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Zhao W, Wang WF, Patnaik LM, Zhang BC, Weng SJ, Xiao SX, Wei DZ, Zhou HF. Residual and bidirectional LSTM for epileptic seizure detection. Front Comput Neurosci 2024; 18:1415967. [PMID: 38952709 PMCID: PMC11215953 DOI: 10.3389/fncom.2024.1415967] [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] [Received: 04/18/2024] [Accepted: 05/28/2024] [Indexed: 07/03/2024] Open
Abstract
Electroencephalogram (EEG) plays a pivotal role in the detection and analysis of epileptic seizures, which affects over 70 million people in the world. Nonetheless, the visual interpretation of EEG signals for epilepsy detection is laborious and time-consuming. To tackle this open challenge, we introduce a straightforward yet efficient hybrid deep learning approach, named ResBiLSTM, for detecting epileptic seizures using EEG signals. Firstly, a one-dimensional residual neural network (ResNet) is tailored to adeptly extract the local spatial features of EEG signals. Subsequently, the acquired features are input into a bidirectional long short-term memory (BiLSTM) layer to model temporal dependencies. These output features are further processed through two fully connected layers to achieve the final epileptic seizure detection. The performance of ResBiLSTM is assessed on the epileptic seizure datasets provided by the University of Bonn and Temple University Hospital (TUH). The ResBiLSTM model achieves epileptic seizure detection accuracy rates of 98.88-100% in binary and ternary classifications on the Bonn dataset. Experimental outcomes for seizure recognition across seven epilepsy seizure types on the TUH seizure corpus (TUSZ) dataset indicate that the ResBiLSTM model attains a classification accuracy of 95.03% and a weighted F1 score of 95.03% with 10-fold cross-validation. These findings illustrate that ResBiLSTM outperforms several recent deep learning state-of-the-art approaches.
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Affiliation(s)
- Wei Zhao
- Chengyi College, Jimei University, Xiamen, China
| | - Wen-Feng Wang
- Shanghai Institute of Technology, Shanghai, China
- London Institute of Technology, International Academy of Visual Arts and Engineering, London, United Kingdom
| | | | | | - Su-Jun Weng
- Chengyi College, Jimei University, Xiamen, China
| | | | - De-Zhi Wei
- Chengyi College, Jimei University, Xiamen, China
| | - Hai-Feng Zhou
- Marine Engineering Institute, Jimei University, Xiamen, China
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De Stefano P, Baumann SM, Grzonka P, Sarbu OE, De Marchis GM, Hunziker S, Rüegg S, Kleinschmidt A, Quintard H, Marsch S, Seeck M, Sutter R. Early timing of anesthesia in status epilepticus is associated with complete recovery: A 7-year retrospective two-center study. Epilepsia 2023; 64:1493-1506. [PMID: 37032415 DOI: 10.1111/epi.17614] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/07/2023] [Accepted: 04/07/2023] [Indexed: 04/11/2023]
Abstract
OBJECTIVE This study was undertaken to investigate the efficacy, tolerability, and outcome of different timing of anesthesia in adult patients with status epilepticus (SE). METHODS Patients with anesthesia for SE from 2015 to 2021 at two Swiss academic medical centers were categorized as anesthetized as recommended third-line treatment, earlier (as first- or second-line treatment), and delayed (later as third-line treatment). Associations between timing of anesthesia and in-hospital outcomes were estimated by logistic regression. RESULTS Of 762 patients, 246 received anesthesia; 21% were anesthetized as recommended, 55% earlier, and 24% delayed. Propofol was preferably used for earlier (86% vs. 55.5% for recommended/delayed anesthesia) and midazolam for later anesthesia (17.2% vs. 15.9% for earlier anesthesia). Earlier anesthesia was statistically significantly associated with fewer infections (17% vs. 32.7%), shorter median SE duration (.5 vs. 1.5 days), and more returns to premorbid neurologic function (52.9% vs. 35.5%). Multivariable analyses revealed decreasing odds for return to premorbid function with every additional nonanesthetic antiseizure medication given prior to anesthesia (odds ratio [OR] = .71, 95% confidence interval [CI] = .53-.94) independent of confounders. Subgroup analyses revealed decreased odds for return to premorbid function with increasing delay of anesthesia independent of the Status Epilepticus Severity Score (STESS; STESS = 1-2: OR = .45, 95% CI = .27-.74; STESS > 2: OR = .53, 95% CI = .34-.85), especially in patients without potentially fatal etiology (OR = .5, 95% CI = .35-.73) and in patients experiencing motor symptoms (OR = .67, 95% CI = .48-.93). SIGNIFICANCE In this SE cohort, anesthetics were administered as recommended third-line therapy in only every fifth patient and earlier in every second. Increasing delay of anesthesia was associated with decreased odds for return to premorbid function, especially in patients with motor symptoms and no potentially fatal etiology.
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Affiliation(s)
- Pia De Stefano
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Sira M Baumann
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Pascale Grzonka
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Oana E Sarbu
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Medical faculty of the University of Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical faculty of the University of Basel, Basel, Switzerland
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Medical faculty of the University of Basel, Basel, Switzerland
| | - Andreas Kleinschmidt
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Medical faculty of the University of Geneva, Geneva, Switzerland
| | - Hervé Quintard
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
- Medical faculty of the University of Geneva, Geneva, Switzerland
| | - Stephan Marsch
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Medical faculty of the University of Basel, Basel, Switzerland
| | - Margitta Seeck
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Medical faculty of the University of Geneva, Geneva, Switzerland
| | - Raoul Sutter
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Medical faculty of the University of Basel, Basel, Switzerland
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Ferlini L, Gaspard N. What's new on septic encephalopathy? Ten things you need to know. Minerva Anestesiol 2023; 89:217-225. [PMID: 35833857 DOI: 10.23736/s0375-9393.22.16689-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Sepsis associated encephalopathy (SAE) is a frequent complication of sepsis and is associated with a higher risk of short-term mortality and long-term cognitive impairment. The EEG is a sensitive complement of the clinical examination that can also detect and quantify encephalopathy and identify features with prognostic value, such as lack of reactivity. Moreover, despite their effect on outcome is still debated, the EEG is the only tool to detect non-convulsive seizures which can occur in a septic setting. Understanding the pathophysiology of SAE is fundamental to define potential therapeutic targets. Neuroinflammation plays an important role in the development of SAE and many blood and imaging biomarkers have recently shown a promising ability to distinguish SAE form non-SAE patient. In recent years, some interesting mediators of inflammation were successfully targeted in animal models, with a significant reduction in the neuroinflammation and in sepsis-induced cognitive decline. However, the complexity of the host response to sepsis currently limits the use of immunomodulation therapies in humans. Alteration in regulatory systems of cerebral blood flow, namely cerebral autoregulation (CA) and neurovascular coupling, contribute to SAE development. Nowadays, clinicians have access to different tools to assess them at the bedside and CA-based blood pressure protocols should be implemented to optimize cerebral perfusion. Its inauspicious consequences, its complex physiopathology and the lack of efficacious treatment make of SAE a highly active research subject.
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Affiliation(s)
- Lorenzo Ferlini
- Department of Neurology, Hôpital Erasme, University of Brussels, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Hôpital Erasme, University of Brussels, Brussels, Belgium -
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Nohara S, Abe G, Ito O, Suzuki S, Morioka T. [Sequential arterial spin labeling findings of status epilepticus showing generalized periodic discharges on EEG following acute infarction in the right occipital lobe]. Rinsho Shinkeigaku 2023; 63:78-84. [PMID: 36725014 DOI: 10.5692/clinicalneurol.cn-001775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In addition to electroencephalogram (EEG), arterial spin labeling (ASL) perfusion images with the dual postlabeling delay (PLD) method are useful for evaluating the hemodynamic state of status epilepticus (SE). A 72-year-old man suffered from an acute infarction in the right occipital lobe, resulting in SE with general periodic discharges on EEG with a higher amplitude on the right side. On ASL, blood flow was increased at a wide area of the right hemisphere centered on this infarct. With improvement of SE, sequential ASL with dual PLD method clearly demonstrated not only the reduction of the signal both in intensity and area but also the decrease of the blood flow velocity.
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Affiliation(s)
- Sohei Nohara
- Department of Neurology, Fukuoka Kieikai Hospital
| | - Gorou Abe
- Department of Neurosurgery, Fukuoka Kieikai Hospital
| | - Osamu Ito
- Department of Neurosurgery, Fukuoka Kieikai Hospital
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Gajate-García V, Gutiérrez-Viedma Á, Romeral-Jiménez M, Serrano-García I, Parejo-Carbonell B, Montalvo-Moraleda T, Valls-Carbó A, García-Morales I. Seizures in the Emergency Department: clinical and diagnostic data from a series of 153 patients. Neurologia 2023; 38:29-34. [PMID: 34836845 DOI: 10.1016/j.nrleng.2020.02.011] [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: 10/14/2019] [Accepted: 02/08/2020] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Seizures are a frequent reason for admission to emergency departments and require early, precise diagnosis and treatment. The objective of this study was to describe the clinical and prognostic characteristics of a series of patients with seizures attended at our hospital's emergency department. METHODS We performed a retrospective, observational study of all patients with seizures who were admitted to our hospital's emergency department and attended by the on-call neurology service between February and August 2017. RESULTS We included 153 patients, representing 9.9% of all neurological emergency department admissions. The median age was 58 years, 52.3% of patients were women, and 51% had history of epilepsy. Onset was focal in 82.4% of cases, and the most frequent aetiology was cerebrovascular disease (24.2%). Twelve patients (7.8%) developed status epilepticus, which was associated with higher scores on the ADAN scale (P < .001) and with history of refractory epilepsy (P = .002). The in-hospital mortality rate was 3.7%, and in-hospital mortality was associated with older age (P = .049) and status epilepticus (P = .018). Eighty percent of patients with no history of epilepsy were diagnosed with epilepsy at the emergency department; all started treatment. The kappa coefficient for epilepsy diagnosis in the emergency department compared to diagnosis after one year of follow-up by the epilepsy unit was 0.45 (diagnosis was modified in 20% of patients). CONCLUSIONS Seizures are a frequent neurological emergency with potential complications and considerable morbidity and mortality rates. In patients with no known history of epilepsy, the condition may be diagnosed in the emergency department, but follow-up at specialised epilepsy units is recommended.
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Affiliation(s)
- V Gajate-García
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Á Gutiérrez-Viedma
- Servicio de Neurología, Hospital Fundación Jiménez Díaz, Madrid, Spain; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Instituto de Investigación Sanitaria de la Fundación Jiménez Díaz (iiSFJD), Madrid, Spain.
| | - M Romeral-Jiménez
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain; Unidad de Epilepsia, Servicio de Neurología, Hospital Clínico San Carlos, Madrid, Spain
| | - I Serrano-García
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain; Unidad de Metodología de Investigación y Epidemiología Clínica, Servicio de Medicina Preventiva, Hospital Clínico San Carlos, Madrid, Spain
| | - B Parejo-Carbonell
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain; Unidad de Epilepsia, Servicio de Neurología, Hospital Clínico San Carlos, Madrid, Spain
| | - T Montalvo-Moraleda
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - A Valls-Carbó
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - I García-Morales
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, Spain; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain; Unidad de Epilepsia, Servicio de Neurología, Hospital Clínico San Carlos, Madrid, Spain
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Wang L, Lu Y, Yang Y, Li H, Wang Y. Elevated body temperature and leukocyte count are associated with elevated creatine kinase after seizures. Heliyon 2022; 8:e12509. [PMID: 36643300 PMCID: PMC9834749 DOI: 10.1016/j.heliyon.2022.e12509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 10/15/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
Objective To evaluate the independent risk factors for elevated creatine kinase (hyperCKemia) after seizures. Methods Data included in this retrospective study were obtained from two hospitals from July 1, 2017, to March 31, 2022. Clinical and laboratory data were acquired from the emergency department or within 24 h after patient admission. Variables that exhibited statistical differences (P < 0.05) were selected for further analysis. Associations between body temperature (BT), leukocyte count (LEU), percentage of neutrophils (NEU), and C-reactive protein (CRP) and creatine kinase (CK) levels were assessed using binary logistic regression analysis. Results One hundred twenty-three patients who exhibited seizures were included in the study, and 39 (31.7%) patients exhibited hyperCKemia based on a CK level that was >1.5 times the upper limit of the normal range for CK. No statistical differences were observed among the patient characteristics, seizure-related parameters, or electrolyte levels. However, BT, LEU, NEU, and CRP were elevated in patients with hyperCKemia compared to patients with normal CK levels. Specifically, a BT ≥ 37.5 °C (fever) and LEU >9.5×109/L (elevated LEU) exhibited positive correlations with hyperCKemia, and presented an adjusted OR of 8.87 (95% CI: 2.11-37.24, P = 0.003) and 3.01 (95% CI: 1.12-8.05, P = 0.029), respectively. Conclusion In this study, hyperCKemia occurred in 31.7% of patients after seizures. Fever and elevated LEU were independent risk factors for seizure-related hyperCKemia. Earlier recognition of risks for seizure-related hyperCKemia would be beneficial in taking prophylactic measures.
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Affiliation(s)
- Lei Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yanan Lu
- Department of Neurology, Anhui Provincial Hospital, Hefei, China
| | - Yujing Yang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hanli Li
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yu Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China,Department of Neurology, Anqing First People's Hospital Affiliated to Anhui Medical University, Anqing, China,Corresponding author.
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Felipe N, Alblaihed L, Dezman Z, Bontempo L. 58-year-old Male with a Headache, Hand Numbness, and Phantosmia. Clin Pract Cases Emerg Med 2022; 6:112-116. [PMID: 35701351 PMCID: PMC9197741 DOI: 10.5811/cpcem.2022.4.56508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/29/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction: A 58-year-old male presents to the emergency department with headache, hand numbness, and phantosmia.
Case Presentation: Magnetic resonance imaging showed multiple acute and early subacute lesions involving the cortex and subcortical white matter of the left frontal lobe, left parietal lobe, left temporal lobe, left caudate, and left putamen.
Discussion: This case takes the reader through the subtle findings that led to the diagnosis and ultimately to treatment.
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Affiliation(s)
- Naillid Felipe
- University of Maryland Medical Center, Department of Emergency Medicine, Baltimore, Maryland
| | - Leen Alblaihed
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Zachary Dezman
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland; University of Maryland, Department of Epidemiology and Public Health, Baltimore, Maryland
| | - Laura Bontempo
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
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Pharmacotherapy for Nonconvulsive Seizures and Nonconvulsive Status Epilepticus. Drugs 2021; 81:749-770. [PMID: 33830480 DOI: 10.1007/s40265-021-01502-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 12/22/2022]
Abstract
Most seizures in critically ill patients are nonconvulsive. A significant number of neurological and medical conditions can be complicated by nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE), with brain infections, hemorrhages, global hypoxia, sepsis, and recent neurosurgery being the most prominent etiologies. Prolonged NCSs and NCSE can lead to adverse neurological outcomes. Early recognition requires a high degree of suspicion and rapid and appropriate duration of continuous electroencephalogram (cEEG) monitoring. Although high quality research evaluating treatment with antiseizure medications and long-term outcome is still lacking, it is probable that expeditious pharmacological management of NCSs and NCSE may prevent refractoriness and further neurological injury. There is limited evidence on pharmacotherapy for NCSs and NCSE, although a few clinical trials encompassing both convulsive and NCSE have demonstrated similar efficacy of different intravenous (IV) antiseizure medications (ASMs), including levetiracetam, valproate, lacosamide and fosphenytoin. The choice of specific ASMs lies on tolerability and safety since critically ill patients frequently have impaired renal and/or hepatic function as well as hematological/hemodynamic lability. Treatment frequently requires more than one ASM and occasionally escalation to IV anesthetic drugs. When multiple ASMs are required, combining different mechanisms of action should be considered. There are several enteral ASMs that could be used when IV ASM options have been exhausted. Refractory NCSE is not uncommon, and its treatment requires a very judicious selection of ASMs aiming at reducing seizure burden along with management of the underlying condition.
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Weber JE, Angermaier A, Bollweg K, Erdur H, Ernst S, Flöel A, Gorski C, Kandil FI, Kinze S, Kleinsteuber K, Kurth T, Schmehl I, Theen S, Endres M, Audebert HJ. Acute neurological care in north-east Germany with telemedicine support (ANNOTeM): protocol of a multi-center, controlled, open-label, two-arm intervention study. BMC Health Serv Res 2020; 20:755. [PMID: 32807159 PMCID: PMC7430113 DOI: 10.1186/s12913-020-05576-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/23/2020] [Indexed: 11/09/2022] Open
Abstract
Background Both diagnosis and treatment of neurological emergencies require neurological expertise and are time-sensitive. The lack of fast neurological expertise in regions with underserved infrastructure poses a major barrier for state-of-the-art care of patients with acute neurological diseases and leads to disparity in provision of health care. The main purpose of ANNOTeM (acute neurological care in North East Germany with telemedicine support) is to establish effective and sustainable support structures for evidence based treatments for stroke and other neurological emergencies and to improve outcome for acute neurological diseases in these rural regions. Methods A “hub-and-spoke” network structure was implemented connecting three academic neurological centres (“hubs”) and rural hospitals (“spokes”) caring for neurological emergencies. The network structure includes (1) the establishment of a 24/7 telemedicine consultation service, (2) the implementation of standardized operating procedures (SOPs) in the network hospitals, (3) a multiprofessional training scheme, and (4) a quality management program. Data from three major health insurance companies as well as data from the quality management program are being collected and evaluated. Primary outcome is the composite of first time of receiving paid outpatient nursing care, first time of receiving care in a nursing home, or death within 90 days after hospital admission. Discussion Beyond stroke only few studies have assessed the effects of telemedically supported networks on diagnosis and outcome of neurological emergencies. ANNOTeM will provide information whether this approach leads to improved outcome. In addition, a health economic analysis will be performed. Study registration German Clinical Trials Register DRKS00013067, date of registration: November 16 th, 2017, URL: http://www.drks.de/DRKS00013068
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Affiliation(s)
- J E Weber
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, D-12203, Berlin, Germany. .,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany. .,Clinical Research Unit, Berlin Institute of Health, Berlin, Germany.
| | - A Angermaier
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany
| | - K Bollweg
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, D-12203, Berlin, Germany
| | - H Erdur
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, D-12203, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - S Ernst
- Clinical Research Unit, Berlin Institute of Health, Berlin, Germany.,Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - A Flöel
- Department of Neurology, University Medicine Greifswald, Greifswald, Germany.,German Center for Neurodegenerative Diseases, partner site, Rostock, Greifswald, Germany
| | - C Gorski
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - F I Kandil
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Institute for Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - S Kinze
- Unfallkrankenhaus Berlin, Berlin, Germany
| | - K Kleinsteuber
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - T Kurth
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - I Schmehl
- Unfallkrankenhaus Berlin, Berlin, Germany
| | - S Theen
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - M Endres
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, D-12203, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany.,Excellence Cluster NeuroCure, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
| | - H J Audebert
- Klinik und Hochschulambulanz für Neurologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, D-12203, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
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Gajate-García V, Gutiérrez-Viedma Á, Romeral-Jiménez M, Serrano-García I, Parejo-Carbonell B, Montalvo-Moraleda T, Valls-Carbó A, García-Morales I. Seizures in the Emergency Department: Clinical and diagnostic data from a series of 153 patients. Neurologia 2020; 38:S0213-4853(20)30047-5. [PMID: 32565035 DOI: 10.1016/j.nrl.2020.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 01/25/2020] [Accepted: 02/08/2020] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Seizures are a frequent reason for admission to emergency departments and require early, precise diagnosis and treatment. The objective of this study was to describe the clinical and prognostic characteristics of a series of patients with seizures attended at our hospital's emergency department. METHODS We performed a retrospective, observational study of all patients with seizures who were admitted to our hospital's emergency department and attended by the on-call neurology service between February and August 2017. RESULTS We included 153 patients, representing 9.9% of all neurological emergency department admissions. The median age was 58 years, 52.3% of patients were women, and 51% had history of epilepsy. Onset was focal in 82.4% of cases, and the most frequent aetiology was cerebrovascular disease (24.2%). Twelve patients (7.8%) developed status epilepticus, which was associated with higher scores on the ADAN scale (P<.001) and with history of refractory epilepsy (P=.002). The in-hospital mortality rate was 3.7%, and in-hospital mortality was associated with older age (P=.049) and status epilepticus (P=.018). Eighty percent of patients with no history of epilepsy were diagnosed with epilepsy at the emergency department; all started treatment. The kappa coefficient for epilepsy diagnosis in the emergency department compared to diagnosis after one year of follow-up by the epilepsy unit was .45 (diagnosis was modified in 20% of patients). CONCLUSIONS Seizures are a frequent neurological emergency with potential complications and considerable morbidity and mortality rates. In patients with no known history of epilepsy, the condition may be diagnosed in the emergency department, but follow-up at specialised epilepsy units is recommended.
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Affiliation(s)
- V Gajate-García
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Á Gutiérrez-Viedma
- Servicio de Neurología, Hospital Fundación Jiménez Díaz, Madrid, España; Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España; Instituto de Investigación Sanitaria de la Fundación Jiménez Díaz (iiSFJD), Madrid, España.
| | - M Romeral-Jiménez
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España; Unidad de Epilepsia, Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España
| | - I Serrano-García
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España; Unidad de Metodología de Investigación y Epidemiología Clínica, Servicio de Medicina Preventiva, Hospital Clínico San Carlos, Madrid, España
| | - B Parejo-Carbonell
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España; Unidad de Epilepsia, Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España
| | - T Montalvo-Moraleda
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - A Valls-Carbó
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - I García-Morales
- Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España; Unidad de Epilepsia, Servicio de Neurología, Hospital Clínico San Carlos, Madrid, España
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11
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Status Epilepticus in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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12
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Hill CE, Parikh AO, Ellis C, Myers JS, Litt B. Timing is everything: Where status epilepticus treatment fails. Ann Neurol 2017; 82:155-165. [PMID: 28681473 DOI: 10.1002/ana.24986] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 06/07/2017] [Accepted: 06/25/2017] [Indexed: 12/27/2022]
Abstract
Status epilepticus is an emergency; however, prompt treatment of patients with status epilepticus is challenging. Clinical trials, such as the ESETT (Established Status Epilepticus Treatment Trial), compare effectiveness of antiepileptic medications, and rigorous examination of effectiveness of care delivery is similarly warranted. We reviewed the medical literature on observed deviations from guidelines, clinical significance, and initiatives to improve timely treatment. We found pervasive, substantial gaps between recommended and "real-world" practice with regard to timing, dosing, and sequence of antiepileptic therapy. Applying quality improvement methodology at the institutional level can increase adherence to guidelines and may improve patient outcomes. Ann Neurol 2017;82:155-165.
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Affiliation(s)
- Chloe E Hill
- Department of Neurology, University of Pennsylvania, Philadelphia, PA.,Center for Healthcare Improvement and Patient Safety, University of Pennsylvania, Philadelphia, PA
| | - Alomi O Parikh
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
| | - Colin Ellis
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
| | - Jennifer S Myers
- Center for Healthcare Improvement and Patient Safety, University of Pennsylvania, Philadelphia, PA.,Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Brian Litt
- Department of Neurology, University of Pennsylvania, Philadelphia, PA.,Department of Bioengineering, University of Pennsylvania, Philadelphia, PA
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13
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Lee T, Warrick BJ, Sarangarm P, Alunday RL, Bussmann S, Smolinske SC, Seifert SA. Levetiracetam in toxic seizures. Clin Toxicol (Phila) 2017; 56:175-181. [DOI: 10.1080/15563650.2017.1355056] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ted Lee
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Brandon J. Warrick
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
- New Mexico Poison and Drug Information Center, Albuquerque, NM, USA
| | - Preeyaporn Sarangarm
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Robert L. Alunday
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Silas Bussmann
- Department of Emergency Medicine, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Susan C. Smolinske
- New Mexico Poison and Drug Information Center, Albuquerque, NM, USA
- College of Pharmacy, University of New Mexico, Albuquerque, NM, USA
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14
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Lee GH, Jung DS. Treatment of Status Epilepticus. JOURNAL OF NEUROCRITICAL CARE 2016. [DOI: 10.18700/jnc.2016.9.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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15
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Mercadé Cerdá J, Toledo Argani M, Mauri Llerda J, López Gonzalez F, Salas Puig X, Sancho Rieger J. The Spanish Society of Neurology's official clinical practice guidelines for epilepsy. NEUROLOGÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.nrleng.2013.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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16
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Mercadé Cerdá J, Toledo Argani M, Mauri Llerda J, López Gonzalez F, Salas Puig X, Sancho Rieger J. Guía oficial de la Sociedad Española de Neurología de práctica clínica en epilepsia. Neurologia 2016; 31:121-9. [DOI: 10.1016/j.nrl.2013.12.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 12/16/2013] [Accepted: 12/29/2013] [Indexed: 10/25/2022] Open
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Abstract
OPINION STATEMENT Convulsive status epilepticus (CSE) is a medical emergency with an associated high mortality and morbidity. It is defined as a convulsive seizure lasting more than 5 min or consecutive seizures without recovery of consciousness. Successful management of CSE depends on rapid administration of adequate doses of anti-epileptic drugs (AEDs). The exact choice of AED is less important than rapid treatment and early consideration of reversible etiologies. Current guidelines recommend the use of benzodiazepines (BNZ) as first-line treatment in CSE. Midazolam is effective and safe in the pre-hospital or home setting when administered intramuscularly (best evidence), buccally, or nasally (the latter two possibly faster acting than intramuscular (IM) but with lower levels of evidence). Regular use of home rescue medications such as nasal/buccal midazolam by patients and caregivers for prolonged seizures and seizure clusters may prevent SE, prevent emergency room visits, improve quality of life, and lower health care costs. Traditionally, phenytoin is the preferred second-line agent in treating CSE, but it is limited by hypotension, potential arrhythmias, allergies, drug interactions, and problems from extravasation. Intravenous valproate is an effective and safe alternative to phenytoin. Valproate is loaded intravenously rapidly and more safely than phenytoin, has broad-spectrum efficacy, and fewer acute side effects. Levetiracetam and lacosamide are well tolerated intravenous (IV) AEDs with fewer interactions, allergies, and contraindications, making them potentially attractive as second- or third-line agents in treating CSE. However, data are limited on their efficacy in CSE. Ketamine is probably effective in treating refractory CSE (RCSE), and may warrant earlier use; this requires further study. CSE should be treated aggressively and quickly, with confirmation of treatment success with epileptiform electroencephalographic (EEG), as a transition to non-convulsive status epilepticus is common. If the patient is not fully awake, EEG should be continued for at least 24 h. How aggressively to treat refractory non-convulsive SE (NCSE) or intermittent non-convulsive seizures is less clear and requires additional study. Refractory SE (RSE) usually requires anesthetic doses of anti-seizure medications. If an auto-immune or paraneoplastic etiology is suspected or no etiology can be identified (as with cryptogenic new onset refractory status epilepticus, known as NORSE), early treatment with immuno-modulatory agents is now recommended by many experts.
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Löscher W, Hirsch LJ, Schmidt D. The enigma of the latent period in the development of symptomatic acquired epilepsy - Traditional view versus new concepts. Epilepsy Behav 2015; 52:78-92. [PMID: 26409135 DOI: 10.1016/j.yebeh.2015.08.037] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 08/30/2015] [Indexed: 01/21/2023]
Abstract
A widely accepted hypothesis holds that there is a seizure-free, pre-epileptic state, termed the "latent period", between a brain insult, such as traumatic brain injury or stroke, and the onset of symptomatic epilepsy, during which a cascade of structural, molecular, and functional alterations gradually mediates the process of epileptogenesis. This review, based on recent data from both animal models and patients with different types of brain injury, proposes that epileptogenesis and often subclinical epilepsy can start immediately after brain injury without any appreciable latent period. Even though the latent period has traditionally been the cornerstone concept representing epileptogenesis, we suggest that the evidence for the existence of a latent period is spotty both for animal models and human epilepsy. Knowing whether a latent period exists or not is important for our understanding of epileptogenesis and for the discovery and the trial design of antiepileptogenic agents. The development of antiepileptogenic treatments to prevent epilepsy in patients at risk from a brain insult is a major unmet clinical need.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine, 30559 Hannover, Germany; Center for Systems Neuroscience, 30559 Hannover, Germany.
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19
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Santamarina E, Gonzalez M, Toledo M, Sueiras M, Guzman L, Rodríguez N, Quintana M, Mazuela G, Salas-Puig X. Prognosis of status epilepticus (SE): Relationship between SE duration and subsequent development of epilepsy. Epilepsy Behav 2015; 49:138-40. [PMID: 26117525 DOI: 10.1016/j.yebeh.2015.04.059] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 04/21/2015] [Accepted: 04/22/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED In animal models, SE duration is related to epileptogenesis. Data in humans are scarce, mainly in NCSE; therefore, we aimed to study the prognosis of SE de novo and which factors may influence subsequent development of epilepsy. METHODS We evaluated patients with SE without previous epilepsy at our hospital (February 2011-February 2014), including demographics, etiology, number of AEDs, duration of SE, mortality, and occurrence of seizures during follow-up. RESULTS Eighty-nine patients were evaluated. Median age was 69 (19-95) years old. Among them, 33.7% were convulsive. Regarding etiology, 59 were considered acute symptomatic (41 lesions, 18 toxic-metabolic), 17 remote or progressive symptomatic, and 13 cryptogenic. The median recovery time was 24h (30 min-360 h). In-hospital mortality was 29% (n = 26). After a median follow-up of 10 months, 58.7% of survivors (n = 37) showed seizures. Subsequently, we analyzed which factors might be related to the development of epilepsy, and we found that epilepsy development was more frequent with longer SE duration (37 vs. 23 h, p = 0.004); furthermore, patients with a toxic-metabolic etiology developed epilepsy less frequently (33% vs. 67%; p = 0.022). Epilepsy was also correlated (tendency) with focal SE (p = 0.073), a lesion in neuroimaging (p = 0.091), and the use of 2 or more AEDs (p = 0.098). Regarding SE duration, a cutoff of above 24h was clearly related to chronic seizures (p = 0.014); however, combining etiology and duration, the association of longer SE and epilepsy was significant in acute lesional SE (p = 0.034), but not in epilepsy with cryptogenic or remote/progressive etiology. After a logistic regression, only a duration longer than 24h (OR = 3.800 (1.277-11.312), p = 0.016) was found to be an independent predictor of the development of epilepsy. CONCLUSION In patients with SE, the longer duration is associated with an increased risk of subsequent epilepsy at follow-up, mainly in symptomatic SE due to an acute lesion. It is unclear if it might be the result of a more severe injury causing both prolonged seizures and subsequent epilepsy, and therefore whether more aggressive treatment in this group might avoid this possibility. Most of the patients with cryptogenic or remote/progressive SE developed epilepsy regardless of SE duration. This article is part of a Special Issue entitled "Status Epilepticus".
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Affiliation(s)
- E Santamarina
- Epilepsy Unit, Hospital Vall Hebron, Barcelona, Spain.
| | - M Gonzalez
- Epilepsy Unit, Hospital Vall Hebron, Barcelona, Spain
| | - M Toledo
- Epilepsy Unit, Hospital Vall Hebron, Barcelona, Spain
| | - M Sueiras
- Department of Neurophysiology, Hospital Vall Hebron, Barcelona, Spain
| | - L Guzman
- Department of Neurophysiology, Hospital Vall Hebron, Barcelona, Spain
| | - N Rodríguez
- Epilepsy Unit, Hospital Vall Hebron, Barcelona, Spain
| | - M Quintana
- Department of Neurology, Hospital Vall Hebron, Barcelona, Spain
| | - G Mazuela
- Epilepsy Unit, Hospital Vall Hebron, Barcelona, Spain
| | - X Salas-Puig
- Epilepsy Unit, Hospital Vall Hebron, Barcelona, Spain
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Aellen J, Abela E, Buerki SE, Kottke R, Springer E, Schindler K, Weisstanner C, El-Koussy M, Schroth G, Wiest R, Gralla J, Verma RK. Focal hemodynamic patterns of status epilepticus detected by susceptibility weighted imaging (SWI). Eur Radiol 2014; 24:2980-8. [DOI: 10.1007/s00330-014-3284-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 05/22/2014] [Accepted: 06/24/2014] [Indexed: 10/24/2022]
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21
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Pugin D, Foreman B, De Marchis GM, Fernandez A, Schmidt JM, Czeisler BM, Mayer SA, Agarwal S, Lesch C, Lantigua H, Claassen J. Is pentobarbital safe and efficacious in the treatment of super-refractory status epilepticus: a cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R103. [PMID: 24886712 PMCID: PMC4095579 DOI: 10.1186/cc13883] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 04/28/2014] [Indexed: 12/01/2022]
Abstract
Introduction Seizures refractory to third-line therapy are also labeled super-refractory status epilepticus (SRSE). These seizures are extremely difficult to control and associated with poor outcome. We aimed to characterize efficacy and side-effects of continuous infusions of pentobarbital (cIV-PTB) treating SRSE. Methods We retrospectively reviewed continuous electroencephalography (cEEG) reports for all adults with RSE treated with cIV-PTB between May 1997 and April 2010 at our institution. Patients with post-anoxic SE and those receiving cIV-PTB for reasons other than RSE were excluded. We collected baseline information, cEEG findings, side-effects and functional outcome at discharge and one year. Results Thirty one SRSE patients treated with cIV-PTB for RSE were identified. Mean age was 48 years old (interquartile range (IQR) 28,63), 26% (N = 8) had a history of epilepsy. Median SE duration was 6.5 days (IQR 4,11) and the mean duration of cIV-PTB was 6 days (IQR 3,14). 74% (N = 23) presented with convulsive SE. Underlying etiology was acute symptomatic seizures in 52% (N = 16; 12/16 with encephalitis), remote 30% (N = 10), and unknown 16% (N = 5). cIV-PTB controlled seizures in 90% (N = 28) of patients but seizures recurred in 48% (N = 15) while weaning cIV-PTB, despite the fact that suppression-burst was attained in 90% (N = 28) of patients and persisted >72 hours in 56% (N = 17). Weaning was successful after adding phenobarbital in 80% (12/15 of the patients with withdrawal seizures). Complications during or after cIV-PTB included pneumonia (32%, N = 10), hypotension requiring pressors (29%, N = 9), urinary tract infection (13%, N = 4), and one patient each with propylene glycol toxicity and cardiac arrest. One-third (35%, N = 11) had no identified new complication after starting cIV-PTB. At one year after discharge, 74% (N = 23) were dead or in a state of unresponsive wakefulness, 16% (N = 5) severely disabled, and 10% (N = 3) had no or minimal disability. Death or unresponsive wakefulness was associated with catastrophic etiology (p = 0.03), but none of the other collected variables. Conclusions cIV-PTB effectively aborts SRSE and complications are infrequent; outcome in this highly refractory cohort of patients with devastating underlying etiologies remains poor. Phenobarbital may be particularly helpful when weaning cIV-PTB.
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22
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Lim SH. Common Complications after Hypoxic-ischemic Encephalopathy. BRAIN & NEUROREHABILITATION 2014. [DOI: 10.12786/bn.2014.7.1.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Seong Hoon Lim
- Department of Rehabilitation Medicine, School of Medicine, The Catholic University of Korea, Korea
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Fernandez A, Lantigua H, Lesch C, Shao B, Foreman B, Schmidt JM, Hirsch LJ, Mayer SA, Claassen J. High-dose midazolam infusion for refractory status epilepticus. Neurology 2013; 82:359-65. [PMID: 24363133 DOI: 10.1212/wnl.0000000000000054] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This study compares 2 treatment protocols allowing low vs high continuous IV midazolam (cIV-MDZ) doses. METHODS We compared adults with refractory status epilepticus treated with a protocol allowing for high-dose cIV-MDZ (n = 100; 2002-2011) with those treated with the previous lower-dose cIV-MDZ (n = 29; 1996-2000). We collected data on baseline characteristics, cIV-MDZ doses, seizure control, hospital course, and outcome. RESULTS Median maximum cIV-MDZ dose was 0.4 mg/kg/h (interquartile range [IQR] 0.2, 1.0) for the high-dose group and 0.2 mg/kg/h (IQR 0.1, 0.3) for the low-dose group (p < 0.001) with similar duration of infusion. Median time from status epilepticus onset to cIV-MDZ start was 1 day (IQR 1, 3) for the high-dose group and 2 days (IQR 1, 5) for the low-dose group (p = 0.016). "Withdrawal seizures" (occurring within 48 hours of discontinuation of cIV-MDZ) were less frequent in the high-dose group (15% vs 64%, odds ratio 0.10, 95% confidence interval 0.03-0.27). "Ultimate cIV-MDZ failure" (patients requiring change to a different cIV antiepileptic medication) and hospital complications were not different between groups. Hypotension was more frequent with higher cIV-MDZ doses but was not associated with worse outcome. Discharge mortality was lower in the high-dose group (40% vs 62%, odds ratio 0.34, 95% confidence interval 0.13-0.92 in multivariate analysis). CONCLUSIONS High-dose cIV-MDZ treatment of refractory status epilepticus can be performed safely, is associated with a lower seizure rate after cIV-MDZ discontinuation, and may be associated with lower mortality than traditional lower-dose protocols. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that midazolam at higher infusion rates is associated with a reduction in seizure recurrence within 48 hours after discontinuation and may be associated with lower mortality.
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Affiliation(s)
- Andres Fernandez
- From the Department of Neurology (A.F., H.L., B.S., B.F., J.M.S., L.J.H., S.A.M., J.C.), Columbia University Medical Center; and Department of Pharmacy (C.L.), New York-Presbyterian Hospital, NY
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Abstract
Seizures are a commonly encountered condition within the emergency department and, because of this, can engender complacency on the part of the physicians and staff. Unfortunately, there is significant associated morbidity and mortality with seizures, and they should never be regarded as routine. This point is particularly important with respect to seizures in pediatric patients. The aim of this review is to provide a current view of the various issues that make pediatric seizures unique and to help elucidate emergent evaluation and management strategies.
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MESH Headings
- Anticonvulsants/therapeutic use
- Child
- Child, Preschool
- Diagnosis, Differential
- Humans
- Infant
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/etiology
- Infant, Newborn, Diseases/therapy
- Seizures/diagnosis
- Seizures/etiology
- Seizures/therapy
- Seizures, Febrile/diagnosis
- Seizures, Febrile/therapy
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Affiliation(s)
- Maneesha Agarwal
- Department of Emergency Medicine, Carolinas Medical Center, 3rd Floor Medical Education Building, 1000 Blythe Boulevard, Charlotte, NC 28203, USA
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25
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Abstract
PURPOSE OF REVIEW This review presents the state of the art in the diagnosis and management of status epilepticus. RECENT FINDINGS In addition to general background, this article presents the most recent findings regarding the diagnosis and treatment of status epilepticus, including the results of the Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART) and the available data on the use of newer antiepileptic and anesthetic drugs in the treatment of refractory status epilepticus. It also presents available guidelines such as those from the Neurocritical Care Society. SUMMARY Despite recent advances, the management of status epilepticus remains a challenge. Rapid treatment, a written treatment protocol, early consideration of nonconvulsive seizures, and avoiding overtreatment and medical complications are the keys to successful management. This article summarizes the current evidence and guidelines.
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Affiliation(s)
- Lawrence J Hirsch
- Yale University School of Medicine, 15 York St, LLCI-714, New Haven, CT 06510, USA.
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Ferguson M, Bianchi MT, Sutter R, Rosenthal ES, Cash SS, Kaplan PW, Westover MB. Calculating the risk benefit equation for aggressive treatment of non-convulsive status epilepticus. Neurocrit Care 2013; 18:216-27. [PMID: 23065689 PMCID: PMC3767472 DOI: 10.1007/s12028-012-9785-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To address the question: does non-convulsive status epilepticus warrant the same aggressive treatment as convulsive status epilepticus? METHODS We used a decision model to evaluate the risks and benefits of treating non-convulsive status epilepticus with intravenous anesthetics and ICU-level aggressive care. We investigated how the decision to use aggressive versus non-aggressive management for non-convulsive status epilepticus impacts expected patient outcome for four etiologies: absence epilepsy, discontinued antiepileptic drugs, intraparenchymal hemorrhage, and hypoxic ischemic encephalopathy. Each etiology was defined by distinct values for five key parameters: baseline mortality rate of the inciting etiology; efficacy of non-aggressive treatment in gaining control of seizures; the relative contribution of seizures to overall mortality; the degree of excess disability expected in the case of delayed seizure control; and the mortality risk of aggressive treatment. RESULTS Non-aggressive treatment was favored for etiologies with low morbidity and mortality such as absence epilepsy and discontinued antiepileptic drugs. The risk of aggressive treatment was only warranted in etiologies where there was significant risk of seizure-induced neurologic damage. In the case of post-anoxic status epilepticus, expected outcomes were poor regardless of the treatment chosen. The favored strategy in each case was determined by strong interactions of all five model parameters. CONCLUSIONS Determination of the optimal management approach to non-convulsive status epilepticus is complex and is ultimately determined by the inciting etiology.
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Affiliation(s)
- Matthew Ferguson
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA
| | - Matt T. Bianchi
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA
| | - Raoul Sutter
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurology, Johns Hopkins Bayview Medical, Center, Baltimore, MD, USA
| | - Eric S. Rosenthal
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA
| | - Sydney S. Cash
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA
| | - Peter W. Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical, Center, Baltimore, MD, USA
| | - M. Brandon Westover
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA; Wang 7 Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Li G, Ren F, Yao J, Wang M, Feng X, Liu D. Human serum amyloid A (SAA) protein changes in acute epilepsy patients. Int J Neurosci 2013; 123:265-8. [DOI: 10.3109/00207454.2012.756876] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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28
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Hirsch LJ. Intramuscular versus intravenous benzodiazepines for prehospital treatment of status epilepticus. N Engl J Med 2012; 366:659-60. [PMID: 22335744 DOI: 10.1056/nejme1114206] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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