Generalised convulsive status epilepticus in Singapore: clinical outcomes and potential prognostic markers

Evaluation of prognostic scores for status epilepticus in the neurology ICU: A retrospective study

OBJECTIVE

Status epilepticus (SE) in the neurology intensive care unit (ICU) is associated with significant morbidity. We aimed to evaluate the utility of existing prognostic scores, namely the Status Epilepticus Severity Score (STESS), Epidemiology Based Mortality Score in Status Epilepticus (EMSE)-EACE and Encephalitis-Nonconvulsive Status Epilepticus-Diazepam Resistance-Image Abnormalities-Tracheal Intubation (END-IT), among SE patients in the neurology ICU.

METHODS

Neurology ICU patients with SE requiring continuous electroencephalography (cEEG) monitoring over a 10 year period were included. The STESS, EMSE-EACE and END-IT scores were applied retrospectively. Receiver operating characteristic (ROC) analysis was performed to assess the discriminatory value of the scores for inpatient mortality and functional decline, as measured by increase in the modified Rankin Scale (mRS) on discharge.

RESULTS

Eighty-five patients were included in the study, of which 71 (83.5%) had refractory SE. Inpatient mortality was 36.5%. Sixty - seven (78.8%) of patients suffered functional decline, with a median mRS of 5 upon hospital discharge. The AUCs of the STESS, EMSE-EACE and END-IT scores associated with inpatient mortality were 0.723 (95% CI 0.613-0.833), 0.722 (95% CI 0.609-0.834) and 0.560 (95% CI 0.436-0.684) respectively. The AUCs of the STESS, EMSE-EACE and END-IT scores associated with functional decline were 0.604 (95% CI 0.468-0.741), 0.596 (95% CI 0.439-0.754) and 0.477 (95% CI 0.331-0.623).

SIGNIFICANCE

SE was associated with high mortality and morbidity in this cohort of neurology ICU patients requiring cEEG monitoring. The STESS and EMSE-EACE scores had acceptable AUCs for prediction of inpatient mortality. However, the STESS, EMSE-EACE and END-IT were poorly-correlated with discharge functional outcomes. Further refinements of the scores may be necessary among neurology ICU patients for predicting discharge functional outcomes.

Long-term follow-up of phenobarbital versus valproate for generalized convulsive status epilepticus in adults: A randomized clinical trial

OBJECTIVE

Intravenous phenobarbital is frequently offered to patients with generalized convulsive status epilepticus (GCSE) in China, but its long-term benefits are unclear. We aimed to evaluate the long-term effects of intravenous phenobarbital on adult patients with GCSE.

METHODS

This randomized clinical trial with a 12-month follow-up was performed in Xuanwu Hospital, Capital Medical University (Beijing, China) between February 2011 and December 2021. After the failure of intravenous diazepam treatment, adult patients with GCSE were randomized to receive either intravenous phenobarbital or valproate. Neurological outcome within 12-month was dichotomized as good (modified Rankin scale, mRS 0-2) or poor (mRS 3-6). Cognitive function was measured by mini-mental state examination (MMSE) and Montreal cognitive assessment (MoCA). Hamilton anxiety scale (HAMA) and Hamilton depression scale (HAMD) were tested for mood disorders.

RESULTS

We consecutively recruited 166 patients with GCSE. After excluding individuals with termination after intravenous diazepam (n = 61), and with other exclusion criteria (n = 7), 98 patients were included and 88.0% (66/75) of survivors achieved seizure freedom at 12-month. Forty-five patients (45.92%) had good outcomes at 3-month and 57 patients (58.16%) had good outcomes at 12-month. And 46.67% (35/75) of survivors showed mRS improvement at 12-month (phenobarbital group, n = 17 vs. valproate group, n = 18, P = 0.321). Despite there was no significant difference with respect to good outcomes at 3-month (54.0% vs. 37.5%, P = 0.101), the rate of good outcomes in phenobarbital group was higher than valproate group at 12-month (68.0% vs. 47.92%, P = 0.044). A total of 43 patients successfully participated cognitive and emotional tests. Mild cognitive impairment was found in 7.14% of phenobarbital group and 50.0% in valproate group (P = 0.026). In addition, there were no significant differences with respect to anxiety (36.36% vs. 38.10%) and depression (31.82% vs. 47.62%) between the phenobarbital and valproate groups.

CONCLUSIONS

Combined with long term conventional therapy, intravenous phenobarbital group had more good outcomes than intravenous valproate group in Chinese adult patients with GCSE up to 12-month follow-up. This finding may prompt the option of intravenous phenobarbital especially in patients with limited access to new antiseizure drugs.

Acute encephalopathy in children with tuberous sclerosis complex

Objective

We examined the clinical manifestations of acute encephalopathy (AE) and identify risk factors for AE in children with tuberous sclerosis complex (TSC).

Methods

The clinical data of 11 children with clinically diagnosed TSC associated with AE and 109 children with clinically diagnosed TSC alone aged 4 years or older were collected from 13 hospitals.

Results

Of the 11 children with AE, 5 had histories of febrile seizures (FS), and all had histories of febrile status epilepticus (FSE). AE developed within 24 h after fever onset in all children with seizures lasting 30 min or longer. All children developed coma after seizure cessation. Head magnetic resonance imaging (MRI) revealed widespread abnormalities in the cerebral cortex, subcortical white matter, corpus callosum, basal ganglia, and thalamus. One child died; seven had severe neurological sequelae; and the other three, mild sequelae. Logistic regression analysis revealed that a history of FSE was correlated with the development of AE.

Significance

AE in children with TSC was characterized by sudden onset after fever, followed by coma, widespread brain edema evident on MRI, and poor outcomes. A history of FSE was a risk factor for the development of AE.

Modulation of Glucose Availability and Effects of Hypo- and Hyperglycemia on Status Epilepticus: What We Do Not Know Yet?

Status epilepticus (SE) can lead to serious neuronal damage and act as an initial trigger for epileptogenic processes that may lead to temporal lobe epilepsy (TLE). Besides promoting neurodegeneration, neuroinflammation, and abnormal neurogenesis, SE can generate an extensive hypometabolism in several brain areas and, consequently, reduce intracellular energy supply, such as adenosine triphosphate (ATP) molecules. Although some antiepileptic drugs show efficiency to terminate or reduce epileptic seizures, approximately 30% of TLE patients are refractory to regular antiepileptic drugs (AEDs). Modulation of glucose availability may provide a novel and robust alternative for treating seizures and neuronal damage that occurs during epileptogenesis; however, more detailed information remains unknown, especially under hypo- and hyperglycemic conditions. Here, we review several pathways of glucose metabolism activated during and after SE, as well as the effects of hypo- and hyperglycemia in the generation of self-sustained limbic seizures. Furthermore, this study suggests the control of glucose availability as a potential therapeutic tool for SE.

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

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

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

Importance

Status epilepticus (SE) is associated with significant morbidity and mortality. Since the late 1990s, a more aggressive management of prolonged convulsive seizures lasting longer than 5 minutes has been advocated.

Objective

To determine if convulsive SE mortality has decreased during a time of increasing advocacy for out-of-hospital treatment and escalating and earlier treatment protocols for prolonged seizures and SE.

Data Source

This systemic review and meta-analysis on studies focused on the mortality of convulsive status epilepticus was conducted by searching MEDLINE, Embase, PsychINFO, CINAHL Plus, and the Cochrane Database of Systematic Reviews between January 1, 1990, and June 30, 2017.

Study Selection

Studies were excluded if they had fewer than 30 participants (<20 for refractory SE), were limited to SE of single specific etiology or an evaluation of a single treatment modality, or were studies of nonconvulsive SE.

Data Extraction and Synthesis

Data were abstracted and their quality was assessed via a modified Newcastle-Ottawa scale independently by 2 reviewers (A.N. and T.D.G.) using the Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines. Data were pooled using a random-effects model.

Main Outcomes and Measures

The main outcome measure was in-hospital mortality or 30-day case fatality expressed as proportional mortality.

Results

Sixty-one studies were included in the analysis. The pooled mortality ratios were 15.9% (95% CI, 12.7-19.2) for adult studies, 13.0% (95% CI, 7.2-19.0) for all-age population studies, 3.6% (95% CI, 2.0%-5.2%) for pediatric studies, and 17.3% (95% CI, 9.8-24.7) for refractory SE studies, with very high between-study heterogeneity. We found no evidence of a change in prognosis over time nor by the definition of SE used.

Conclusions and Relevance

The mortality of convulsive SE is higher in adults than in children and there was no evidence for improved survival over time. Although there are many explanations for these findings, they can be explained by aetiology of SE being the major determinant of mortality. However, there are potential confounders, including differences in case ascertainment and study heterogeneity. This meta-analysis highlights the need for strict international guidelines for the study of this condition.

Nutritional and Bioenergetic Considerations in Critically Ill Patients with Acute Neurological Injury

The brain, due to intensive cellular processes and maintenance of electrochemical gradients, is heavily dependent on a constant supply of energy. Brain injury, and critical illness in general, induces a state of increased metabolism and catabolism, which has been proven to lead to poor outcomes. Of all the biochemical interventions undertaken in the ICU, providing nutritional support is perhaps one of the most undervalued, but potentially among the safest, and most effective interventions. Adequate provisions of calories and protein have been shown to improve patient outcomes, and guidelines for the nutritional support of the critically ill patient are reviewed. However, there are no such specific guidelines for the critically ill patient with neurological injury. Patients with primary or secondary neurological disorders are frequently undernourished, while data suggest this population would benefit from early and adequate nutritional support, although comprehensive clinical evidence is lacking. We review the joint recommendations from the Society for Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition, as they pertain to neurocritical care, and assess the recommendations for addressing nutrition in this patient population.

Acute Systemic Complications of Convulsive Status Epilepticus-A Systematic Review

OBJECTIVES

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

DATA SOURCES

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

STUDY SELECTION

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

DATA EXTRACTION

Key data were extracted using standardized data collection forms.

DATA SYNTHESIS

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

CONCLUSIONS

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

Prediction of acute encephalopathy with biphasic seizures and late reduced diffusion in patients with febrile status epilepticus

INTRODUCTION

Acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) is the most common subtype of acute encephalopathy among children in Japan. The pathogenesis of AESD is mostly delayed cerebral edema caused by excitotoxic injury. It is difficult to discriminate AESD and complex febrile seizure in the early phase. Many cases have neurologic sequelae because early intervention is difficult.

METHODS

To establish an early diagnostic method, we assessed 213 hospitalized cases of febrile status epilepticus (FSE) between January 2004 and August 2014. We categorized FSE cases into an AESD group and a non-AESD group and compared their clinical courses, laboratory data and cranial computed tomography (CT) findings.

RESULTS

Of 213 hospitalized FSE cases, 19 (9%) were AESD. Univariate analysis showed that the AESD group took a significantly longer time to wake after FSE, had a higher degree of respiratory acidemia, and higher levels of serum AST, ALT, LD, hyperglycemia and hyperammonemia than the non-AESD group. We developed a scoring model that predicts AESD based on multivariate analysis. Using cut-off points of 4 and more with this scoring model, we could identify the AESD cases with 93% sensitivity and 91% specificity. These scores also had a positive correlation with prognosis.

DISCUSSION

Our scoring model enables early diagnosis of AESD. Patients with high scores should be observed carefully and early intervention should be considered.

Hyperglycemia associated with seizure control in status epilepticus

BACKGROUND

Status epilepticus (SE) is a serious neurological condition and has a high mortality rate. Factors associated with seizure control measures in nonneurointensive care units (non-NICU) are limited.

METHODS

Adult patients diagnosed with SE at Khon Kaen hospital, Thailand from October 1st, 2010 to September 30th, 2012 were enrolled. Patients were categorized as having controlled seizures and having uncontrolled seizures. Controlled seizures were defined as seizures that were aborted without any recurrence, while uncontrolled seizures were defined as unstoppable or recurrent seizures. Clinical factors were analyzed to find factors associated with uncontrolled SE.

RESULTS

During the study period, there were 211 patients diagnosed with SE. Of those, 57 patients (27.01%) were in the group with controlled SE. Plasma glucose and serum albumin were two significant factors with adjusted ORs (95% CI) of 1.008 (1.001, 1.027) and 0.166 (0.059, 0.466) that differentiated patients with controlled seizures from patients with uncontrolled seizures. Central nervous system infections and cardiac arrests were also completely associated with the uncontrolled SE in the multivariate logistic analysis.

CONCLUSIONS

In the etiology of SE, high plasma glucose and low serum albumin levels were associated with uncontrolled seizures in patients with SE in the non-NICU setting. This article is part of a Special Issue entitled "Status Epilepticus".

Early predictors of status epilepticus-associated mortality and morbidity in children

BACKGROUND

Early predictors of status epilepticus (SE)-associated mortality and morbidity have not been systematically studied in children, considerably impeding the identification of patients at risk.

OBJECTIVES

To determine reliable early predictors of SE-associated mortality and morbidity and identify the etiology of SE-associated sequelae in Japanese children.

METHODS

We conducted a prospective multicenter study of clinical findings and initial laboratory data acquired at SE onset, and assessed outcomes at the last follow-up examination. In-hospital death during the acute period and neurological sequelae were classified as poor outcomes.

RESULTS

Of the 201 children who experienced their first SE episode, 16 exhibited poor outcome that was most commonly associated with acute encephalopathy. Univariate analysis revealed that the following were associated with poor outcomes: young age (⩽24 months); seizure duration >90 min; seizure intractability (failure of the second anticonvulsive drug); biphasic seizures; abnormal blood glucose levels (<61 or >250 mg/dL); serum aspartate aminotransferase (AST) ⩾56 U/L; and C-reactive protein (CRP) levels >2.00 mg/dL. Multivariate analysis revealed that young age, seizure intractability, abnormal blood glucose levels, and elevated AST and CRP levels were statistically significant.

CONCLUSIONS

Young age and seizure intractability were highly predictive of poor outcomes in pediatric SE. Moreover, abnormal blood glucose levels and elevated AST and CRP levels were predictors that might be closely associated with the etiology, especially acute encephalopathy and severe bacterial infection (sepsis and meningitis) in Japanese children.

Factors associated with poor discharge status in patients with status epilepticus at Khon Kaen Hospital

BACKGROUND

Status epilepticus (SE) is a serious neurological condition and has high a mortality rate. Data on importance of factors associated with poor outcomes in Asian or Thai populations are limited.

METHODS

Adult patients diagnosed as SE at Khon Kaen Hospital, Thailand from October 1, 2010 to September 30, 2012 were enrolled. Patients were categorized as good or poor outcomes at discharge. Good outcomes were defined by improvement at discharge and absence of neurological deficits, while poor outcomes were defined by: not being improved at discharge; being discharged against advice; death; or presence of a neurological deficit. Clinical factors were compared between both groups.

RESULTS

During the study period, there were 211 patients diagnosed as SE. Of those, 130 patients were male (61.61%). The mean age of all patients was 53.28 years. Acute stroke was the most common cause of SE in 33 patients (15.64%). At discharge, there were 91 patients (43.13%) who had poor outcomes. Only initial plasma glucose levels were significantly associated with poor outcomes with an adjusted odds ratio of 1.012 (95% confidence interval of 1.003 and 1.021).

CONCLUSION

Initial plasma glucose is associated with poor discharge status in patients with SE.

Risk factors for complications of drug-induced seizures

The purpose of this study is to determine clinical factors associated with complications of drug-induced seizures. This prospective observational study was conducted at an American Association of Poison Control Centers-certified regional poison control center (PCC) over a 1-year period. All consecutive cases reported to a PCC involving seizures were forwarded to investigators, who obtained standardized information including the specific drug or medication exposure, dose, reason for exposure, vital signs, laboratory data, treatment, and outcome. Patients were monitored by daily telephone follow-up until death or discharge. Subjects were excluded if the seizure was deemed to be unrelated to exposure. Odds ratios were used to analyze variables for associations with admission to the hospital for >72 h, endotracheal intubation, status epilepticus, anoxic brain injury, or death. One hundred twenty-one cases met inclusion criteria. Sixty-three (52%) were male, and the mean age was 30 (SD14) years. Common exposures included: antidepressants (33%), stimulants (15%), and anticholinergics (10%). One hundred and three (85%) of the exposures were intentional, of which 74 were suicide attempts and 16 were drug abuse or misuse. Forty-nine (40%) patients required endotracheal intubation, 12(10%) had status epilepticus, 50(41%) were hospitalized for more than 72 h, and one patient died. Median hospital stay was 3 days. Variables significantly associated with complications included stimulant exposure (odds ratios, OR = 11 [95% confidence intervals (CI) 1.9–52]), suicide attempt (OR = 2.2 [95% CI 1.02–4.7]), initial hypotension (OR = 11.2 [95% CI 1.4–89.3]), admission glucose >130 mg/dL (OR = 5.4 [95% CI 1.6–18.1]), and admission HCO₃ < 20 mEq/L (OR = 4.0 [95% CI 1.4–11.3]). Significant clinical factors associated with complications of drug-related seizures include stimulant exposure, suicide attempt, initial hypotension, and admission acidosis or hyperglycemia.

Outcome and prognosis of status epilepticus in children

The ultimate goal of treating status epilepticus is to provide the best opportunity for a good outcome. This review discusses the current literature on the outcome after status epilepticus in children, including the risk of recurrence, morbidity, and mortality. The outcome seems most dependent on etiology, with age and duration of status epilepticus also contributing. Convulsive status epilepticus has considerably more supporting literature, whereas the data on nonconvulsive status epilepticus are hindered by the lack of a standard definition and presumed under recognition. Future studies will need to address some of these methodological issues to provide the best information when discussing outcome with the family members of children with status epilepticus.