause-of-death and demographic data were from the National Center for Health Statistics (1979-2021) and population estimates were from the US Census Bureau. We used the joinpoint regression model to analyze secular trends in the mortality of epilepsy spanning from 1979 to 2021. Age-adjusted mortality from epilepsy was assessed based on the year 2000 U.S. population data, stratified by age, sex, and race. RESULTS The age-adjusted mortality from epilepsy increased from 0.78 per 100,000 population in 1979 to 1.01 per 100,000 population in 2021, with an average annual percent change (AAPC) of 0.58% (95% confidence interval [CI]: 0.45% - 0.72%). The overall age-adjusted mortality of epilepsy had been on the rise between 2011 and 2021. The mortality rate generally increases with age. The mortality of epilepsy was higher in the Afro-American people and men. The mortality of epilepsy in both sexes declined first and then increased, with AAPC 1.02% (95% CI: 0.88%, 1.23%) in women and 0.10% (95% CI: -0.002%, 0.21%) in men. Mortality in all races including White, Afro-American people, and other races individuals fell first and then rose. The AAPC of mortality in White, other races, and Afro-American people were 0.89% (95% CI: 0.79%, 1.02%), -0.87% (95% CI: -1.84%, 0.88%), and -0.31% (95% CI: -0.48%, -0.13%), respectively. CONCLUSION Although the mortality rate from epilepsy has experienced a period of decline, it is worth noting that the last decade has seen a rapid increase. A comprehensive assessment of long-term trends in mortality from epilepsy holds significance for healthcare prioritization.
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Affiliation(s)
- Qi Liu
- Department of Epidemiology, School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, PR China
| | - Qingya Zhao
- Department of Epidemiology, School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, PR China
| | - Qianqian Ji
- Department of Epidemiology, School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, PR China
| | - Xiaogang Lv
- Department of Epidemiology, School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, PR China
| | - Xiaoping Huang
- Department of Epidemiology, School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, PR China
| | - Xiaowei Xu
- Department of Neurology, The Seventh Affiliated Hospital, Sun Yat-Sen University, Shenzhen, PR China.
| | - Yiqiang Zhan
- Department of Epidemiology, School of Public Health (Shenzhen), Sun Yat-Sen University, Shenzhen, PR China; Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
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Tedrus GMAS. Ictal EEG: Etiology and Mortality in Older Adults With Nonconvulsive Status Epilepticus. Clin EEG Neurosci 2024; 55:278-282. [PMID: 37498994 DOI: 10.1177/15500594231183554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Clinical-electroencephalogram (EEG), as well as etiological and prognostic data on subtypes of nonconvulsive status epilepticus (NCSE) are yet to be established. Objective: Evaluate the clinical semiology and EEG findings and prognostic data of older adults with NCSE. Methodology: Characterize the clinical-EEG and prognostic data in the subtypes of NCSE in older adults consecutively admitted to the emergency room of the Pontifícia Universidade Católica de Campinas (PUC-Campinas) University Hospital. Results: When evaluating 105 older adults with altered consciousness, it was possible to diagnose NCSE in 50 (47.6%) older adults, with a mean age of 72.8 ± 8.8 years. NCSE-coma occurred in 6 cases, with NCSE-without coma in 44 cases. The etiology was structural in 41(82%) cases, metabolic in 5 cases, and unknown etiology in 4 cases. Twelve cases had a history of epileptic seizures. On the EEG, epileptiform discharges (EDs > 2.5 Hz) were present in 34(68%) cases and rhythmic delta activity /lateralized periodic patterns occurred in 35(70%) cases. There was clinical improvement after the initial pharmacological treatment in 36 cases and, within 30 days, 18 cases died. The better prognosis was associated with a good response to initial pharmacological treatment (n = 14) and with EDs > 2.5 Hz on EEG (Fisher's exact test; 26 vs 8; P = .012). Conclusion: Focal NCSE with impaired consciousness was the most frequent subtype. The most frequent finding on the EEG was the recording of focal/regional seizures. A high number of cases showed initial clinical improvement, but mortality was high. The favorable prognosis was associated with initial clinical improvement and the presence of EDs > 2.5 Hz. There was no relationship between EEG patterns and the etiology and subtypes of NCSE in older adults.
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Affiliation(s)
- Glória M A S Tedrus
- Postgraduate Program in Health Sciences, Pontifícia Universidade Católica de Campinas, Campinas, SP, Brasil
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Bechri I, Shimi A, Derkaoui A, Khatouf M. Status Epilepticus in a Tertiary Care Hospital in Morocco: A Retrospective Analysis. Cureus 2023; 15:e50591. [PMID: 38222150 PMCID: PMC10788123 DOI: 10.7759/cureus.50591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 01/16/2024] Open
Abstract
Background Status epilepticus (SE) is a common neurologic emergency with high rates of mortality and morbidity. Objective To analyze the clinical characteristics, causes, management, and outcomes of patients with SE in a tertiary care hospital in Morocco. Methods A retrospective study was conducted from January 2019 to December 2021, including all patients admitted to the medico-surgical general intensive care unit (ICU) with a diagnosis of SE. We recorded demographic characteristics, SE clinical history, management, causes, and discharge outcomes. Results Overall, 82 patients with SE were included, the median age was 39.5 years (18-95), 61% of the patients were male, the majority of semiology was convulsive SE (93%, N: 77), epilepsy of unknown cause was the most common diagnosis (41.2%, N: 34), and the most known etiology was acute/subacute cerebrovascular events (12 patients, 14.4%). All patients received benzodiazepines, 96.4% of them received phenobarbital as a second line of treatment, 65 patients required anesthesia, 52 patients developed one complication at least - the most common complication being systemic infection, and the mortality rate was noted to be 38% among patients with SE (N: 31). In this study, the factors associated with mortality were ischemic stroke (as an etiology of SE (p=0.048), history of epilepsy (p=0.005), poor therapeutic adherence (p=0.001), cardiovascular complications, presence of multiple complications (p=0.0001), pneumonia (p=0.0001), and the recurrence of SE (p=0.050). Conclusions We provide a single-center retrospective analysis of admissions in SE and note that mortality among SE patients is high in our settings. Improving prehospital emergency care and implementing elective ICU admission for patients at high risk could improve the mortality rate.
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Affiliation(s)
- Ibrahim Bechri
- Anesthesiology and Intensive Care Department, Hassan II University Hospital, Fez, MAR
| | - Abdelkrarim Shimi
- Anesthesiology and Intensive Care Department, Hassan II University Hospital, Fez, MAR
| | - Ali Derkaoui
- Anesthesiology and Intensive Care Department, Hassan II University Hospital, Fez, MAR
| | - Mohammed Khatouf
- Anesthesiology and Intensive Care Department, Hassan II University Hospital, Fez, MAR
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Fawcett J, Davis S, Manford M. Further advances in epilepsy. J Neurol 2023; 270:5655-5670. [PMID: 37458794 DOI: 10.1007/s00415-023-11860-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 10/15/2023]
Abstract
In 2017, one of us reviewed advances in epilepsy (Manford in J Neurol 264:1811-1824, 2017). The current paper brings that review up to date and gives a slight change in emphasis. Once again, the story is of evolution rather than revolution. In recognition that most of our current medications act on neurotransmitters or ion channels, and not on the underlying changes in connectivity and pathways, they have been renamed as antiseizure (ASM) medications rather than antiepileptic drugs. Cenobamate is the one newly licensed medication for broader use in focal epilepsy but there have been a number of developments for specific disorders. We review new players and look forward to new developments in the light of evolving underlying science. We look at teratogenicity; old villains and new concerns in which clinicians play a vital role in explaining and balancing the risks. Medical treatment of status epilepticus, long without evidence, has benefitted from high-quality trials to inform practice; like buses, several arriving at once. Surgical treatment continues to be refined with improvements in the pre-surgical evaluation of patients, especially with new imaging techniques. Alternatives including stereotactic radiotherapy have received further focus and targets for palliative stimulation techniques have grown in number. Individuals' autonomy and quality of life continue to be the subject of research with refinement of what clinicians can do to help persons with epilepsy (PWE) achieve control. This includes seizure management but extends to broader considerations of human empowerment, needs and desires, which may be aided by emerging technologies such as seizure detection devices. The role of specialist nurses in improving that quality has been reinforced by specific endorsement from the International League against Epilepsy (ILAE).
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Affiliation(s)
- Joanna Fawcett
- Department of Neurology, Royal United Hospital, Bath, UK
| | - Sarah Davis
- Department of Neurology, Royal United Hospital, Bath, UK
| | - Mark Manford
- Department of Neurology, Royal United Hospital, Bath, UK.
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Tedrus GMAS. Focal nonconvulsive status epilepticus with impaired consciousness in older adults: Prognosis-related variables. Epilepsy Behav 2023; 144:109257. [PMID: 37271017 DOI: 10.1016/j.yebeh.2023.109257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To assess the prognosis-related clinical-EEG characteristics in older adults with focal nonconvulsive status epilepticus with impaired consciousness (focal NCSE). METHODOLOGY We prospectively assessed clinical variables and EEG data at diagnosis and after an initial pharmacological protocol (within 24 hours) and their relationship with prognosis in older adults with focal NCSE treated at the emergency room. RESULTS The clinical presentation of focal NCSE in 45 adults (mean age 73.5 ± 9.1 years) was characterized by decreased consciousness and the presence of subtle ictal phenomena in 24 cases. On the initial EEG, there were lateralized periodic discharges (LPDs) and lateralized rhythmic delta activity (RDA) in 25 cases and epileptiform discharges (EDs > 2.5 Hz) in 32 cases. After the drug protocol, 33 (73.3%) cases had effective clinical improvement. Death after 30 days occurred in 10 (22.2%) cases. In simple and multiple logistic regression, it was observed that older adults with a history of epilepsy/seizures have a greater chance of clinical improvement. The occurrence of death was associated with the presence of RDA in the initial EEG and its subsequent disappearance (OR 6.93, 95% CI 1.20-46.01, p = 0.033). Higher mortality was associated with the presence of LPDs in the initial EEG and with the presence of LPDs/EDs > 2.5 Hz in the EEG after treatment. CONCLUSION The presence of ED > 2.5 Hz in the initial EEG was the most frequent pattern at focal NCSE. Clinical improvement was associated with a history of epilepsy/seizures. Mortality in the focal NCSE was high and was associated with the presence of RDA in the initial EEG and the occurrence of LPDs/ED > 2.5 Hz after treatment.
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Affiliation(s)
- Gloria M A S Tedrus
- Postgraduate Program in Health Sciences, Pontifical Catholic University of Campinas. PUC-Campinas, Av. John Boyd Dunlop s/n - Jardim Ipaussurama, Campinas, SP, Brazil.
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Beghi E, Giussani G, Costa C, DiFrancesco JC, Dhakar M, Leppik I, Kwan P, Akamatsu N, Cretin B, O'Dwyer R, Kraemer G, Piccenna L, Faught E. The epidemiology of epilepsy in older adults: A narrative review by the ILAE Task Force on Epilepsy in the Elderly. Epilepsia 2023; 64:586-601. [PMID: 36625133 DOI: 10.1111/epi.17494] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 11/21/2022] [Accepted: 12/15/2022] [Indexed: 01/11/2023]
Abstract
In an aging world, it is important to know the burden of epilepsy affecting populations of older persons. We performed a selective review of epidemiological studies that we considered to be most informative, trying to include data from all parts of the world. We emphasized primary reports rather than review articles. We reviewed studies reporting the incidence and prevalence of epilepsy that focused on an older population as well as studies that included a wider age range if older persons were tabulated as a subgroup. There is strong evidence that persons older than approximately 60 years incur an increasing risk of both acute symptomatic seizures and epilepsy. In wealthier countries, the incidence of epilepsy increases sharply after age 60 or 65 years. This phenomenon was not always observed among reports from populations with lower socioeconomic status. This discrepancy may reflect differences in etiologies, methods of ascertainment, or distribution of ages; this is an area for more research. We identified other areas for which there are inadequate data. Incidence data are scarcer than prevalence data and are missing for large areas of the world. Prevalence is lower than would be expected from cumulative incidence, possibly because of remissions, excess mortality, or misdiagnosis of acute symptomatic seizures as epilepsy. Segmentation by age, frailty, and comorbidities is desirable, because "epilepsy in the elderly" is otherwise too broad a concept. Data are needed on rates of status epilepticus and drug-resistant epilepsy using the newer definitions. Many more data are needed from low-income populations and from developing countries. Greater awareness of the high rates of seizures among older adults should lead to more focused diagnostic efforts for individuals. Accurate data on epilepsy among older adults should drive proper allocation of treatments for individuals and resources for societies.
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Affiliation(s)
- Ettore Beghi
- Laboratory of Neurological Disorders, Department of Neuroscience, Mario Negri Institute of Pharmacological Research, Scientific Institute for Research and Health Care, Milan, Italy
| | - Giorgia Giussani
- Laboratory of Neurological Disorders, Department of Neuroscience, Mario Negri Institute of Pharmacological Research, Scientific Institute for Research and Health Care, Milan, Italy
| | - Cinzia Costa
- Section of Neurology, Santa Maria della Misericordia Hospital, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Jacopo C DiFrancesco
- Department of Neurology, Istituto di Ricovero e Cura a Caraterre Scientifico, San Gerardo Foundation, University of Milan-Bicocca, Monza, Italy
| | - Monica Dhakar
- Department of Neurology, Brown University, Providence, Rhode Island, USA
| | - Ilo Leppik
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Naoki Akamatsu
- Division of Neurology, Neuroscience Center, Fukuoka Samo Hospital, International University of Health and Welfare, Fukuoka, Japan
| | - Benjamin Cretin
- Neuropsychology Unit, Department of Neurology of the University Hospitals of Strasbourg, Strasbourg, France
| | - Rebecca O'Dwyer
- Department of Neurological Sciences, Rush Medical College, Chicago, Illinois, USA
| | | | - Loretta Piccenna
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Health, Melbourne, Victoria, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Edward Faught
- Department of Neurology, Emory University, Atlanta, Georgia, USA
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Osman GM, Hocker SE. Status Epilepticus in Older Adults: Diagnostic and Treatment Considerations. Drugs Aging 2023; 40:91-103. [PMID: 36745320 DOI: 10.1007/s40266-022-00998-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 02/07/2023]
Abstract
Status epilepticus (SE) is one of the leading life-threatening neurological emergencies in the elderly population, with significant morbidity and mortality. SE presents unique diagnostic and therapeutic challenges in the older population given overlap with other causes of encephalopathy, complicating diagnosis, and the common occurrence of multiple comorbid diseases complicates treatment. First-line therapy involves the use of rescue benzodiazepine in the form of intravenous lorazepam or diazepam, intramuscular or intranasal midazolam and rectal diazepam. Second-line therapies include parenteral levetiracetam, fosphenytoin, valproate and lacosamide, and underlying comorbidities guide the choice of appropriate medication, while third-line therapies may be influenced by the patient's code status as well as the cause and type of SE. The standard of care for convulsive SE is treatment with an intravenous anesthetic, including midazolam, propofol, ketamine and pentobarbital. There is currently limited evidence guiding appropriate therapy in patients failing third-line therapies. Adjunctive strategies may include immunomodulatory treatments, non-pharmacological strategies such as ketogenic diet, neuromodulation therapies and surgery in select cases. Surrogate decision makers should be updated early and often in refractory episodes of SE and informed of the high morbidity and mortality associated with the disease as well as the high probability of subsequent epilepsy among survivors.
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Affiliation(s)
- Gamaleldin M Osman
- Department of Neurology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN, 55905, USA.
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Yuan F, Damien C, Gaspard N. Prognostic scores in status epilepticus: A systematic review and meta-analysis. Epilepsia 2023; 64:17-28. [PMID: 36271624 DOI: 10.1111/epi.17442] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/20/2022] [Accepted: 10/20/2022] [Indexed: 01/21/2023]
Abstract
The performance of prognostic scores of status epilepticus (SE) has been reported in very heterogeneous cohorts. We aimed to provide a summary of the available evidence on their respective performance. PubMed and EMBASE were searched for relevant articles. Studies were reviewed for eligibility for meta-analysis of the area under the receiver-operating characteristic curve (AUC) and for meta-analysis of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in predicting in-hospital mortality with scores in which at least two external evaluations had been published. This study was registered with PROSPERO (international prospective register of systematic reviews) (CRD42022325766). Study quality was assessed using Prediction model Risk Of Bias ASsessment Tool (PROBAST). In the meta-analysis of AUC, 21 studies were pooled for STESS (Status Epilepticus Severity Score), five for EMSE-EAC (Epidemiology-based Mortality Score in Status Epilepticus - Etiology, Age, level of Consciousness), five for EMSE-EACE (EMSE - Etiology, Age, level of Consciousness, EEG), and two for ENDIT (Encephalitis, nonconvulsive status epilepticus, Diazepam resistance, Imaging abnormalities, Tracheal intubation). The pooled AUC of STESS, EMSE-EAC, EMSE-EACE, and ENDIT was 0.74 (95% CI: 0.71-0.78), 0.68 (95% CI 0.63-0.72), 0.77 (95% CI: 0.72-0.81), and 0.78 (95% CI: 0.70-0.87), respectively. The pooled sensitivity of STESS-3, STESS-4, EMSE-EACE-64, and ENDIT-4 was 0.83 (95% CI: 0.80-0.86), 0.60 (95% CI: 0.55-0.65), 0.76 (95% CI: 0.67-0.83), and 0.70 (95% CI: 0.55-0.82), respectively. Their pooled specificity was 0.50 (95% CI: 0.48-0.52), 0.74 (95% CI: 0.72-0.76), 0.63 (95% CI: 0.59-0.67), and 0.65 (95% CI: 0.61-0.70), respectively. Their pooled PPV was 0.27 (95% CI: 0.24-0.30), 0.35 (95% CI: 0.29-0.41), 0.33 (95% CI: 0.24-0.43), and 0.20 (95% CI: 0.13-0.27). Their pooled NPV was 0.94 (95% CI: 0.93-0.96), 0.90 (95% CI: 0.89-0.92), 0.89 (95% CI: 0.80-0.98), and 0.95 (95% CI: 0.92-0.98). Variations in performance were observed in patients' subgroups, such as critically ill patients and refractory cases. Investigated scores only have acceptable AUC, sensitivity, and specificity for predicting in-hospital mortality, with the EMSE-EAC having a lower discriminative power. STESS-3 has the highest sensitivity, and STESS-4 the highest specificity, but neither combines acceptable sensitivity and specificity. All these scores had high NPV but very low PPV. Caution should be exercised in their clinical use. Further studies are required to develop more accurate scores.
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Affiliation(s)
- Fang Yuan
- Neurology Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.,Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Charlotte Damien
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium.,Neurology Department, Yale University School of Medicine, New Haven, Connecticut, USA
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12
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Lekoubou A, Wu EY, Bishu KG, Ovbiagele B. Prevalence, predictors, and prognosis of mortality among elderly stroke patients with convulsive status epilepticus in the United States. J Neurol Sci 2022; 440:120342. [PMID: 35908304 DOI: 10.1016/j.jns.2022.120342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 06/10/2022] [Accepted: 07/13/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Stroke is the most common cause of epilepsy in the elderly. However, despite the high mortality typically associated with convulsive status epilepticus (CSE), there is a dearth of nationwide data on the magnitude and association of CSE with mortality among hospitalized elderly with stroke in the United States. METHODS We analyzed the 2006-2014 National Inpatient Sample (NIS) to identify elderly patients (65+ years) with a primary discharge diagnosis of stroke using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) codes 433.X1, 434.X1, 436, 430, 431, 432.0, 432.1, and 432.9. We examined a subgroup with a secondary discharge diagnosis of convulsive status epilepticus (ICD-9-CM: 345.3). We estimated the hospital mortality rate by CSE status and then evaluated the independent association of CSE and other key factors with mortality among hospitalized elderly with stroke. RESULTS A total of 1220 elderly patients (0.14%) had a secondary discharge diagnosis of CSE. Inpatient mortality rate was 25.8% among those with CSE vs. 7.7% for non-CSE patients. CSE was independently associated with a 4-fold increased odds of in-hospital death. Increased age, medical comorbidities, weekend admissions, being a Medicare beneficiary, and hospitalization in large urban teaching hospitals were also independently associated with a greater likelihood of in-hospital death. The small number of events did not allow analysis by stroke subtypes. CONCLUSION While CSE occurs in just 14 of 10,000 hospitalized elderly stroke patients in the United States, it is associated with a 4-fold higher odds of in-hospital death.
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Affiliation(s)
- Alain Lekoubou
- Department of Neurology, Penn State University, Hershey Medical Center, Hershey, PA, USA.
| | - Emma Y Wu
- Penn State College of Medicine, Hershey, PA, USA.
| | - Kinfe G Bishu
- Department of Medicine, Medical University of South Carolina, Charleston, SC & Section of Health Systems Research and Policy, Medical University of South Carolina, Charleston, SC, USA.
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, USA.
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13
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Development and Validation of a Nomogram Based on the Epidemiology-Based Mortality Score in Status Epilepticus (EMSE) Parameters to Predict 30-day Mortality in Status Epilepticus. Neurocrit Care 2022; 37:754-760. [PMID: 35778648 DOI: 10.1007/s12028-022-01548-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/04/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND To develop a nomogram using the parameters of the Epidemiology-Based Mortality Score in Status Epilepticus (EMSE) and to evaluate its accuracy compared with the EMSE alone in the prediction of 30-day mortality in patients with status epilepticus (SE). METHODS We included a cohort of patients with SE aged ≥ 21 years admitted from 2013 to 2021. Regression coefficients from the multivariable logistic regression model were used to generate a nomogram predicting the risk of 30-day mortality. Discrimination of the nomogram was evaluated using the area under the receiver operating characteristic curve (AUCROC) with 95% confidence interval. Internal validation was performed by bootstrap resampling. RESULTS Among 698 patients with SE, the 30-day mortality rate was 28.9% (202 of 698). On the multivariable analysis, all EMSE parameters (except for the comorbidity group including metastatic solid tumor or AIDS) were associated with a significantly higher risk of 30-day mortality and were included in the nomogram. The discriminatory capability of the nomogram with bootstrap resampling (5000 resamples) had an AUCROC of 0.830 (95% confidence interval 0.798-0.862). Conversely, the AUCROC of the EMSE was 0.777 (95% confidence interval 0.742-0.813). Thus, the probability that a patient who died within 30 days from SE had a higher score than a patient who survived was 83%, indicating good discriminatory power of the nomogram. Conversely, the risk predicted using the EMSE alone was 77%. The nomogram was well calibrated. CONCLUSIONS A nomogram based on EMSE parameters appears superior to the EMSE in predicting the risk of 30-day mortality after SE. The discrimination and calibration of the nomogram shows a better predictive accuracy than the EMSE alone.
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14
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Tedrus GM, Nogueira E, Vidal MA. Elderly patients with nonconvulsive status epilepticus: Clinical-EEG data, hospital mortality, STESS and EMSE. Seizure 2021; 94:18-22. [PMID: 34808547 DOI: 10.1016/j.seizure.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/18/2021] [Accepted: 11/08/2021] [Indexed: 11/27/2022] Open
Abstract
Purpose To assess the clinical-EEG aspects, characterization of subtypes, relationships with prognostic scales and the occurrence of death in elderly patients in the acute phase of nonconvulsive status epilepticus (NCSE). Methodology Clinical variables, EEG data, Status epilepticus severity score (STESS), and the Epidemiology-based mortality score in status epilepticus (EMSE) were related to the death of 96 patients who were over 60 years old, with NCSE. Results NCSE with coma was observed in 31 patients (19 non-subtle and 12 "subtle" SE) and focal NCSE with impairment of consciousness in 65 cases. There were no significant EEG differences according to the type of NCSE. Higher STESS scores occurred in the comatose NCSE patients when compared to those with focal NCSE and impairment of consciousness (4.8 ± 1.2 vs 3.7 ± 1.2; T-Test; p<0.001). It was observed that 25 (26%) elderly died, with a mean survival time of 19.3 days. Elderly people with a higher risk of death are those diagnosed with NCSE with coma (HR 2.76; 95% CI 1.15-6.65; p = 0.023), with STESS≥3 (HR 16.0; CI 1.77-45.08; p = 0.014), with EMSE≥64 (HR 3.67; CI 1.54-8.72; p = 0.003), and those with no history of recurrent SE (HR 6.80; CI 1.42-32.64; p = 0.017), in Cox regression. Conclusion The ictal EEG patterns did not distinguish the subtypes of NCSE. Thirty-day mortality rate was high in elderly patients with NCSE. The clinical variables are related to prognosis. Mortality in the elderly was associated with comatose NCSE patients, with STESS≥3, with EMSE≥64, and no history of recurrent SE.
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15
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Abstract
Neurologists increasingly care for people with significant frailty in both clinic and ward settings. Such care demands a balanced approach to investigation, diagnosis and treatment, as well-intentioned actions can produce adverse effects. This article presents a practical approach to the identification and management of patients with frailty and neurological conditions. We address medicines optimisation, common causes of deterioration in those with frailty, communication, decisions about intensity of treatment, and shared decision-making including ethical aspects of withholding or withdrawing life-prolonging treatment, with a view to improving the experience both of people living with frailty and of the teams who care for them.
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Affiliation(s)
- Lucy Pollock
- Care of Older People, Somerset NHS Foundation Trust, Taunton, TA1 5DA, UK
| | - Matthew Smith
- Aging and Movement Research Group, Faculty of Health Sciences, University of Bristol, Bristol, BS81QU, UK
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16
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Godau J, Bharad K, Rösche J, Nagy G, Kästner S, Weber K, Bösel J. Automated Pupillometry for Assessment of Treatment Success in Nonconvulsive Status Epilepticus. Neurocrit Care 2021; 36:148-156. [PMID: 34331202 DOI: 10.1007/s12028-021-01273-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/11/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Altered pupillary function may reflect nonconvulsive status epilepticus (NCSE). Neurological pupil index (NPi) assessed by automated pupillometry is a surrogate marker of global pupillary function. We aimed to assess NPi changes in relation to NCSE treatment response. METHODS In this prospective observational study, serial automated pupillometry was performed in 68 NCSE episodes. In accordance with local standards, patients were treated with clonazepam (1-2 mg), levetiracetam (40 mg/kg), and lacosamide (5 mg/kg) in a stepwise approach under continuous electroencephalography monitoring until NCSE was terminated. Patients with refractory NCSE received individualized regimens. NPi was assessed bilaterally before and after each treatment step. For statistical analysis, the lower NPi of both sides (minNPi) was used. Nonparametric testing for matched samples and Cohen's d to estimate effect size were performed. Principal component analysis was applied to assess the contribution of baseline minNPi, age, sex, and NCSE duration to treatment outcome. RESULTS In 97.1% of 68 episodes, NCSE could be terminated; in 16.2%, NCSE was refractory. In 85.3% of episodes, an abnormal baseline minNPi ≤ 4.0 was obtained. After NCSE termination, minNPi increased significantly (p < 0.001). Cohen's d showed a strong effect size of 1.24 (95% confidence interval 0.88-1.61). Baseline minNPi was higher in clonazepam nonresponders vs. responders (p = 0.008), minNPi increased in responders (p < 0.001) but not in nonresponders. NCSE refractivity was associated with normal baseline minNPi (principal component analysis, component 1, 32.6% of variance, r = 0.78), male sex, and longer NCSE duration (component 2, 27.1% of variance, r = 0.62 and r = 0.78, respectively). CONCLUSIONS Automated pupillometry may be a helpful noninvasive neuromonitoring tool for the assessment of patients with NCSE and response to treatment.
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Affiliation(s)
- Jana Godau
- Department of Neurology, Klinikum Kassel, Kassel, Germany. .,Emergency Department, Klinikum Kassel, Kassel, Germany.
| | - Kaushal Bharad
- Department of Neurology, Klinikum Kassel, Kassel, Germany.,Emergency Department, Klinikum Kassel, Kassel, Germany
| | - Johannes Rösche
- Department of Neurology, Klinikum Kassel, Kassel, Germany.,Department of Neurology, University of Rostock, Rostock, Germany
| | - Gabor Nagy
- Department of Neurology, Klinikum Kassel, Kassel, Germany.,Department of Neurosurgery, Klinikum Kassel, Kassel, Germany
| | | | - Klaus Weber
- Emergency Department, Klinikum Kassel, Kassel, Germany
| | - Julian Bösel
- Department of Neurology, Klinikum Kassel, Kassel, Germany
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17
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Rohracher A, Trinka E. [Epilepsy in the aged : Challenges in diagnostics and treatment]. Z Gerontol Geriatr 2021; 54:395-408. [PMID: 33891210 PMCID: PMC8222019 DOI: 10.1007/s00391-021-01882-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/25/2021] [Indexed: 12/01/2022]
Abstract
Epilepsy is the third most frequent neurological disorder in aged patients after stroke and dementia. The incidence of epilepsy increases with age with the highest rates in patients ≥ 65 years old. Due to demographic changes the number of aged patients with epilepsy is expected to increase further in the coming years. The leading cause of new onset epilepsy in aged patients is cerebrovascular disease followed by dementia. The recognition of seizures in aged patients is often delayed. Status epilepticus occurs more frequently in aged patients and is associated with a high mortality and morbidity. Antiepileptic drug (AED) treatment of aged patients is complicated by comorbidities and polypharmacy and AEDs with a low interaction profile and high tolerability should be selected. Levetiracetam and lamotrigine are the AEDs of choice due to low interactions and good tolerability.
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Affiliation(s)
- Alexandra Rohracher
- Paracelsus Medizinische Privatuniversität Salzburg, Universitätsklinik für Neurologie, Ignaz-Harrer-Str. 79, 5020, Salzburg, Österreich
| | - Eugen Trinka
- Paracelsus Medizinische Privatuniversität Salzburg, Universitätsklinik für Neurologie, Ignaz-Harrer-Str. 79, 5020, Salzburg, Österreich.
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18
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Derex L, Rheims S, Peter-Derex L. Seizures and epilepsy after intracerebral hemorrhage: an update. J Neurol 2021; 268:2605-2615. [PMID: 33569652 DOI: 10.1007/s00415-021-10439-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/30/2021] [Indexed: 02/05/2023]
Abstract
Seizures are common after intracerebral hemorrhage, occurring in 6-15% of the patients, mostly in the first 72 h. Their incidence reaches 30% when subclinical or non-convulsive seizures are diagnosed by continuous electroencephalogram. Several risk factors for seizures have been described including cortical location of intracerebral hemorrhage, presence of intraventricular hemorrhage, total hemorrhage volume, and history of alcohol abuse. Seizures after intracerebral hemorrhage may theoretically be harmful as they can lead to sudden blood pressure fluctuations, increased intracranial pressure, and neuronal injury due to increased metabolic demand. Some recent studies suggest that acute symptomatic seizures (occurring within 7 days of stroke) are associated with worse functional outcome and increased risk of death despite accounting for other known prognostic factors such as age and baseline hemorrhage volume. However, the impact of seizures on prognosis is still debated and it remains unclear if treating or preventing seizures might lead to improved clinical outcome. Thus, the currently available scientific evidence does not support the routine use of antiseizure medication as primary prevention among patients with intracerebral hemorrhage. Only prospective adequately powered randomized-controlled trials will be able to answer whether seizure prophylaxis in the acute or longer term settings is beneficial or not in patients with intracerebral hemorrhage.
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Affiliation(s)
- Laurent Derex
- Stroke Center, Department of Neurology, Neurological Hospital, Hospices Civils de Lyon, University of Lyon, 59 boulevard Pinel, 69677, Bron cedex, France.
- Research On Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France.
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, University of Lyon, Lyon, France
- Lyon 1 University, Lyon, France
- INSERM U1028-CNRS UMR 5292, Lyon Neuroscience Research Center, Lyon, France
| | - Laure Peter-Derex
- Lyon 1 University, Lyon, France.
- INSERM U1028-CNRS UMR 5292, Lyon Neuroscience Research Center, Lyon, France.
- Center for Sleep Medicine and Respiratory Diseases, Croix-Rousse Hospital, Hospices Civils de Lyon, University of Lyon, 103 Grande rue de la Croix-Rousse, 69004, Lyon, France.
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Prediction of in-hospital mortality in status epilepticus: Evaluation of four scoring tools in younger and older adult patients. Epilepsy Behav 2021; 114:107572. [PMID: 33268015 DOI: 10.1016/j.yebeh.2020.107572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 10/19/2020] [Accepted: 10/19/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The goal of this study was to evaluate the predictive capacity of four scoring tools: the Status Epilepticus Severity Score (STESS), the Encephalitis-NCSE-Diazepam resistance-Image abnormalities-Tracheal intubation (END-IT) score, and two variable combinations of the Epidemiology-based Mortality Score in Status Epilepticus (EMSE) in younger and older adult patients with status epilepticus (SE). METHODS We present a retrospective hospital-based analysis with a focus on adult patients with SE at three tertiary care hospitals in the Zhejiang province of China. Data were collected from January 2013 to December 2018. The patients were divided into two groups: younger adult patients (18-64 years old) and older adult patients (≥65 years old). Clinical outcomes (dead or alive) were assessed at hospital discharge. The four scoring tools were used to predict in-hospital mortality in both younger and older adult patients. RESULTS The mortality rate in older adult patients (25.4%) was higher than in younger adult patients (12.9%). Compared with the elderly, the younger adult patients had a higher proportion of encephalitis, while acute cerebrovascular disease and Charlson Complications Index (CCI) were lower. For the younger adult patients, END-IT had the largest area under the curve (AUC) of 0.843 (95% CI, 0.772-0.899), which was higher than the EMSE-EAL value of 0.687 (95% CI, 0.603-0.763, p < 0.05) and EMSE-EAC of 0.646 (95% CI, 0.561-0.725, p < 0.05). For the older adult patients, EMSE-EAL had the largest AUC of 0.843 (95% CI, 0.738-0.919), which was significantly higher than STESS with an AUC of 0.676 (95% CI, 0.554-0.782, p < 0.05). Moreover, the AUC of EMSE-EAL in the elderly was larger than in younger adult patients. The cutoffs in younger adult patients were STESS ≥ 4 (sensitivity 0.444, specificity 0.951), END-IT ≥ 3 (sensitivity 0.833, specificity 0.672), EMSE-EAL ≥ 31 (sensitivity 0.778, specificity 0.566), and EMSE-EAC ≥ 33 (sensitivity 0.833, specificity 0.492). However, the cutoffs in older adult patients were STESS ≥ 5 (sensitivity 0.500, specificity 0.925), END-IT ≥ 2 (sensitivity 0.944, specificity 0.547), EMSE-EAL ≥ 30 (sensitivity 0.944, specificity 0.623), and EMSE-EAC ≥ 31 (sensitivity 0.944, specificity 0.415). CONCLUSION Our results indicated that the STESS, END-IT, EMSE-EAC, and EMSE-EAL scores have excellent capacity to predict in-hospital mortality in both younger and older adult patients with SE. Our study supports the use of END-IT in patients under 65 years of age and suggests that EMSE-EAL is the most suitable scoring tool for patients over 65.
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20
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Brigo F, Lattanzi S. Pharmacotherapeutic considerations for late-onset epilepsy. Expert Opin Pharmacother 2020; 22:389-391. [PMID: 33377404 DOI: 10.1080/14656566.2020.1865311] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Francesco Brigo
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Ancona, Italy
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21
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Quantitative Infrared Pupillometry in Nonconvulsive Status Epilepticus. Neurocrit Care 2020; 35:113-120. [PMID: 33215395 DOI: 10.1007/s12028-020-01149-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 11/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Nonconvulsive status epilepticus (NCSE) is a frequent disorder in neurocritical care and diagnosing it can be challenging. NCSE patients often show altered pupil function, but nature and extent may vary. Infrared pupillometry allows detection of subtle changes of pupil function. The neurological pupil index (NPi) is considered a surrogate marker of global pupil function which is supposed to be independent of absolute parameters such as the pupil diameter. OBJECTIVE Cross-sectional observational study to assess whether NPi is altered in NCSE. METHODS 128 consecutive adult emergency patients who had experienced a suspected seizure, have not reached their prior functional level regarding level of consciousness, mental status or focal deficits, had no obvious clinical signs of status epilepticus and had an EEG indication as determined by the treating clinician for exclusion of NCSE were examined by routine EEG and pupillometry. Exclusion criteria were ocular comorbidity (n = 21) and poor EEG quality (n = 4). Pupillometry was performed once directly before the beginning of EEG recording. NCSE diagnosis (no NCSE, possible NCSE and confirmed NCSE) was established according to Salzburg consensus criteria blinded to pupillometry results. Group comparison was performed for right NPi, left NPi, lowest NPi of both sides (minNPi) and the absolute difference of both sides (diffNPi) applying non-parametric testing. In post-hoc analysis, receiver operating characteristics (ROC) of NCSE diagnosis (combined confirmed NCSE and possible NCSE) were performed for minNPi and diffNPi. RESULTS From 103 patients included in the final analysis, 5 (4.9%) had confirmed NCSE, 7 (6.8%) had possible NCSE. Right NPi (p = 0.002), left NPi (p < 0.001) and minNPi (p < 0.001) were significantly lower in "confirmed NCSE" and "possible NCSE" compared to "no NCSE"; diffNPi was significantly higher in "confirmed NCSE" and "possible NCSE" compared to "no NCSE" (p < 0.001). There was no significant difference of minNPi and diffNPi between "confirmed NCSE" and "possible NCSE". ROC analysis showed an optimal cut-off of minNPi for NCSE diagnosis of 4.0 (AUC = 0.93, 95% CI 0.86-0.99). Optimal ROC analysis cut-off of diffNPi for NCSE diagnosis was 0.2 (AUC = 0.89, 95% CI 0.80-0.99). CONCLUSIONS NPi was significantly reduced and the difference between left and right NPi was significantly higher in confirmed NCSE. An NPi < 4.0 on either side as well as an NPi difference of both sides > 0.2 may be potential indicators of NCSE. Infrared pupillometry may be a helpful diagnostic tool in the assessment of NCSE and should be studied further in larger populations.
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22
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Rohracher A, Kalss G, Kuchukhidze G, Neuray C, Leitinger M, Höfler J, Kreidenhuber R, Rossini F, Volna K, Mauritz M, Poppert N, Lattanzi S, Brigo F, Trinka E. New anti-seizure medication for elderly epilepsy patients - a critical narrative review. Expert Opin Pharmacother 2020; 22:621-634. [PMID: 33111598 DOI: 10.1080/14656566.2020.1843636] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: The number of elderly patients with epilepsy is growing in resource rich countries due to demographic changes and increased longevity. Management in these patients is challenging as underlying etiology, co-morbidities, polypharmacy, age-related pharmacokinetic and pharmacodynamic changes need to be considered.Areas covered: Lacosamide, eslicarbazepine acetate, brivaracetam, and perampanel have been approved in the USA and Europe for monotherapy and/or adjunctive treatment of seizures in the last few years. The authors review the pharmacological properties and safety profile of these drugs and provide recommendations for their use in in the elderly.Expert opinion: There are only limited data available on more recent antiseizure medications (ASMs). Drugs with a low risk of interaction (lacosamide, brivaracetam) are preferred choices. Once daily formulations (perampanel and eslicarbazepine acetate) have the advantage of increased compliance. Intravenous formulations (brivaracetam and lacosamide) are useful in emergency situations and in patients who have difficulties to swallow. Dose adjustments are necessary for all ASMs used in the elderly with slow titration and lower target doses than in the regulatory trials. The adverse event profile does not significantly differ from that found in the general adult population.
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Affiliation(s)
- A Rohracher
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - G Kalss
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - G Kuchukhidze
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - C Neuray
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - M Leitinger
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - J Höfler
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - R Kreidenhuber
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - F Rossini
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - K Volna
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - M Mauritz
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - N Poppert
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
| | - S Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - F Brigo
- Department of Neurology, Franz Tappeiner Hospital, Meran, Italy
| | - E Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, affiliated partner of the ERN EpiCARE Center for Cognitive Neuroscience, Paracelsus Medical University Salzburg, and Christian Doppler Medical Centre, Salzburg, Austria
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Nonconvulsive status epilepticus in the elderly. Rev Neurol (Paris) 2020; 176:701-709. [DOI: 10.1016/j.neurol.2019.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 12/11/2019] [Accepted: 12/17/2019] [Indexed: 11/18/2022]
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Sadeghi M, Eshraghi M, Akers KG, Hadidchi S, Kakara M, Nasseri M, Mahulikar A, Marawar R. Outcomes of status epilepticus and their predictors in the elderly-A systematic review. Seizure 2020; 81:210-221. [PMID: 32862117 DOI: 10.1016/j.seizure.2020.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 11/16/2022] Open
Abstract
Status epilepticus (SE) is associated with high mortality and morbidity. Although SE is frequently seen in elderly patients, there is a lack of a cohesive report of outcome measures and associated factors within this population. Our aim was to systematically review studies reporting outcomes of SE among elderly patients and factors influencing these outcomes. A literature search was conducted in PubMed/MEDLINE, EMBASE, CINAHL Complete, and Cochrane Library from database conception to April 22, 2018. A total of 85 studies were included in this systematic review. The included studies show that mortality is higher in elderly patients than in adult patients. Lesional etiologies, higher number of comorbidities, NCSE, RSE, longer hospital and intensive care unit stays, and infection during hospitalization are associated with poor outcome. Future studies should consider measuring functional outcomes, comparative studies between elderly and adults and AED clinical trials specific for elderly with SE.
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Affiliation(s)
- Mahsa Sadeghi
- Department of Neurology, Wayne State University/Detroit Medical Center, University Health Center, 4201 St Antoine Ave, Detroit, MI, 4820, USA
| | - Mehdi Eshraghi
- Department of Internal Medicine, Wayne State University, University Health Center-4201 St. Antoine- Suite 2E, Detroit, MI, 48201, USA
| | - Kathrine G Akers
- Shiffman Medical Library, Wayne State University, 232C Shiffman Medical Library, Detroit, MI, 48201, USA
| | - Shahram Hadidchi
- Department of Radiology, Wayne State University/Detroit Medical Center, Detroit Receiving Hospital 3L-8, 4201 St. Antoine Ave, Detroit, MI, 48201, USA
| | - Mihir Kakara
- Department of Neurology, Wayne State University/Detroit Medical Center, University Health Center, 4201 St Antoine Ave, Detroit, MI, 4820, USA
| | - Morad Nasseri
- Department of Neurology, Wayne State University/Detroit Medical Center, University Health Center, 4201 St Antoine Ave, Detroit, MI, 4820, USA
| | - Advait Mahulikar
- Department of Neurology, Wayne State University/Detroit Medical Center, University Health Center, 4201 St Antoine Ave, Detroit, MI, 4820, USA
| | - Rohit Marawar
- Department of Neurology, Wayne State University/Detroit Medical Center, University Health Center, 4201 St Antoine Ave, Detroit, MI, 4820, USA.
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Seo JG, Cho YW, Kim KT, Kim DW, Yang KI, Lee ST, Byun JI, No YJ, Kang KW, Kim D. Pharmacological Treatment of Epilepsy in Elderly Patients. J Clin Neurol 2020; 16:556-561. [PMID: 33029960 PMCID: PMC7542002 DOI: 10.3988/jcn.2020.16.4.556] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/13/2020] [Accepted: 07/14/2020] [Indexed: 02/06/2023] Open
Abstract
The incidence and prevalence of epilepsy are highest in elderly people, and the etiologies of epilepsy in the elderly differ from those in other age groups. Moreover, diagnosing and treating epilepsy in elderly people may be challenging due to differences in clinical characteristics and physiological changes associated with aging. This review focuses on the pharmacological treatment of epilepsy in elderly patients.
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Affiliation(s)
- Jong Geun Seo
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Yong Won Cho
- Department of Neurology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea.
| | - Keun Tae Kim
- Department of Neurology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Dong Wook Kim
- Department of Neuroloy, Konkuk University School of Medicine, Seoul, Korea
| | - Kwang Ik Yang
- Department of Neurology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Soon Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Ick Byun
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Young Joo No
- Department of Neurology, Samsung Noble County, Yongin, Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Daeyoung Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
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Verma A, K K, Kumar A. Clinical profile and comparison of scoring tools for the prediction of in-hospital mortality in convulsive status epilepticus in elderly. Epilepsy Behav 2019; 101:106571. [PMID: 31675605 DOI: 10.1016/j.yebeh.2019.106571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 09/12/2019] [Accepted: 09/12/2019] [Indexed: 12/14/2022]
Abstract
PURPOSE The present study was aimed to study the clinical profile, etiologies, and outcome of convulsive status epilepticus (CSE) in elderly patients and also to compare the predictive accuracy of the Status Epilepticus Severity Score (STESS) and Epidemiology-based Mortality Score in Status Epilepticus - etiology, age, level of consciousness (EMSE-EAL) score for in-hospital mortality. METHODS Eighty-five elderly patients (≥60 years of age) with a diagnosis of CSE were consecutively enrolled. The distinction between the score performances was determined by comparing the means area under the receiver operating characteristic curve (AUC). RESULTS The mean age of respondents was 66.3 ± 7.4 years; the most common etiology of CSE was stroke (acute and remote symptomatic) in 48.2% of cases. In-hospital mortality was 16.5% in our series, and on multivariate analysis, variables significantly related with mortality were lack of response to first-line drugs (odds ratio (OR) = 43.05, 95% confidence interval (CI) = 4.7-386.8; p = .001) and higher EMSE-EAL score (OR = 0.08, 95% CI = 0.015-0.47; p = .005). On comparison, STESS with the cutoff value of ≥3 has AUC of 0.678 (95%CI = 0.54-0.81), whereas ESME-EAL with the cutoff value of ≥40 showed AUC of 0.901 (95% CI = 0.83-0.97). CONCLUSIONS Most frequent cause of CSE in elderly in our series was stroke and was also associated with high mortality. For the prediction of in-hospital mortality in elderly, EMSE-EAL-40 score is superior to STESS-3, which can be easily applied in resource-poor sectors with limited diagnostic facilities especially where continuous video-electroencephalogram (EEG) monitoring is unavailable.
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Affiliation(s)
- Archana Verma
- Department of Neurology, UP University of Medical Sciences, Saifai, Etawah 206301, U.P., India.
| | - Kiran K
- Department of Community Medicine, UP University of Medical Sciences, Saifai, Etawah 206301, U.P., India
| | - Alok Kumar
- Forensic Medicine & Toxicology, UP University of Medical Sciences, Saifai, Etawah 206130, U.P., India
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Crawshaw AA, Cock HR. Medical management of status epilepticus: Emergency room to intensive care unit. Seizure 2019; 75:145-152. [PMID: 31722820 DOI: 10.1016/j.seizure.2019.10.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Ania A Crawshaw
- Specialist Trainee Neurology, Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Hannah R Cock
- Professor of Epilepsy & Medical Education, Consultant Neurologist. Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, and Institute of Medical & Biomedical Education, St George's University of London, London, UK.
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Neligan A, Noyce AJ, Gosavi TD, Shorvon SD, Köhler S, Walker MC. Change in Mortality of Generalized Convulsive Status Epilepticus in High-Income Countries Over Time: A Systematic Review and Meta-analysis. JAMA Neurol 2019; 76:897-905. [PMID: 31135807 DOI: 10.1001/jamaneurol.2019.1268] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Status epilepticus (SE) is associated with significant morbidity and mortality. Since the late 1990s, a more aggressive management of prolonged convulsive seizures lasting longer than 5 minutes has been advocated. Objective To determine if convulsive SE mortality has decreased during a time of increasing advocacy for out-of-hospital treatment and escalating and earlier treatment protocols for prolonged seizures and SE. Data Source This systemic review and meta-analysis on studies focused on the mortality of convulsive status epilepticus was conducted by searching MEDLINE, Embase, PsychINFO, CINAHL Plus, and the Cochrane Database of Systematic Reviews between January 1, 1990, and June 30, 2017. Study Selection Studies were excluded if they had fewer than 30 participants (<20 for refractory SE), were limited to SE of single specific etiology or an evaluation of a single treatment modality, or were studies of nonconvulsive SE. Data Extraction and Synthesis Data were abstracted and their quality was assessed via a modified Newcastle-Ottawa scale independently by 2 reviewers (A.N. and T.D.G.) using the Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines. Data were pooled using a random-effects model. Main Outcomes and Measures The main outcome measure was in-hospital mortality or 30-day case fatality expressed as proportional mortality. Results Sixty-one studies were included in the analysis. The pooled mortality ratios were 15.9% (95% CI, 12.7-19.2) for adult studies, 13.0% (95% CI, 7.2-19.0) for all-age population studies, 3.6% (95% CI, 2.0%-5.2%) for pediatric studies, and 17.3% (95% CI, 9.8-24.7) for refractory SE studies, with very high between-study heterogeneity. We found no evidence of a change in prognosis over time nor by the definition of SE used. Conclusions and Relevance The mortality of convulsive SE is higher in adults than in children and there was no evidence for improved survival over time. Although there are many explanations for these findings, they can be explained by aetiology of SE being the major determinant of mortality. However, there are potential confounders, including differences in case ascertainment and study heterogeneity. This meta-analysis highlights the need for strict international guidelines for the study of this condition.
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Affiliation(s)
- Aidan Neligan
- Homerton University Hospital NHS Foundation Trust, Homerton Row, London, England.,University College London Queen Square Institute of Neurology, Queen Square, London, England.,Preventive Neurology Unit, Wolfson Institute of Preventative Medicine, Queen Mary University of London, London, England
| | - Alastair John Noyce
- University College London Queen Square Institute of Neurology, Queen Square, London, England.,Preventive Neurology Unit, Wolfson Institute of Preventative Medicine, Queen Mary University of London, London, England
| | | | - Simon D Shorvon
- University College London Queen Square Institute of Neurology, Queen Square, London, England
| | - Sebastian Köhler
- Maastricht University Medical Centre, School for Mental Health and Neuroscience, Alzheimer Centre Limburg, Maastricht, the Netherlands
| | - Matthew C Walker
- University College London Queen Square Institute of Neurology, Queen Square, London, England
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Status Epilepticus among Older Adults in the United States. Geriatrics (Basel) 2019; 4:geriatrics4030045. [PMID: 31340576 PMCID: PMC6787625 DOI: 10.3390/geriatrics4030045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/04/2019] [Accepted: 07/12/2019] [Indexed: 02/03/2023] Open
Abstract
Objective: This study aimed to identify temporal time trends and risk factors associated with mortality for hospitalized older adults with status epilepticus (SE). Design: A retrospective study was performed. Setting: Hospitalized patients were identified utilizing an administrative database—The Nationwide Inpatient Sample database from 1998 through September 2015. Patients: Patients were older adults 65 years and older with SE. Interventions: No interventions were undertaken. Measurements and Main Results: Demographic, temporal trends, clinical characteristics, and outcome data were abstracted. The results indicated that hospitalized elderly Americans with SE increased over the 11-year study period. Univariate and multivariate analyses were performed to evaluate risk factors associated with mortality in the study cohort. From the weighted sample, 130,109 subjects were included. Overall mortality was 19%. For age subgroups, the mortality was highest for the >85 years age group (24.1%) compared to the 65–75 years (19%) and 75–85 years (23%) age groups. Among investigated etiologies, the three most common causes of SE were acute ischemic stroke (11.2% of total) followed by non-traumatic brain hemorrhage (5.4%) and malignant brain lesions (4.9%). The highest mortality by etiology was noted for acute traumatic brain injury (TBI) (31.5%), non-traumatic brain hemorrhage (31%), and acute ischemic stroke (AIS) (30.1%). Multivariate analysis indicated that non-survivors when compared to survivors were more like to have the following characteristics: older age group, acute TBI, brain neoplasms, non-traumatic brain hemorrhage, AIS and central nervous system (CNS) infections, and utilization of mechanical ventilation. Associated conditions significantly increasing risk of mortality were sodium imbalance, cardiac arrest, anoxic brain injury, pneumonia, and sepsis. Comorbidities associated with increased risk of mortality included valvular heart disease, renal failure, liver disease, and neoplasms. Conclusions: The number of hospitalized elderly Americans with SE increased over the 11-year study period. Overall mortality was 19%, with even higher mortality among various patient subsets. Several demographic and co-morbid factors are associated with increased mortality in this age group.
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Kim DW, Oh J. Comparison of new-onset and persistent epilepsy in the elderly. Acta Neurol Scand 2019; 139:395-398. [PMID: 30485413 DOI: 10.1111/ane.13058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 11/01/2018] [Accepted: 11/23/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Previous studies on elderly epilepsy included only patients with new-onset disease, but there are many patients who developed epilepsy earlier and aged. AIM We compared the characteristics of new-onset and persistent epilepsy in the elderly. METHODS We performed a 10-year retrospective analysis of elderly patients with epilepsy divided into two groups according to the onset of seizure: new-onset epilepsy (onset age ≥65) and persistent epilepsy (onset age<65). RESULTS Nearly half (78/172, 45.3%) of patients in the new-onset group presented as status epilepticus, and one-fourth of these (19/78, 24.4%) died during the initial treatment for status epilepticus. Patients in the new-onset epilepsy group presented more frequently as status epilepticus (59/153 vs 12/78, P < 0.001) and had a past history of status epilepticus (63/153 vs 20/78, P = 0.02). History of stroke (81/153 vs 30/78, P = 0.04), hypertension (83/153 vs 29/78, P = 0.01), and dyslipidemia (53/153 vs 17/78, P = 0.05) was more common in the new-onset group, but patients in the persistent group used more antiepileptic drugs (AEDs; P = 0.036) and total AED drug loads (P = 0.028). CONCLUSIONS Our study shows that new-onset epilepsy has a higher incidence of status epilepticus and more stroke-related risk factors but may require fewer AEDs for epilepsy control.
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Affiliation(s)
- Dong Wook Kim
- Department of Neurology; Konkuk University School of Medicine; Seoul Korea
| | - Jeeyoung Oh
- Department of Neurology; Konkuk University School of Medicine; Seoul Korea
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Evaluation of cerebral blood flow in older patients with status epilepticus using arterial spin labeling. eNeurologicalSci 2019; 14:56-59. [PMID: 30619954 PMCID: PMC6313842 DOI: 10.1016/j.ensci.2018.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 09/06/2018] [Accepted: 12/16/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction Although older patients with status epilepticus (SE) have a high mortality rate and poor outcome, it is difficult to perform emergent electroencephalography (EEG) to diagnose SE in community hospitals. Arterial spin labeling (ASL) is a non-invasive magnetic resonance imaging (MRI) technique that can rapidly assess cerebral blood flow (CBF). Further, ASL can detect increased CBF in the ictal period. Therefore, ASL may be a useful tool for diagnosing SE in older patients. However, its effectiveness in this population is unknown. Methods We retrospectively investigated differences in CBF abnormalities between older patients (≥70 years) and non-older patients (<70 years) with SE using ASL. Participants were diagnosed with convulsive status epilepticus (CSE) or non-convulsive status epilepticus (NCSE) based on symptoms, brain MRI, and EEG. Results ASL detected CBF abnormalities in 40% of older patients with CSE or NCSE. Rates of CBF abnormalities in older patients were not significantly different compared with that in non-older patients. Conclusions ASL did not detect a higher rate of CBF abnormalities in older patients, but may help physicians diagnose SE in older patients in a community hospital setting if emergent EEG cannot be immediately performed. ASL is a non-invasive MRI technique. ASL can assess CBF in a short time. ASL showed abnormality in CBF in 40% of older patients with SE. ASL detected CBF abnormality more often in older patients with NCSE than with CSE. ASL may be an aid to diagnosing SE in older patients.
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Yoshimura H, Matsumoto R, Ueda H, Ariyoshi K, Ikeda A, Takahashi R, Kohara N. Status epilepticus in the elderly: Comparison with younger adults in a comprehensive community hospital. Seizure 2018; 61:23-29. [DOI: 10.1016/j.seizure.2018.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/10/2018] [Accepted: 07/18/2018] [Indexed: 12/12/2022] Open
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Baysal-Kirac L, Feddersen B, Einhellig M, Rémi J, Noachtar S. Does semiology of status epilepticus have an impact on treatment response and outcome? Epilepsy Behav 2018; 83:81-86. [PMID: 29660507 DOI: 10.1016/j.yebeh.2018.03.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/16/2018] [Accepted: 03/17/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study investigated whether there is an association between semiology of status epilepticus (SE) and response to treatment and outcome. METHOD Two hundred ninety-eight consecutive adult patients (160 females, 138 males) with SE at the University of Munich Hospital were prospectively enrolled. Mean age was 63.2±17.5 (18-97) years. Patient demographics, SE semiology and electroencephalography (EEG) findings, etiology, duration of SE, treatment, and outcome measures were investigated. Status epilepticus semiology was classified according to a semiological status classification. Patient's short-term outcome was determined by Glasgow Outcome Scale (GOS). RESULTS The most frequent SE type was nonconvulsive SE (NCSE) (39.2%), mostly associated with cerebrovascular etiology (46.6%). A potentially fatal etiology was found in 34.8% of the patients. More than half (60.7%) of the patients had poor short-term outcome (GOS≤3) with an overall mortality of 12.4%. SE was refractory to treatment in 21.5% of the patients. Older age, potentially fatal etiology, systemic infections, NCSE in coma, refractory SE, treatment with anesthetics, long SE duration (>24h), low Glasgow Coma Scale (GCS) (≤8) at onset, and high Status Epilepticus Severity Score (STESS-3) (≥3) were associated with poor short-term outcome and death (p<0.05). Potentially fatal etiology and low GCS were the strongest predictors of poor outcome (Exp [b]: 4.74 and 4.10 respectively, p<0.05). CONCLUSION Status epilepticus semiology has no independent association with outcome, but potentially fatal etiology and low GCS were strong predictive factors for poor short-term outcome of SE.
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Affiliation(s)
- Leyla Baysal-Kirac
- Epilepsy Center, Department of Neurology, University of Munich, Munich, Germany
| | - Berend Feddersen
- Epilepsy Center, Department of Neurology, University of Munich, Munich, Germany
| | - Marion Einhellig
- Epilepsy Center, Department of Neurology, University of Munich, Munich, Germany
| | - Jan Rémi
- Epilepsy Center, Department of Neurology, University of Munich, Munich, Germany
| | - Soheyl Noachtar
- Epilepsy Center, Department of Neurology, University of Munich, Munich, Germany.
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Abstract
PURPOSE OF REVIEW Status epilepticus has a high morbidity and mortality. There are little definitive data to guide management; however, new recent data continue to improve understanding of management options of status epilepticus. This review examines recent advancements regarding the critical care management of status epilepticus. RECENT FINDINGS Recent studies support the initial treatment of status epilepticus with early and aggressive benzodiazepine dosing. There remains a lack of prospective randomized controlled trials comparing different treatment regimens. Recent data support further study of intravenous lacosamide as an urgent-control therapy, and ketamine and clobazam for refractory status epilepticus. Recent data support the use of continuous EEG to help guide treatment for all patients with refractory status epilepticus and to better understand epileptic activity that falls on the ictal-interictal continuum. Recent data also improve our understanding of the relationship between periodic epileptic activity and brain injury. SUMMARY Many treatments are available for status epilepticus and there are much new data guiding the use of specific agents. However, there continues to be a lack of prospective data supporting specific regimens, particularly in cases of refractory status epilepticus.
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Fatuzzo D, Novy J, Rossetti AO. Use of newer antiepileptic drugs and prognosis in adults with status epilepticus: Comparison between 2009 and 2017. Epilepsia 2018; 59:e98-e102. [DOI: 10.1111/epi.14434] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Daniela Fatuzzo
- Department of Neurology; CHUV and University of Lausanne; Lausanne Switzerland
- G. F. Ingrassia Department of Medical and Surgical Sciences and Advanced Technologies; University of Catania; Catania Italy
| | - Jan Novy
- Department of Neurology; CHUV and University of Lausanne; Lausanne Switzerland
| | - Andrea O. Rossetti
- Department of Neurology; CHUV and University of Lausanne; Lausanne Switzerland
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Vilella L, González Cuevas M, Quintana Luque M, Toledo M, Sueiras Gil M, Guzmán L, Salas Puig J, Santamarina Pérez E. Prognosis of status epilepticus in elderly patients. Acta Neurol Scand 2018; 137:321-328. [PMID: 29168175 DOI: 10.1111/ane.12867] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the clinical features and prognosis of status epilepticus (SE) in patients above 70 years old. METHODS Retrospective analysis of all patients ≥70 years old with SE registered prospectively during 4 years. Follow-up after discharge was performed. RESULTS Ninety patients were evaluated. Acute symptomatic etiology was the most prevalent. The mean number of antiepileptic drugs (AEDs) used was 2.7 ± 1.2, and 21% of the patients required sedation. A poor outcome was considered when death (31.1%) or developing of new neurological impairment at discharge (32.2%) occurred. After multivariate analysis, four variables predicted a poor outcome: acute symptomatic etiology (OR: 6.320; 95% CI: 1.976-20.217; P = .002), focal motor SE type (OR: 9.089; 95% CI: 2.482-33.283; P = .001), level of consciousness (OR: 4.596; 95% CI: 1.903-11.098; P = .001), and SE duration >12 hours (OR: 3.763; 95% CI: 1.130-12.530; P = .031). Independent predictive factors of mortality were SE duration >12 hours (OR: 4.306; 95% CI: 1.044-17.757; P = .043), modified Status Epilepticus Severity Score (mSTESS) (OR: 2.216; 95% CI: 1.313-3.740; P = .003), and development of complications (OR: 3.334; 95% CI: 1.004-11.070, P = .049). Considering long-term mortality, age (HR 1.036; 95% CI 1.001-1.071; P = .044), a potentially fatal underlying cause (HR 2.609; 95% CI 1.497- 4.548; P = .001), and mSTESS score >4 (HR 1.485; 95% CI 1.158-1.903; P = .002) remained as predictive factors. There was no association between sedation and the number of AEDs used with outcome at discharge or long-term mortality (P > .05). CONCLUSIONS SE above 70 years old has a high morbimortality. Prognosis is not related to treatment aggressiveness.
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Affiliation(s)
- L. Vilella
- Department of Neurology; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - M. González Cuevas
- Department of Neurology; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - M. Quintana Luque
- Department of Neurology; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - M. Toledo
- Department of Neurology; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - M. Sueiras Gil
- Department of Neurophysiology; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - L. Guzmán
- Department of Neurophysiology; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - J. Salas Puig
- Department of Neurology; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
| | - E. Santamarina Pérez
- Department of Neurology; Hospital Universitari Vall d'Hebron; Universitat Autònoma de Barcelona; Barcelona Spain
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The electroclinical spectrum, etiologies, treatment and outcome of nonconvulsive status epilepticus in the elderly. Epilepsy Behav 2018; 79:53-57. [PMID: 29253676 DOI: 10.1016/j.yebeh.2017.10.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/24/2017] [Accepted: 10/27/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Nonconvulsive status epilepticus (NCSE) in the elderly is particularly difficult to diagnose, mainly due to subtle clinical manifestations and associated comorbidities. The recently validated electroencephalography (EEG) diagnostic criteria for NCSE and the proposed operational classification of status epilepticus provide tools that can allow an earlier diagnosis and better management of NCSE in this age group, possibly contributing to reduce its high mortality. MATERIAL AND METHODS we used these tools to identify and characterize a cohort of elderly (>60year-old) patients admitted at our institution in a 3-year period; the video-EEG and clinical files of the patients fulfilling EEG diagnostic criteria for NCSE were reviewed, being in this study described their electroclinical spectrum, etiologies, treatment, inhospital mortality, and status epilepticus severity score (STESS). RESULTS Fourty patients (23 women; mean age 76.6years) were identified. Although dyscognitive NCSE associated with >2.5Hz of epileptiform discharges (ED) was the most frequent electroclinical phenotype, this was quite heterogeneous, ranging from patients with aura continua to patients in coma, associated with frequent ED or rhythmic slow activities. Acute symptomatic (45%) and multifactorial (27.5%) etiologies were the most common, and associated with the worst prognosis. There was a trend to use newer antiepileptic drugs in the early steps of NCSE treatment. The inhospital mortality was high (22.5%) and predicted by STESS scores ≥3. CONCLUSION In the elderly, NCSE has heterogeneous electroclinical phenotypes and etiologies. In spite of the treatment limitations conditioned by the comorbidities, more aggressive treatments could be justified to reduce mortality in patients with high STESS scores.
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Marquetand J, Knake S, Strzelczyk A, Steinhoff BJ, Lerche H, Synofzik M, Focke NK. Periodic EEG patterns in sporadic Creutzfeld-Jakob-Disease can be benzodiazepine-responsive and be difficult to distinguish from non-convulsive status epilepticus. Seizure 2017; 53:47-50. [PMID: 29125945 DOI: 10.1016/j.seizure.2017.10.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 10/29/2017] [Accepted: 10/31/2017] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Periodic discharges in EEG and a history of rapidly progressive dementia are known to be associated with sporadic Creutzfeld-Jakob Disease (sCJD). Doubts regarding this rare but fatal diagnosis can arise, when episodic symptoms (seizures, psychiatric features, speech disturbances) are present and the EEG shows epileptiform discharges within this periodicity. This scenario may indicate non-convulsive status epilepticus (NCSE), which is - in contrast to sCJD - a treatable and frequent condition. METHODS Herein we report a small retrospective study of 4 elderly patients, who suffered from sCJD, but due to episodic symptoms and benzodiazepine-responsive epileptiform discharges in combination to a subacute cognitive decline, NCSE was considered as a potential differential diagnosis and therefore treated aggressively. RESULTS Ultimately, this treatment was not successful and sCJD was diagnosed in all cases. Hence, there was no diagnostic and prognostic value of abolishing periodic discharges in EEG via benzodiazepines in differentiating sCJD from NCSE in our series. CONCLUSION These findings indicate that periodic discharges in sCJD can be responsive to benzodiazepines andnot necessarily help to differentiate differentiation between sCJD and NCSE of other causes. We argue that an aggressive anticonvulsive treatment in this scenario should be considered cautiously, especially for invasive options like general anesthesia.
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Affiliation(s)
- Justus Marquetand
- Department of Epileptology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Germany.
| | - Susanne Knake
- Epilepsy Center Hessen, Department of Neurology, Philipps-University Marburg, Germany
| | - Adam Strzelczyk
- Epilepsy Center Hessen, Department of Neurology, Philipps-University Marburg, Germany; Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Germany
| | | | - Holger Lerche
- Department of Epileptology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Germany
| | - Matthis Synofzik
- Department of Neurodegenerative Diseases, Hertie-Institute for Clinical Brain Research, University of Tübingen, Germany; German Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | - Niels K Focke
- Department of Epileptology, Hertie-Institute for Clinical Brain Research, University of Tübingen, Germany
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Atmaca MM, Bebek N, Baykan B, Gökyiğit A, Gürses C. Predictors of outcomes and refractoriness in status epilepticus: A prospective study. Epilepsy Behav 2017; 75:158-164. [PMID: 28866335 DOI: 10.1016/j.yebeh.2017.07.046] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 07/25/2017] [Accepted: 07/26/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of this study was to determine the predictors of outcomes and refractoriness in status epilepticus (SE). METHODS This is a prospective study of 59 adult patients with SE who were admitted to the Emergency Department between February 2012 and December 2013. The effects of clinical, demographic, and electrophysiologic features of patients with SE were evaluated. To evaluate outcome in SE, STESS, mSTESS, and EMSE scales were used. RESULTS Logistic regression analysis showed that being aged ≥65years (p=0.02, OR: 17.68, 95% CI: [1.6-198.4]) for the short term and having potentially fatal etiology (p=0.027, OR: 11.7, 95% CI: [1.3-103]) for the long term were the only independent predictors of poor outcomes; whereas, the presence of periodic epileptiform discharges (PEDs) in EEG was the only independent predictor of refractoriness (p=0.032, OR: 13.7, 95% CI: [1.3-148.5]). The patients with ≥3 Status Epilepticus Severity Score (STESS) did not have poorer outcomes in the short- (p=0.157) and long term (p=0.065). There was no difference between patients with 0-2, 3-4, and ≥4 mSTESS in the short- and long term in terms of outcome (p=0.28 and 0.063, respectively). Also, there was no difference between subgroups (convulsive SE [CSE], nonconvulsive SE [NCSE], and epilepsia partialis continua [EPC]) in terms of STESS and mSTESS. When patients with EPC were excluded, both STESS and mSTESS scores of the patients correlated with poorer long-term outcomes (p=0.025 and 0.017, respectively). The patients with ≥64 points in the Epidemiology-based Mortality in SE-Etiology, age, comorbidity, EEG (EMSE-EACE) score and those with ≥27 points in EMSE-Etiology, age, comorbidity (EMSE-EAC) score did not have poorer outcomes in the short term (p=0.06 and 0.274, respectively) while they had significantly poorer outcome in the long term (p<0.001 and 0.002, respectively). In subgroup analysis, patients with CSE with ≥64 points in EMSE-EACE had significantly poorer outcome in the both short- and long term (p=0.014 and 0.012, respectively), and patients with CSE with ≥27 points in EMSE-EAC had significantly poorer outcome in the long term (p=0.03) but not in the short term (p=0.186). Outcomes did not correlate with EMSE scores in patients with NCSE and EPC. Status epilepticus was terminated with intravenous (IV) levetiracetam (LEV) in 68.75% of patients and with IV phenytoin (PHT) in 83.3% of patients. No statistically significant difference was found between the two groups in terms of efficacy (p=0.334). CONCLUSION Being aged ≥65years predicts poor short-term outcomes, and having potentially fatal etiology predicts poor long-term outcomes, which highlight the importance of SE treatment management in the elderly. Both STESS and mSTESS are not predictive for poor outcomes in EPC. Excluding patients with EPC, STESS, and mSTESS could predict poor long-term outcomes but not in the short term in SE. Epidemiology-based Mortality in Status Epilepticus score could predict poor outcome in the long term better than STESS and mSTESS. Specifically, EMSE scores correlated with poor outcome in patients with CSE but not with NCSE and EPC. New scales are needed to predict outcome especially in patients with NCSE and EPC. The presence of PEDs in EEG is a predictor of RSE, and EMSE score can also be used to predict RSE. There was no difference in the efficacy of IV LEV and IV PHT in SE. This study is significant for having one of the longest follow-up periods in the literature.
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Affiliation(s)
- Murat Mert Atmaca
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, Turkey.
| | - Nerses Bebek
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, Turkey
| | - Betül Baykan
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, Turkey
| | - Ayşen Gökyiğit
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, Turkey
| | - Candan Gürses
- Istanbul University, Istanbul Faculty of Medicine, Department of Neurology, Turkey.
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Kinney MO, Craig JJ, Kaplan PW. Hidden in plain sight: Non-convulsive status epilepticus-Recognition and management. Acta Neurol Scand 2017; 136:280-292. [PMID: 28144933 DOI: 10.1111/ane.12732] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2017] [Indexed: 01/03/2023]
Abstract
Non-convulsive status epilepticus (NCSE) is an electroclinical state associated with an altered level of consciousness but lacking convulsive motor activity. It can present in a multitude of ways, but classification based on the clinical presentation and electroencephalographic appearances assists in determining prognosis and planning treatment. The aggressiveness of treatment should be based on the likely prognosis and the underlying cause of the NCSE.
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Affiliation(s)
- M. O. Kinney
- Department of Neurology; Royal Victoria Hospital, Belfast; Antrim UK
| | - J. J. Craig
- Department of Neurology; Royal Victoria Hospital, Belfast; Antrim UK
| | - P. W. Kaplan
- Department of Neurology; Johns Hopkins University School of Medicine; Johns Hopkins Bayview Medical Centre; Baltimore MD USA
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Malter MP, Nass RD, Kaluschke T, Fink GR, Burghaus L, Dohmen C. New onset status epilepticus in older patients: Clinical characteristics and outcome. Seizure 2017; 51:114-120. [PMID: 28843069 DOI: 10.1016/j.seizure.2017.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/09/2017] [Accepted: 08/13/2017] [Indexed: 10/19/2022] Open
Abstract
PURPOSE We here evaluated (1) the differential characteristics of status epilepticus (SE) in older (≥60 years) compared to younger adults (18-59 years). In particular, we were interested in (2) the proportion and characteristics of new onset SE in patients with no history of epilepsy (NOSE) in older compared to younger adults, and (3) predictive parameters for clinical outcome in older subjects with NOSE. METHODS We performed a monocentric retrospective analysis of all adult patients (≥18years) admitted with SE to our tertiary care centre over a period of 10 years (2006-2015) to evaluate clinical characteristics and short-time outcome at discharge. RESULTS One-hundred-thirty-five patients with SE were included in the study. Mean age at onset was 64 years (range 21-90), eighty-seven of the patients (64%) were older than 60 years. In 76 patients (56%), SE occurred as NOSE, sixty-seven percent of them were aged ≥60 years. There was no age-dependent predominance for NOSE. NOSE was not a relevant outcome predictor, especially regarding age-related subgroups. Older patients with NOSE had less frequently general tonic clonic SE (GTCSE; p=0.001) and were more often female (p=0.01). Regarding outcome parameters and risk factors in older patients with NOSE, unfavourable outcome was associated with infections during in-hospital treatment (0.04), extended stay in ICU (p=0.001), and generally in hospital (p<0.001). CONCLUSION In our cohort, older patients represented the predominant subgroup in patients with SE. Older patients suffered more often from non-convulsive semiology and had a less favourable short-time outcome. NOSE was not a predictive outcome parameter in older patients. Data suggest that avoiding infections should have a priority because higher infection rates were associated with unfavourable outcome.
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Affiliation(s)
- M P Malter
- Department of Neurology, University of Cologne, Germany.
| | - R D Nass
- Department of Neurology, University of Cologne, Germany; Department of Epileptology, University of Bonn, Germany
| | - T Kaluschke
- Department of Neurology, University of Cologne, Germany
| | - G R Fink
- Department of Neurology, University of Cologne, Germany; Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Centre Jülich, Jülich, Germany
| | - L Burghaus
- Department of Neurology, University of Cologne, Germany; Heilig Geist Krankenhaus, Cologne, Germany
| | - C Dohmen
- Department of Neurology, University of Cologne, Germany
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Kantanen AM, Reinikainen M, Parviainen I, Kälviäinen R. Long-term outcome of refractory status epilepticus in adults: A retrospective population-based study. Epilepsy Res 2017; 133:13-21. [DOI: 10.1016/j.eplepsyres.2017.03.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 02/07/2017] [Accepted: 03/28/2017] [Indexed: 01/21/2023]
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Tiamkao S, Pranboon S, Thepsuthammarat K, Sawanyawisuth K. Status epilepticus in the elderly patients: A national data study in Thailand. J Neurol Sci 2016; 372:501-505. [PMID: 27842985 DOI: 10.1016/j.jns.2016.11.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 11/06/2016] [Accepted: 11/08/2016] [Indexed: 11/28/2022]
Abstract
There are limited data in terms of incidence, clinical features, and outcomes in elderly patients with status epilepticus (SE) in national level. We retrospectively explored national data in Thailand for reimbursement of all SE in elderly patients admitted in the fiscal year 2004-2012. SE in elderly patients (age>60years old) were diagnosed and searched based on ICD 10 (G41) from the national database of from the National Health and Security Office. There were 3326 SE in elderly patients. The national incidence of SE was highest at 8.78patients/100,000/year in 2012. The average age was 72.02years and most were males (1379 patients; 58.8%). At discharge, 66% of patients had improved and in-hospital mortality rate was 14.5%. Predictors of poor outcomes were older age≥80years, being female, hospital levels, chronic renal failure, central nervous system infection, respiratory failure, pneumonia, septicemia, shock, acute renal failure, and hyperkalemia. In conclusion, the number of cases of SE in elderly patients in Thailand has been increasing annually. Increasing age was associated with poor outcome in admitted elderly SE patients.
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Affiliation(s)
- Somsak Tiamkao
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; Integrated Epilepsy Research Group, Khon Kaen University, Khon Kaen, Thailand
| | - Sineenard Pranboon
- Nursing Division, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand; Integrated Epilepsy Research Group, Khon Kaen University, Khon Kaen, Thailand
| | | | - Kittisak Sawanyawisuth
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; Research Center in Back, Neck Other Joint Pain and Human Performance (BNOJPH), Khon Kaen University, Khon Kaen, Thailand; Non-communicable Diseases Research Group, Khon Kaen University, Khon Kaen, Thailand.
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