Nonconvulsive status epilepticus after convulsive status epilepticus: Clinical features, outcomes, and prognostic factors

Nonconvulsive status epilepticus in neurocritical care: A critical reappraisal of outcome prediction scores

OBJECTIVE

Nonconvulsive status epilepticus (NCSE) is a frequent condition in the neurocritical care unit (NCCU) patient population, with high morbidity and mortality. We aimed to assess the validity of available outcome prediction scores for prognostication in an NCCU patient population in relation to their admission reason (NCSE vs. non-NCSE related).

METHODS

All 196 consecutive patients diagnosed with NCSE during the NCCU stay between January 2010 and December 2020 were included. Demographics, Simplified Acute Physiology Score II (SAPS II), NCSE characteristics, and in-hospital and 3-month outcome were extracted from the electronic charts. Status Epilepticus Severity Score (STESS), Epidemiology-Based Mortality Score in Status Epilepticus (EMSE), and encephalitis, NCSE, diazepam resistance, imaging features, and tracheal intubation score (END-IT) were evaluated as previously described. Univariable and multivariable analysis and comparison of sensitivity/specificity/positive and negative predictive values/accuracy were performed.

RESULTS

A total of 30.1% died during the hospital stay, and 63.5% of survivors did not achieve favorable outcome at 3 months after onset of NCSE. Patients admitted primarily due to NCSE had longer NCSE duration and were more likely to be intubated at diagnosis. The receiver operating characteristic (ROC) for SAPS II, EMSE, and STESS when predicting mortality was between .683 and .762. The ROC for SAPS II, EMSE, STESS, and END-IT when predicting 3-month outcome was between .649 and .710. The accuracy in predicting mortality/outcome was low, when considering both proposed cutoffs and optimized cutoffs (estimated using the Youden Index) as well as when adjusting for admission reason.

SIGNIFICANCE

The scores EMSE, STESS, and END-IT perform poorly when predicting outcome of patients with NCSE in an NCCU environment. They should be interpreted cautiously and only in conjunction with other clinical data in this particular patient group.

Nonconvulsive status epilepticus characteristics in glioma patients: a retrospective study

PURPOSE

Epilepsy is a common complication of gliomas. The diagnosis of nonconvulsive status epilepticus (NCSE) is challenging because it causes impaired consciousness and mimics glioma progression. NCSE complication rate in the general brain tumor patient population is approximately 2%. However, there are no reports focusing on NCSE in glioma patient population. This study aimed to reveal the epidemiology and features of NCSE in glioma patients to enable appropriate diagnosis.

METHODS

We enrolled 108 consecutive glioma patients (45 female, 63 male) who underwent their first surgery between April 2013 and May 2019 at our institution. We retrospectively investigated glioma patients diagnosed with tumor-related epilepsy (TRE) or NCSE to explore disease frequency of TRE/NCSE and patient background. NCSE treatment approaches and Karnofsky Performance Status Scale (KPS) changes following NCSE were surveyed. NCSE diagnosis was confirmed using the modified Salzburg Consensus Criteria (mSCC).

RESULTS

Sixty-one out of 108 glioma patients experienced TRE (56%), and five (4.6%) were diagnosed with NCSE (2 female, 3 male; mean age, 57 years old; WHO grade II 1, grade III 2, grade IV 2). All NCSE cases were controlled by stage 2 status epilepticus treatment as recommended in the Clinical Practice Guidelines for Epilepsy by the Japan Epilepsy Society. The KPS score significantly decreased after NCSE.

CONCLUSION

Higher prevalence of NCSE in glioma patients was observed. The KPS score significantly decreased after NCSE. Actively taking electroencephalograms analyzed by mSCC may facilitate accurate NCSE diagnosis and improve the activities of daily living in glioma patients.

Prognostic indicators of non-convulsive status epilepticus in intensive care unit

BACKGROUND

To determine the rate of non-convulsive status epilepticus with/without prominent motor phenomena (SE-PM/ NCSE) and predictive value of electroclinical findings of continious electroencephalography (cEEG) monitoring of these patients and its association with prognosis in intensive care units (ICU).

METHODS

We retrospectively collected data of 218 patients whose cEEG was performed in ICU between 2016 and 2018. The cEEG for NCSE diagnosis was evaluated according to Salzburg Consensus Criteria (SCC).

RESULTS

The mean age of patients was 57.09 ± 18.9 (16-95) years and 49.1% (107) were female. Of 218 patients, 32 (14.7%) had SE-PM/NCSE. According to SCC the rate of NCSE (NCSE + possible NCSE) was 9.6% (n = 21). Prior to cEEG recording, 38.9% (n = 85) of overall patients had a history of seizure/convulsion, and 22.7% (n = 21) of these patients diagnosed with NCSE based on cEEG. The mortality rates in critically ill patients were 41.3% (30.8%, 42.8%; for SE-PM and NCSE respectively). Prognosis was associated with age, epilepsy diagnosis, having convulsion/seizure history on follow-up, GCS, need for ventilation, kind of drugs, sepsis diagnosis, and minimum frequency of background activity of the cEEG (p = 0.001, 0.002, 0.001, 0.020, 0.001, 0.001, 0.001, 0.0001 respectively).

CONCLUSIONS

NCSE findings are mostly found in patients who were comatose and had seizure/convulsion history on follow-up. Mortality is higher in patients diagnosed with NCSE followed in the ICU compared to SE-PM.

Management of Status Epilepticus and Indications for Inpatient Electroencephalography Monitoring

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

Elderly patients with nonconvulsive status epilepticus: Clinical-EEG data, hospital mortality, STESS and EMSE

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.

Nonconvulsive Status Epilepticus in Metabolic Encephalopathy in Indonesia Referral Hospital

Background

Nonconvulsive status epilepticus (NCSE) is often underdiagnosed in patients with metabolic encephalopathy (ME). The diagnosis of ME should be made specifically to recognize the underlying etiology. Delay in seizure identification and making a diagnosis of NCSE contributed to the poor outcome.

Objective

This study aimed to find the incidence and outcome of NCSE in patients with ME.

Methods and Material

This was an observational prospective cross-sectional study in patients with ME in emergency and critical care units in Cipto Mangunkusumo General Hospital. The diagnosis of NCSE was based on EEG using Salzburg Criteria for Nonconvulsive Status Epilepticus (SCNC). The outcome was assessed within 30 days after the NCSE diagnosis has been made.

Results

A total of 50 patients with ME were involved in this study. NCSE was confirmed in 32 subjects (64%). The most common etiology of ME was sepsis (58%). The mortality rate in the NCSE and non-NCSE group was 40.6% vs 44.4%. Multiple aetiologies were risk factors to poor outcome in the NCSE group.

Conclusions

The incidence of NCSE among patients with ME at our hospital was high. Despite the anti-epileptic treatment of the NCSE group, the underlying cause of ME is still the main factor that affected the outcome. Therefore, aggressive treatment of anti-epileptic drug (AED) should be very carefully considered knowing the possible side-effect that might worsen the outcome of patients with ME.

Refractory Status Epilepticus Responsive to Electroacupuncture at Shuigou Acupoint: A Case Report

Refractory status epilepticus (RSE) is a critical and intractable neurological emergency. Around 55% of RSE episodes still persist despite high dose of continuous infusion of anesthetics. It's a clinical urgency and challenge to search for novel alternative treatments to control RSE as soon as possible. Here, we reported a case of RSE in a 67-year-old woman with varicella-zoster virus encephalitis. She had persistent non-convulsive SE despite the continuous infusion of midazolam. On the basis of fundamental treatments, she was given electroacupuncture at Shuigou acupoint for 10 min. An immediate EEG suppression was seen after the electroacupuncture treatment and lasted for 9 min, and lasting epileptic discharges (> 10 s) and clinical seizures were not observed any more. Midazolam was withdrawn gradually 24 h later. This case report may bring an alternative treatment for RSE.

Thirty-day readmission after status epilepticus in the United States: Insights from the nationwide readmission database

OBJECTIVE

To determine the incidence, causes, predictors, and costs of 30-day readmissions in patients admitted with status epilepticus (SE) from a large representative United States (US) population.

METHODS

Adults (age ≥18 years) hospitalized with a primary diagnosis of SE (International Classification of Diseases-Ninth Revision-CM codes 345.2 or 345.3) between January 2013 and September 2015 were identified using the Nationwide Readmissions Database. A multivariable logistic regression model was used to identify predictors of 30-day readmissions.

RESULTS

Of 42,232 patients with index SE, 6372 (15.0%) were readmitted within 30 days. In the multivariable analysis, intracranial hemorrhage (odds ratio, 1.56; 95% confidence interval, 1.12-2.18), psychosis (1.26 95%, 1.05-1.50), diabetes mellitus (1.12, 95%, 1.00-1.25), chronic kidney disease (1.50, 95%, 1.31-1.72), chronic liver disease (1.51; 95%, 1.24-1.84), >3 Elixhauser comorbidities (1.18; 95%, 1.06-1.31), length of stay >4 days during index hospitalization (1.41; 95%, 1.28-1.56) and discharge to skilled nursing facility (SNF) (1.14; 95%, 1.01-1.28) were independent predictors of 30-day readmission. The most common reason for readmission was seizures (45.1%). Median length of stay and costs of readmission were 4 days (interquartile range [IQR], 2-7 days) and $7882 (IQR, $4649-$15,012), respectively.

CONCLUSION

Thirty-day readmissions after SE occurs in 15% of patients, the majority of which were due to seizures. Readmitted patients are more likely to have multiple comorbidities, a longer length of stay, and discharge to SNF. Awareness of these predictors can help identify and target high-risk patients for interventions to reduce readmissions and costs.

Causes of Death in Status Epilepticus

OBJECTIVES

To determine the causes of death in patients with status epilepticus. To analyze the relative contributions of seizure etiology, seizure refractoriness, use of mechanical ventilation, anesthetic drugs for seizure control, and medical complications to in-hospital and 90-day mortality, hospital length of stay, and discharge disposition.

DESIGN

Retrospective cohort.

SETTING

Single-center neuroscience ICU.

PARTICIPANTS

Patients with status epilepticus were identified by retrospective search of electronic database from January 1, 2011, to December 31, 2016.

INTERVENTIONS

Review of electronic medical records.

MEASUREMENTS AND MAIN RESULTS

Demographics, clinical characteristics, treatments, and outcomes were collected. Univariable and multivariable logistic regression analysis were used to determine whether the use of anesthetic drugs, mechanical ventilation, Status Epilepticus Severity Score, refractoriness of seizures, etiology of seizures, or medical complications were associated with in-hospital, 90-day mortality or discharge disposition. Among 244 patients with status epilepticus (mean age was 64 yr [interquartile range, 42-76], 55% male, median Status Epilepticus Severity Score 3 [interquartile range, 2-4]), 24 received anesthetic drug infusions for seizure control. In-hospital and 90-day mortality rates were 9.2% and 19.2%, respectively. Death was preceded by withdrawal of life-sustaining treatment in 19 patients (86.3%) and cardiac arrest in three (13.7%). Only Status Epilepticus Severity Score was associated with in-hospital and 90-day mortality, whereas the use of anesthetic drugs for seizure control, mechanical ventilation, medical complications, etiology, and refractoriness of seizures were not. Hospital length of stay was longer in patients with medical complications (p = 0.0091), refractory seizures (p = 0.0077), and in those who required anesthetic drugs for seizure control (p = 0.0035). Patients who had refractory seizures were less likely to be discharged home (odds ratio, 0.295; CI, 0.143-0.608; p = 0.0009).

CONCLUSIONS

In this cohort, death primarily resulted from the underlying neurologic disease and withdrawal of life-sustaining treatment and not from our treatment choices. Use of anesthetic drugs, medical complications, and mechanical ventilation were not associated with in-hospital and 90-day mortality.

Multimodal Predictions of Super-Refractory Status Epilepticus and Outcome in Status Epilepticus Due to Acute Encephalitis

Objective: Status epilepticus (SE) is one of the most critical symptoms of encephalitis. Studies on early predictions of progression to super-refractory status epilepticus (SRSE) and poor outcome in SE due to acute encephalitis are scarce. We aimed to investigate the values of neuroimaging and continuous electroencephalogram (EEG) in the multimodal prediction. Methods: Consecutive patients with convulsive SE due to acute encephalitis were included in this study. Demographics, clinical features, neuro-imaging characteristics, medical interventions, and anti-epileptic treatment responses were collected. All the patients had EEG monitoring for at least 24 h. We determined the early predictors of SRSE and prognostic factors of 3-month outcome using multivariate logistic regression analyses. Results: From March 2008 to February 2018, 570 patients with acute encephalitis were admitted to neurological intensive care unit (N-ICU) of Xijing hospital. Among them, a total of 94 patients with SE were included in this study. The percentage of non-SRSE and SRSE were 76.6 and 23.4%. Cortical or hippocampal abnormality on neuroimaging (p = 0.002, OR 20.55, 95% CI 3.16-133.46) and END-IT score (p < 0.001, OR 4.07, 95% CI 1.91-8.67) were independent predictors of the progression to SRSE. At 3 months after N-ICU discharge, 56 (59.6%) patients attained good outcomes, and 38 (40.4%) patients had poor outcomes. The recurrence of clinical or EEG seizures within 2 h after the infusion rate of a single anesthetic drug >50% proposed maximal dose (p = 0.044, OR 4.52, 95% CI 1.04-19.68), tracheal intubation (p = 0.011, OR 4.99, 95% CI 1.37-11.69) and emergency resuscitation (p = 0.040, OR 9.80, 95% 1.11-86.47) predicted poor functional outcome. Interpretation: Initial neuro-imaging findings assist early identification of the progression to SRSE. Continuous EEG monitoring contributes to outcome prediction in SE due to acute encephalitis.

External validation of the epidemiology-based mortality score in status epilepticus in an American intensive care population

INTRODUCTION

Although overall mortality of status epilepticus is high, baseline patient characteristics and co-morbidities may be helpful to predict outcomes and shape treatment decisions. Two previously published scoring systems exist to predict outcomes: the Status Epilepticus Severity Score (STESS) and the Epidemiology-based Mortality Score in Status Epilepticus (EMSE). However, a comparison of the two scores has not previously been completed in an American intensive care unit. We hypothesize that both scores will adequately predict the primary outcome of in-hospital death, but that the EMSE may more accurately predict functional outcomes, and significantly impact treatment decisions for both clinicians and families.

METHODS

We performed a retrospective analysis of all cases of status epilepticus admitted to the Neuro-Critical Care Unit (NCCU) at the Ohio State University Wexner Medical Center from 6/1/2014 - 8/31/2015. We collected data on age, comorbidities, EEG findings, and seizure history. The primary outcome measured was in-hospital death; secondary outcomes included length of stay in the NCCU, placement of a tracheostomy and/or a percutaneous endoscopic gastrostomy upon discharge, and discharge location were used as surrogate markers for outcome severity. A sensitivity and specificity analysis was carried out, in addition to a student's t-test for a comparison of the two scores. ANOVA was completed to compare secondary outcomes RESULTS: Forty-six patients were admitted to the NCCU for management of status epilepticus during June 2014 and January 2016, thirteen of which experienced in-hospital death. The median age of the sample was 60, with approximately half of the sample (52.63%) having 3 or more comorbidities. The sensitivity of both EMSE and STESS were very high (100% and 90% respectively); however, the specificities were very low (28.6% and 42.9% respectively). A student's t-test between those who experienced in-hospital death and those who did not was only significant for EMSE at the p < 0.1 level (p = 0.055). Additionally, mean EMSE scores but not STESS scores, were significantly higher (p < 0.001) for those patients who were discharged to skilled nursing facilities or with hospice than compared to those who were discharged to home or to acute inpatient rehabilitation.

CONCLUSIONS

The EMSE and STESS may be useful to predict outcomes of status epilepticus in populations with few comorbid conditions, but are less helpful when patients have multiple medical problems. Secondly, while neither score may be specific enough to differentiate for the primary outcome of death, their utility may be helpful to predict secondary outcomes that strongly affect clinical decisions. Based on these results, we believe a prospective trial of EMSE and STESS should be carried out to obtain more information on their utility, especially in American patients who may have more relevant comorbidities than in other countries.