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Lee W, Kim EY, Kim D, Kim JM. Relationship between continuous EEG monitoring findings and prognostic factors in patients with status epilepticus. Epilepsy Behav 2024; 158:109921. [PMID: 38991422 DOI: 10.1016/j.yebeh.2024.109921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 06/20/2024] [Accepted: 06/24/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND AND PURPOSE Little information is available regarding the use of continuous electroencephalography (cEEG) monitoring findings to predict the prognosis of patients with status epilepticus, which could aid in prognostication. This study investigated the relationship between cEEG monitoring findings and various prognostic indicators in patients with status epilepticus. METHODS We reviewed the clinical profiles and cEEG monitoring data of 28 patients with status epilepticus over a ten-year period. Patient demographics, etiology, EEG features, duration of hospital stay, number of antiseizure medications, and outcome measures were analyzed. Functional outcomes were assessed using the modified Rankin Scale (mRS), which evaluates the degree of daily living impairment and dependence on others resulting from neurological injury. RESULTS Patients exhibiting electrographic status epilepticus (ESE) demonstrated significantly longer duration of status epilepticus (77.75 ± 58.25 vs. 39.86 ± 29.81 h, p = 0.024) and total length of hospital stay (13.00 ± 6.14 vs. 8.14 ± 5.66 days, p = 0.038) when compared to those with ictal-interictal continuum (IIC). Individuals who displayed any increase in modified Rankin Scale (mRS) score between their premorbid state and discharge also had significantly longer duration of status epilepticus (74.09 ± 34.94 vs. 51.56 ± 54.25 h, p = 0.041) and total length of hospital stay (15.89 ± 6.05 vs. 8.05 ± 4.80 days, p = 0.004) when compared to those who showed no difference. The most prevalent etiology of status epilepticus in our study was chronic structural brain lesions. CONCLUSIONS This suggests that ESE may serve as a predictor of prolonged duration of status epilepticus and increased hospitalization among patients with status epilepticus.
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Affiliation(s)
- Wankiun Lee
- Department of Neurology, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea.
| | - Eun Young Kim
- Department of Neurology, Chungnam National University Sejong Hospital, 20 Bodeum7-ro, Sejong 30099, Korea
| | - Daeyoung Kim
- Department of Neurology, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea
| | - Jae-Moon Kim
- Department of Neurology, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon 35015, Korea.
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Jacobwitz M, Mulvihill C, Kaufman MC, Gonzalez AK, Resendiz K, Francoeur C, Helbig I, Topjian AA, Abend NS. A Comparison of Ketamine and Midazolam as First-Line Anesthetic Infusions for Pediatric Status Epilepticus. Neurocrit Care 2024; 40:984-995. [PMID: 37783824 DOI: 10.1007/s12028-023-01859-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/08/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Pediatric refractory status epilepticus (RSE) often requires management with anesthetic infusions, but few data compare first-line anesthetics. This study aimed to compare the efficacy and adverse effects of midazolam and ketamine infusions as first-line anesthetics for pediatric RSE. METHODS Retrospective single-center study of consecutive study participants treated with ketamine or midazolam as the first-line anesthetic infusions for RSE at a quaternary care children's hospital from December 1, 2017, until September 15, 2021. RESULTS We identified 117 study participants (28 neonates), including 79 (68%) who received midazolam and 38 (32%) who received ketamine as the first-line anesthetic infusions. Seizures terminated more often in study participants administered ketamine (61%, 23/38) than midazolam (28%, 22/79; odds ratio [OR] 3.97, 95% confidence interval [CI] 1.76-8.98; P < 0.01). Adverse effects occurred more often in study participants administered midazolam (24%, 20/79) than ketamine (3%, 1/38; OR 12.54, 95% CI 1.61-97.43; P = 0.016). Study participants administered ketamine were younger, ketamine was used more often for children with acute symptomatic seizures, and midazolam was used more often for children with epilepsy. Multivariable logistic regression of seizure termination by first-line anesthetic infusion (ketamine or midazolam) including age at SE onset, SE etiology category, and individual seizure duration at anesthetic infusion initiation indicated seizures were more likely to terminate following ketamine than midazolam (OR 4.00, 95% CI 1.69-9.49; P = 0.002) and adverse effects were more likely following midazolam than ketamine (OR 13.41, 95% CI 1.61-111.04; P = 0.016). Survival to discharge was higher among study participants who received midazolam (82%, 65/79) than ketamine (55%, 21/38; P = 0.002), although treating clinicians did not attribute any deaths to ketamine or midazolam. CONCLUSIONS Among children and neonates with RSE, ketamine was more often followed by seizure termination and less often associated with adverse effects than midazolam when administered as the first-line anesthetic infusion. Further prospective data are needed to compare first-line anesthetics for RSE.
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Affiliation(s)
- Marin Jacobwitz
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Caitlyn Mulvihill
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Michael C Kaufman
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
- The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexander K Gonzalez
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
- The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Karla Resendiz
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Conall Francoeur
- Division of Critical Care, Québec, QC, Canada
- Department of Pediatrics, Centre Hospitalier Universitaire de Québec-University of Laval Research Center, Québec, QC, Canada
| | - Ingo Helbig
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
- The Epilepsy NeuroGenetics Initiative, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Alexis A Topjian
- Department of Anesthesia and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nicholas S Abend
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, 34th and Civic Center Blvd, Philadelphia, PA, 19104, USA
- Departments of Neurology and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Anesthesia and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Charalambous M, Muñana K, Patterson EE, Platt SR, Volk HA. ACVIM Consensus Statement on the management of status epilepticus and cluster seizures in dogs and cats. J Vet Intern Med 2024; 38:19-40. [PMID: 37921621 PMCID: PMC10800221 DOI: 10.1111/jvim.16928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/19/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Seizure emergencies (ie, status epilepticus [SE] and cluster seizures [CS]), are common challenging disorders with complex pathophysiology, rapidly progressive drug-resistant and self-sustaining character, and high morbidity and mortality. Current treatment approaches are characterized by considerable variations, but official guidelines are lacking. OBJECTIVES To establish evidence-based guidelines and an agreement among board-certified specialists for the appropriate management of SE and CS in dogs and cats. ANIMALS None. MATERIALS AND METHODS A panel of 5 specialists was formed to assess and summarize evidence in the peer-reviewed literature with the aim to establish consensus clinical recommendations. Evidence from veterinary pharmacokinetic studies, basic research, and human medicine also was used to support the panel's recommendations, especially for the interventions where veterinary clinical evidence was lacking. RESULTS The majority of the evidence was on the first-line management (ie, benzodiazepines and their various administration routes) in both species. Overall, there was less evidence available on the management of emergency seizure disorders in cats in contrast to dogs. Most recommendations made by the panel were supported by a combination of a moderate level of veterinary clinical evidence and pharmacokinetic data as well as studies in humans and basic research studies. CONCLUSIONS AND CLINICAL RELEVANCE Successful management of seizure emergencies should include an early, rapid, and stage-based treatment approach consisting of interventions with moderate to preferably high ACVIM recommendations; management of complications and underlying causes related to seizure emergencies should accompany antiseizure medications.
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Affiliation(s)
| | - Karen Muñana
- North Carolina State UniversityRaleighNorth CarolinaUSA
| | | | | | - Holger A. Volk
- University of Veterinary Medicine HannoverHannoverGermany
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Sharshar T, Porcher R, Asfar P, Grimaldi L, Jabot J, Argaud L, Lebert C, Bollaert PE, Harlay ML, Chillet P, Maury E, Santoli F, Blanc P, Sonneville R, Vu DC, Rohaut B, Mazeraud A, Alvarez JC, Navarro V, Clair B, Outin H, Azabou E, Beloncle F, Ben-Hadj O, Blanc P, Bollaert PE, Bolgert F, Bouadma L, Chillet P, Clair B, Corne P, Clere-Jehl R, Cour M, Crespel A, Déiler V, Dellamonica J, Demeret S, Harley ML, Henry-Lagarrigue M, Jabot J, Heming N, Hernu R, Kouatchet A, Lebert C, Lerolle N, Maury E, Letrou S, Mazeraud A, Mercat A, Mortaza S, Mourvillier B, Outin H, Paugham-Burtz C, Pierrot M, Provent M, Rohaut B, De La Salle S, Santoli F, Schenk M, Siami S, Souday V, Sharshar T, Sonneville R, Timsit JF, Thuong M, Weiss N. Valproic acid as adjuvant treatment for convulsive status epilepticus: a randomised clinical trial. Crit Care 2023; 27:8. [PMID: 36624526 PMCID: PMC9830759 DOI: 10.1186/s13054-022-04292-7] [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: 09/15/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Generalised convulsive status epilepticus (GCSE) is a medical emergency. Guidelines recommend a stepwise strategy of benzodiazepines followed by a second-line anti-seizure medicine (ASM). However, GCSE is uncontrolled in 20-40% patients and is associated with protracted hospitalisation, disability, and mortality. The objective was to determine whether valproic acid (VPA) as complementary treatment to the stepwise strategy improves the outcomes of patients with de novo established GCSE. METHODS This was a multicentre, double-blind, randomised controlled trial in 244 adults admitted to intensive care units for GCSE in 16 French hospitals between 2013 and 2018. Patients received standard care of benzodiazepine and a second-line ASM (except VPA). Intervention patients received a 30 mg/kg VPA loading dose, then a 1 mg/kg/h 12 h infusion, whilst the placebo group received an identical intravenous administration of 0.9% saline as a bolus and continuous infusion. Primary outcome was proportion of patients discharged from hospital by day 15. The secondary outcomes were seizure control, adverse events, and cognition at day 90. RESULTS A total of 126 (52%) and 118 (48%) patients were included in the VPA and placebo groups. 224 (93%) and 227 (93%) received a first-line and a second-line ASM before VPA or placebo infusion. There was no between-group difference for patients hospital-discharged at day 15 [VPA, 77 (61%) versus placebo, 72 (61%), adjusted relative risk 1.04; 95% confidence interval (0.89-1.19); p = 0.58]. There were no between-group differences for secondary outcomes. CONCLUSIONS VPA added to the recommended strategy for adult GCSE is well tolerated but did not increase the proportion of patients hospital-discharged by day 15. TRIAL REGISTRATION NO NCT01791868 (ClinicalTrials.gov registry), registered: 15 February 2012.
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Affiliation(s)
- Tarek Sharshar
- grid.508487.60000 0004 7885 7602Neuro-Intensive Care Medicine, Anaesthesiology and ICU Department, GHU-Psychiatry and Neurosciences, Pole Neuro, Sainte-Anne Hospital, Institute of Psychiatry and Neurosciences of Paris, INSERM U1266, Université Paris Cité, Paris, France
| | - Raphaël Porcher
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004 Paris, France ,grid.411394.a0000 0001 2191 1995Centre d’Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004 Paris, France
| | - Pierre Asfar
- grid.411147.60000 0004 0472 0283Department of Medical Intensive Care, University Hospital, Angers, France
| | - Lamiae Grimaldi
- grid.50550.350000 0001 2175 4109Clinical Research Unit, Assistance Publique - Hôpitaux de Paris University Paris-Saclay. Faculty of medicine, University of Versailles Saint-Quentin en Yvelines. Inserm U1018 Team Anti-infective evasion and pharmacoepidemiology, Boulogne-Billancourt, France
| | - Julien Jabot
- Medical-Surgical Intensive Care Unit, CHU Felix-Guyon, Saint-Denis, La Réunion, France
| | - Laurent Argaud
- grid.412180.e0000 0001 2198 4166Service de Médecine Intensive-Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Christine Lebert
- grid.477015.00000 0004 1772 6836Médecine Intensive Réanimation, Centre Hospitalier Départemental de Vendée, La Roche-sur-Yon, France
| | - Pierre-Edouard Bollaert
- grid.29172.3f0000 0001 2194 6418CHRU-Nancy, Service de Médecine Intensive Réanimation, Université de Lorraine, 54000 Nancy, France
| | - Marie Line Harlay
- grid.412201.40000 0004 0593 6932Médecine Intensive Réanimation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Patrick Chillet
- Service de Médecine Intensive - Réanimation, Centre hospitalier Léon Bourgeois, Châlons en Champagne, France
| | - Eric Maury
- grid.462844.80000 0001 2308 1657Service de Médecine Intensive et Réanimation Hôpital Saint-Antoine, Paris-Sorbonne Université, Paris, France
| | - Francois Santoli
- grid.414308.a0000 0004 0594 0368Médecine Intensive—Réanimation, Centre Hospitalier Robert Ballanger, Aulnay sous Bois, France
| | - Pascal Blanc
- grid.440383.80000 0004 1765 1969Réanimation Médico Chirurgicale, Centre Hospitalier René Dubos, Pontoise, France
| | - Romain Sonneville
- Université de Paris Cité, INSERM UMR1137, Paris, France ,grid.411119.d0000 0000 8588 831XAPHP Nord, Médecine Intensive – Réanimation, Hôpital Bichat—Claude Bernard, Paris, France
| | - Dinh Chuyen Vu
- General Intensive Care Unit, Sud-Essonne Hospital, Etampes, France
| | - Benjamin Rohaut
- grid.462844.80000 0001 2308 1657Department of Neurology, Neuro-ICU & Brain institute - ICM, Pitié-Salpêtrière Hospital APHP, Sorbonne Université, Paris, France
| | - Aurelien Mazeraud
- grid.508487.60000 0004 7885 7602Anaesthesiology and ICU Department, GHU-Psychiatry and Neurosciences, Pole Neuro, Sainte-Anne Hospital, Perception and Memory Unit, Neurosciences Department, Institut Pasteur, Université Paris Cité, Paris, France
| | - Jean-Claude Alvarez
- grid.12832.3a0000 0001 2323 0229Department of Pharmacology and Toxicology, Inserm U-1173, Raymond Poincare Hospital, AP-HP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, 104 Boulevard Raymond Poincare, 92380 Garches, France
| | - Vincent Navarro
- grid.425274.20000 0004 0620 5939AP-HP, Epilepsy Unit, Pitié-Salpêtrière Hospital, Sorbonne Université, and Paris Brain Institute, Paris, France
| | - Bernard Clair
- grid.12832.3a0000 0001 2323 0229General Intensive Care Unit, APHP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Hervé Outin
- grid.418056.e0000 0004 1765 2558Intensive Care Unit Centre Hospitalier Intercommunal, Poissy/Saint-Germain-en-Laye, France
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Evaluation and Treatment of Adult Status Epilepticus in the Emergency Department. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022. [DOI: 10.1007/s40138-022-00250-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Factors associated with mortality in patients with super-refractory status epilepticus. Sci Rep 2022; 12:9670. [PMID: 35690663 PMCID: PMC9188563 DOI: 10.1038/s41598-022-13726-9] [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: 02/16/2022] [Accepted: 05/26/2022] [Indexed: 11/08/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is a critical condition in which seizures persist despite anesthetic use for 24 h or longer. High mortality has been reported in patients with SRSE, but the cause of death remains unclear. We investigated the factors associated with mortality, including clinical characteristics, SE etiologies and severities, treatments, and responses in patients with SRSE in a 13-year tertiary hospital-based retrospective cohort study comparing these parameters between deceased and surviving patients. SRSE accounted for 14.2% of patients with status epilepticus, and 28.6% of SRSE patients died. Deceased patients were mostly young or middle-aged without known systemic diseases or epilepsy. All deceased patients experienced generalized convulsive status epilepticus and failure of anesthetic tapering-off, significantly higher than survivors. An increased number of second-line anesthetics besides midazolam was observed in the deceased (median, 3, interquartile range 2–3) compared to surviving (1, 1–1; p = 0.0006) patients with prolonged use durations (p = 0.047). For mortality, the cut-off number of second-line anesthetics was 1.5 (AUC = 0.906, p = 0.004). Deceased patients had significantly higher renal and cardiac complications and metabolic acidosis than survivors. In SRSE management, multi-anesthetic use should be carefully controlled to avoid systemic complications and mortality.
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Treatment of refractory status epilepticus with intravenous anesthetic agents: A systematic review. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.1016/j.tacc.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Cruickshank M, Imamura M, Booth C, Aucott L, Counsell C, Manson P, Scotland G, Brazzelli M. Pre-hospital and emergency department treatment of convulsive status epilepticus in adults: an evidence synthesis. Health Technol Assess 2022; 26:1-76. [PMID: 35333156 PMCID: PMC8977974 DOI: 10.3310/rsvk2062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Convulsive status epilepticus is defined as ≥ 5 minutes of either continuous seizure activity or repetitive seizures without regaining consciousness. It is regarded as an emergency condition that requires prompt treatment to avoid hospitalisation and to reduce morbidity and mortality. Rapid pre-hospital first-line treatment of convulsive status epilepticus is currently benzodiazepines, administered either by trained caregivers in the community (e.g. buccal midazolam, rectal diazepam) or by trained health professionals via intramuscular or intravenous routes (e.g. midazolam, lorazepam). There is a lack of clarity about the optimal treatment for convulsive status epilepticus in the pre-hospital setting. OBJECTIVES To assess the current evidence on the clinical effectiveness and cost-effectiveness of treatments for adults with convulsive status epilepticus in the pre-hospital setting. DATA SOURCES We searched major electronic databases, including MEDLINE, EMBASE, PsycInfo®, CINAHL, CENTRAL, NHS Economic Evaluation Database, Health Technology Assessment Database, Research Papers in Economics, and the ISPOR Scientific Presentations Database, with no restrictions on publication date or language of publication. Final searches were carried out on 21 July 2020. REVIEW METHODS Systematic review of randomised controlled trials assessing adults with convulsive status epilepticus who received treatment before or on arrival at the emergency department. Eligible treatments were any antiepileptic drugs offered as first-line treatments, regardless of their route of administration. Primary outcomes were seizure cessation, seizure recurrence and adverse events. Two reviewers independently screened all citations identified by the search strategy, retrieved full-text articles, extracted data and assessed the risk of bias of the included trials. Results were described narratively. RESULTS Four trials (1345 randomised participants, of whom 1234 were adults) assessed the intravenous or intramuscular use of benzodiazepines or other antiepileptic drugs for the pre-hospital treatment of convulsive status epilepticus in adults. Three trials at a low risk of bias showed that benzodiazepines were effective in stopping seizures. In particular, intramuscular midazolam was non-inferior to intravenous lorazepam. The addition of levetiracetam to clonazepam did not show clear advantages over clonazepam alone. One trial at a high risk of bias showed that phenobarbital plus optional phenytoin was more effective in terminating seizures than diazepam plus phenytoin. The median time to seizure cessation from drug administration varied from 1.6 minutes to 15 minutes. The proportion of people with recurrence of seizures ranged from 10.4% to 19.1% in two trials reporting this outcome. Across trials, the rates of respiratory depression among participants receiving active treatments were generally low (from 6.4% to 10.6%). The mortality rate ranged from 2% to 7.6% in active treatment groups and from 6.2% to 15.5% in control groups. Only one study based on retrospective observational data met the criteria for economic evaluation; therefore, it was not possible to draw any robust conclusions on cost-effectiveness. LIMITATIONS The limited number of identified trials and their differences in terms of treatment comparisons and outcomes hindered any meaningful pooling of data. None of the included trials was conducted in the UK and none assessed the use of buccal midazolam or rectal diazepam. The review of economic evaluations was hampered by lack of suitable data. CONCLUSIONS Both intravenous lorazepam and intravenous diazepam administered by paramedics are more effective than a placebo in the treatments of adults with convulsive status epilepticus, and intramuscular midazolam is non-inferior to intravenous lorazepam. Large well-designed clinical trials are needed to establish which benzodiazepines are more effective and preferable in the pre-hospital setting. STUDY REGISTRATION This study is registered as PROSPERO CRD42020201953. FUNDING This project was funded by the National Institute for Health Research (NIHR) Evidence Synthesis programme and will be published in full in Health Technology Assessment; Vol. 26, No. 20. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Mari Imamura
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Lorna Aucott
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Carl Counsell
- Institute of Applied Health Sciences, University of Aberdeen, UK
- NHS Grampian, Aberdeen, UK
| | - Paul Manson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graham Scotland
- Health Services Research Unit and Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Miriam Brazzelli
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Osuntokun OS, Abdulwahab UF, Akanji NO, Adedokun KI, Adekomi AD, Olayiwola G. Anticonvulsant and neuroprotective effects of carbamazepine-levetiracetam adjunctive treatment in convulsive status epilepticus rat model: Inhibition of cholinergic transmission. Neurosci Lett 2021; 762:136167. [PMID: 34389480 DOI: 10.1016/j.neulet.2021.136167] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/29/2021] [Accepted: 08/06/2021] [Indexed: 11/30/2022]
Abstract
This study evaluated the anticonvulsant and neuroprotective effects of carbamazepine (CBZ), levetiracetam (LEV), and CBZ + LEV adjunctive treatment in convulsive status epilepticus (CSE) rat model. Twenty-five male Wistar rats were randomized into five groups (n = 5). Groups I and II received 0.2 ml of normal saline intraperitoneally (i.p), while groups III-V received CBZ (25 mg/kg i.p), LEV (50 mg/kg i.p) or combination of sub-therapeutic doses of CBZ (12.5 mg/kg i.p) and LEV (25 mg/kg i.p). Thirty minutes later, seizure was kindled with pilocarpine hydrochloride (350 mg/kg) in group II-V rats. Seizure indices, markers of excitotoxicity, and astroglioses were determined, while the hippocampal morphometry was also evaluated. The data was analysed using descriptive and inferential statistics, while the results were presented as mean ± SEM in graphs or tables, and the level of significance was taken at p < 0.05. The anticonvulsant treatments delayed the inception of seizure indices (p = 0.0006), while the percentage mortality decreased significantly (p = 0.0001) in all the treatment groups. The hippocampal concentrations of acetylcholine, malondialdehyde, and tissue necrotic factor-alpha decreased significantly (p = 0.0077) in all the treated group relative to the positive control. The reactive astrogliosis in the hippocampus (CA 1) increased significantly (p = 0.0001) compared with the control but abrogated in all the treatment groups relative to the positive control. The anticonvulsant and neuroprotective effects are in this order: LEV < CBZ + CBZ < CBZ. The drug efficacy is attributable to the inhibition of cholinergic transmission.
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Affiliation(s)
- Opeyemi Samson Osuntokun
- Department of Physiology, Faculty of Basic Medical Sciences, Federal University Oye Ekiti, Ekiti State, Nigeria.
| | - Umar Faruq Abdulwahab
- Department of Physiology, Faculty of Basic Medical Sciences, Osun State University Osogbo, Nigeria
| | - Nafisat Omolola Akanji
- Department of Physiology, Faculty of Basic Medical Sciences, Osun State University Osogbo, Nigeria
| | - Kabiru Isola Adedokun
- Department of Physiology, Faculty of Basic Medical Sciences, Osun State University Osogbo, Nigeria
| | | | - Gbola Olayiwola
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy Obafemi, Awolowo University, Ile-Ife, Osun State, Nigeria
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Kirmani BF, Au K, Ayari L, John M, Shetty P, Delorenzo RJ. Super-Refractory Status Epilepticus: Prognosis and Recent Advances in Management. Aging Dis 2021; 12:1097-1119. [PMID: 34221552 PMCID: PMC8219503 DOI: 10.14336/ad.2021.0302] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/02/2021] [Indexed: 12/12/2022] Open
Abstract
Super-refractory status epilepticus (SRSE) is a life-threatening neurological emergency with high morbidity and mortality. It is defined as “status epilepticus (SE) that continues or recurs 24 hours or more after the onset of anesthesia, including those cases in which SE recurs on the reduction or withdrawal of anesthesia.” This condition is resistant to normal protocols used in the treatment of status epilepticus and exposes patients to increased risks of neuronal death, neuronal injury, and disruption of neuronal networks if not treated in a timely manner. It is mainly seen in patients with severe acute onset brain injury or presentation of new-onset refractory status epilepticus (NORSE). The mortality, neurological deficits, and functional impairments are significant depending on the duration of status epilepticus and the resultant brain damage. Research is underway to find the cure for this devastating neurological condition. In this review, we will discuss the wide range of therapies used in the management of SRSE, provide suggestions regarding its treatment, and comment on future directions. The therapies evaluated include traditional and alternative anesthetic agents with antiepileptic agents. The other emerging therapies include hypothermia, steroids, immunosuppressive agents, electrical and magnetic stimulation therapies, emergent respective epilepsy surgery, the ketogenic diet, pyridoxine infusion, cerebrospinal fluid drainage, and magnesium infusion. To date, there is a lack of robust published data regarding the safety and effectiveness of various therapies, and there continues to be a need for large randomized multicenter trials comparing newer therapies to treat this refractory condition.
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Affiliation(s)
- Batool F Kirmani
- 1Texas A&M University College of Medicine, College Station, TX, USA.,3Epilepsy and Functional Neurosurgery Program, Department of Neurology, CHI St. Joseph Health, Bryan, TX, USA
| | - Katherine Au
- 2George Washington University, School of Medicine & Health Sciences, Washington DC, USA
| | - Lena Ayari
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Marita John
- 1Texas A&M University College of Medicine, College Station, TX, USA
| | - Padmashri Shetty
- 4M. S. Ramaiah Medical College, M. S. Ramaiah Nagar, Bengaluru, Karnataka, India
| | - Robert J Delorenzo
- 5Department of Neurology, Virginia Commonwealth University School of Medicine, Richmond, VA
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Pires PC, Fazendeiro AC, Rodrigues M, Alves G, Santos AO. Nose-to-brain delivery of phenytoin and its hydrophilic prodrug fosphenytoin combined in a microemulsion - formulation development and in vivo pharmacokinetics. Eur J Pharm Sci 2021; 164:105918. [PMID: 34174414 DOI: 10.1016/j.ejps.2021.105918] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/25/2021] [Accepted: 06/20/2021] [Indexed: 11/16/2022]
Abstract
Phenytoin is a low aqueous solubility antiepileptic drug, but its phosphate ester prodrug fosphenytoin is soluble, although less permeable. In a previous study, the intranasal administration of aqueous-based formulations of fosphenytoin led to high but delayed phenytoin bioavailability compared to the intravenous route. In this work, we hypothesized that formulating an association of the prodrug fosphenytoin and the drug phenytoin (the active and diffusible form), could result in a faster and/or more effective brain targeting. Hence, nano or microemulsions containing both active drug and prodrug were developed and characterized regarding viscosity, osmolality, pH, mean size and in vitro drug release. Then, in vivo pharmacokinetics of a selected microemulsion containing fosphenytoin and phenytoin was evaluated in mice following intranasal administration and compared with a similar microemulsion containing fosphenytoin only. Both microemulsions led to higher brain drug levels at short time points than previously developed simpler aqueous based fosphenytoin formulations, likely due to the microemulsion's permeation enhancing effect. In addition, having a small amount of phenytoin in the formulation led to an equivalent maximum brain drug concentration and an overall higher absolute bioavailability, with a prolonged drug exposure. Hence, it can be concluded that if there is a need for a fast and prolonged therapeutic effect, a drug/phosphate ester prodrug combination in a microemulsion is ideal, but if a fast effect is all that is needed, having the prodrug alone could be enough, while considering a formulation with permeation enhancing components.
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Affiliation(s)
- Patrícia C Pires
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Ana C Fazendeiro
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Márcio Rodrigues
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Research Unit for Inland Development (UDI-IPG), Polytechnic Institute of Guarda, 6300-559 Guarda, Portugal.
| | - Gilberto Alves
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Adriana O Santos
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
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12
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Comparison of the efficacy and safety of levetiracetam and phenytoin in the treatment of established status epilepticus: A systematic review and meta-analysis. J Clin Neurosci 2021; 89:422-429. [PMID: 34053822 DOI: 10.1016/j.jocn.2021.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/21/2021] [Accepted: 05/02/2021] [Indexed: 12/14/2022]
Abstract
Status epilepticus (SE) is the second most critical neurological illness after cerebrovascular disease. Phenytoin has traditionally been considered the second-line drug of first choice after failure of first-line treatment using benzodiazepines. In recent years, levetiracetam has been proposed as a potential substitute for phenytoin. To comprehensively evaluate the efficacy and safety of levetiracetam and phenytoin in the treatment of patients with established SE, we integrated the data from 11 eligible studies and conducted a systematic review and meta-analysis. The PubMed, Web of Science, Cochrane Library, and Embase databases were searched to identify eligible articles reporting outcomes including clinical seizure cessation within 60 min, clinical recurrence rate within 24 h, good final outcome at discharge, and adverse events (AEs) of treatment with levetiracetam and phenytoin. Our study included a total of 11 trials including a total of 1933 patients. The outcomes showed that the pooled Risk Raito (RR) of clinical seizure cessation within 60 min was 1.08 (95% CI = 1.02-1.14, P = 0.01). The pooled RR of clinical recurrence rate within 24 h was 1.03 (95% CI = 0.66-1.59, P = 0.91). The pooled RR of AEs was 0.83 (95% CI = 0.57-1.21, P = 0.34). The pooled RRs of life-threatening hypotension and acute respiratory depression were 0.29 (95% CI = 0.10-0.81, P = 0.02) and 0.63 (95% CI = 0.40-0.98, P = 0.04), respectively. Levetiracetam might be more effective than phenytoin for the treatment of established SE and is associated with a lower incidence of more serious AEs. Levetiracetam can be used as an alternative to phenytoin for the treatment of benzodiazepine-refractory SE.
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13
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Huertas González N, Barros González A, Hernando Requejo V, Díaz Díaz J. Focal status epilepticus: a review of pharmacological treatment. NEUROLOGÍA (ENGLISH EDITION) 2021; 37:757-766. [DOI: 10.1016/j.nrleng.2019.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 02/27/2019] [Indexed: 11/16/2022] Open
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Savage T, Ross M. Comparison of three anticonvulsive agents for benzodiazepine resistant status epilepticus. CAN J EMERG MED 2021; 23:29-31. [PMID: 33683605 DOI: 10.1007/s43678-020-00021-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 08/21/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Tyson Savage
- Department of Emergency Medicine, University of Calgary, C231 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada.
| | - Marshall Ross
- Department of Emergency Medicine, University of Calgary, C231 3280 Hospital Dr. NW, Calgary, AB, T2N 4Z6, Canada
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Charalambous M, Volk HA, Van Ham L, Bhatti SFM. First-line management of canine status epilepticus at home and in hospital-opportunities and limitations of the various administration routes of benzodiazepines. BMC Vet Res 2021; 17:103. [PMID: 33663513 PMCID: PMC7934266 DOI: 10.1186/s12917-021-02805-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/16/2021] [Indexed: 12/22/2022] Open
Affiliation(s)
- Marios Charalambous
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium.
| | - Holger A Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, 30559, Hannover, Germany
| | - Luc Van Ham
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium
| | - Sofie F M Bhatti
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium
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Roynard P, Bilderback A, Dewey CW. Intravenous Ketamine Bolus(es) for the Treatment of Status Epilepticus, Refractory Status Epilepticus, and Cluster Seizures: A Retrospective Study of 15 Dogs. Front Vet Sci 2021; 8:547279. [PMID: 33681317 PMCID: PMC7925624 DOI: 10.3389/fvets.2021.547279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 01/07/2021] [Indexed: 12/02/2022] Open
Abstract
Status epilepticus (SE) and cluster seizures (CS) are common occurrences in veterinary neurology and frequent reasons of admission to veterinary hospitals. With prolonged seizure activity, gamma amino-butyric acid (GABA) receptors (GABAa receptors) become inactive, leading to a state of pharmacoresistance to benzodiazepines and other GABAergic medications, which is called refractory status epilepticus (RSE). Prolonged seizure activity is also associated with overexpression of N-methyl-D-aspartic (NMDA) receptors. Rodent models have shown the efficacy of ketamine (KET) in treating RSE, and its use has been reported in one canine case of RSE. Boluses of KET 5 mg/kg IV have become the preferred treatment for RSE in our hospital. A retrospective study was performed to evaluate and report our experience with KET IV bolus to treat prolonged and/or repeated seizure activity in cases of canine CS, SE, and RSE. A total of 15 dogs were retrieved, for 20 hospitalizations and 28 KET IV injections over 3 years. KET IV boluses were used 12 times for RSE (9 generalized seizures, 3 focal seizures) and KET terminated the episode of RSE 12/12 times (100%); however, seizures recurred 4/12 times (33%) within ≤6 h of KET IV bolus. When used for CS apart from episodes of RSE, KET IV bolus was associated with termination of the CS episode only 4/14 times (29%). Only 4/28 (14%) KET IV boluses were associated with adverse effects imputable only to the use of KET. One dog experienced a short, self-limited seizure activity during administration of KET IV, which was most likely related to a pre-mature use of KET IV (i.e., before GABAergic resistance and NMDA receptor overexpression had taken place). This study indicates that KET 5 mg/kg IV bolus may be successful for the treatment of RSE in dogs.
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Affiliation(s)
- Patrick Roynard
- Long Island Veterinary Specialists, Department of Neurology/Neurosurgery, Plainview, NY, United States
| | - Ann Bilderback
- VCA Northwest Veterinary Specialists, Clackamas, OR, United States
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Gömceli Y, Altındağ E, Baykan B. Different attitudes in the management of different types of status epilepticus: A survey study among neurologists demonstrating evidence gap. NEUROL SCI NEUROPHYS 2021. [DOI: 10.4103/nsn.nsn_70_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Meziane-Tani A, Foreman B, Mizrahi MA. Status Epilepticus: Work-Up and Management in Adults. Semin Neurol 2020; 40:652-660. [PMID: 33176372 DOI: 10.1055/s-0040-1719112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Status epilepticus is one of the most common neurological emergencies and is likely to have increasing prevalence in coming years given an aging "baby boomer" population in the United States. Because status epilepticus is associated with significant morbidity and mortality, identification and treatment are paramount. Care should be taken to exclude nonorganic mimics and infectious and metabolic causes. Status epilepticus can be classified into stages with associated recommendations for escalation in therapy, increasing from push-dose benzodiazepines to continuous anesthetic infusions and other nontraditional therapies. Concurrent electroencephalogram monitoring helps to identify, localize, and assess resolution of ictal patterns alongside antiseizure drug administration. A protocol is proposed for the management of status epilepticus in a step-wise fashion.
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Affiliation(s)
- Assia Meziane-Tani
- Division of Neurocritical Care, Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
| | - Moshe A Mizrahi
- Division of Neurocritical Care, Department of Neurology, University of Cincinnati Academic Health Center, Cincinnati, Ohio
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Pires PC, Santos LT, Rodrigues M, Alves G, Santos AO. Intranasal fosphenytoin: The promise of phosphate esters in nose-to-brain delivery of poorly soluble drugs. Int J Pharm 2020; 592:120040. [PMID: 33157214 DOI: 10.1016/j.ijpharm.2020.120040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 10/23/2022]
Abstract
Intranasal administration could increase both safety and efficacy of drugs acting on the central nervous system, but low solubility severely limits administration through this route. Phenytoin's prodrug, fosphenytoin, is hydrophilic and freely soluble in water, but less permeable since it is dianionic. We aimed to assess whether this phosphoester prodrug could be a suitable alternative to phenytoin in intranasal delivery. Secondly, we aimed to compare simple formulation strategies in fosphenytoin delivery. Fosphenytoin formulations containing thermosensitive and/or mucoadhesive (hydroxypropyl methylcellulose, HPMC) polymers were developed, guided by viscosity, gelling temperatures, osmolality, and in vitro drug release tests. Then, a pharmacokinetic study was performed, comparing an intravenous fosphenytoin solution, an intranasal fosphenytoin solution, and intranasal fosphenytoin mucoadhesive formulations with or without albumin. Formulations containing HPMC allowed high drug strengths, and had a relatively fast release profile, which was not changed by albumin. Intranasal administration of a formulation with HPMC and albumin prolonged drug concentration over time and led to complete or even increased absolute bioavailability. Moreover, phenytoin's blood levels did not reach the high peak obtained with intravenous administration. In conclusion, the use of phosphate ester prodrugs could be an efficient and safe strategy to increase the intranasal bioavailability of poorly soluble drugs.
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Affiliation(s)
- Patrícia C Pires
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Liliana T Santos
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Márcio Rodrigues
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Research Unit for Inland Development (UDI-IPG), Polytechnic Institute of Guarda, 6300-559 Guarda, Portugal.
| | - Gilberto Alves
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Adriana O Santos
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
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Ugur Yilmaz C, Emik S, Orhan N, Temizyurek A, Atis M, Akcan U, Khodadust R, Arican N, Kucuk M, Gurses C, Ahishali B, Kaya M. Targeted delivery of lacosamide-conjugated gold nanoparticles into the brain in temporal lobe epilepsy in rats. Life Sci 2020; 257:118081. [DOI: 10.1016/j.lfs.2020.118081] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 07/05/2020] [Accepted: 07/07/2020] [Indexed: 11/16/2022]
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Rituximab for Autoimmune Encephalitis with Epilepsy. Case Rep Neurol Med 2020; 2020:5843089. [PMID: 32655958 PMCID: PMC7330651 DOI: 10.1155/2020/5843089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 05/26/2020] [Accepted: 06/08/2020] [Indexed: 11/18/2022] Open
Abstract
Intractable epilepsy remains a significant medical challenge, resulting in recurrent and prolonged intensive care unit (ICU) admissions. Autoimmune encephalitis is emerging as a treatable cause of intractable epilepsy. It is characterized by antibodies against cerebral antigens, such as potassium channels such as leucine-rich, glioma inactivated 1 (LGI1) and contactin-associated protein 2 (CASPR2), calcium channels such as the voltage-gated calcium channel (VGCC), or neurotransmitter receptors such as the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR), gamma aminobutyric acid receptor (GABAR), and N-methyl-D-aspartate receptor (NMDAR). Diagnosis requires a syndrome consistent with an antibody identified in serum or cerebrospinal fluid (CSF) using methods that minimize risk of false-positives. Although there is no officially approved therapy for these disorders, typical approaches involve chronic high-dose steroids, intravenous immunoglobulin (IVIG), or plasma exchange. Rituximab is effective for antibody-associated disorders such as lupus, myasthenia gravis, and neuromyelitis optica. Here, we present three patients who were admitted with recalcitrant status epilepticus and demonstrated serum antibodies against NMDAR, LGI1, or VGCC using a cell-based assay. All patients demonstrated complete, long-term epilepsy control and improvement in symptoms with rituximab.
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Li L, Zhang Y, Jia L, Jia D, Faramand A, Chong W, Fang Y, Ma L, Fang F. Levetiracetam versus phenytoin for the treatment of established status epilepticus: A systematic review and meta-analysis of randomized controlled trials. Seizure 2020; 78:43-48. [PMID: 32182544 DOI: 10.1016/j.seizure.2020.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 03/01/2020] [Accepted: 03/03/2020] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES To compare the efficacy and safety of levetiracetam and phenytoin for the treatment of established status epilepticus. METHODS In this systematic review, we searched Medline, Embase, and Cochrane databases from their inception with no language restrictions until May 8, 2019 and updated on February 5, 2020, for randomized controlled trials comparing the efficacy and safety of levetiracetam and phenytoin for the treatment of established status epilepticus. A Meta-analysis was conducted to calculate the risk ratio (RR) using random-effects models. RESULTS We identified 7 trials with a total of 1028 participants. Levetiracetam was not associated with an increased rate of clinical seizure cessation within 60 min compared with phenytoin (RR, 1.02; 95 %CI, 0.92-1.13; I2 = 3%; 60.0 % [309/515] vs 59.3 % [275/463];12 more events [95 % CI, -48 to 77] per 1000 participants; moderate-quality evidence). Results were similar in the subgroup analysis of adults and children. The sample size met the optimum size in trial sequential analysis. There were also no statistically significant effects on good functional outcome (RR, 1.05; 95 % CI, 0.90-1.23), admission to critical care (RR, 1.09; 95 % CI, 0.95-1.24), or all-cause mortality (RR, 1.09; 95 % CI, 0.55-2.16). CONCLUSIONS Moderate-quality evidence suggested that levetiracetam was not significantly superior to phenytoin in seizure cessation in patients with established status epilepticus.
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Affiliation(s)
- Linjie Li
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Zhang
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Lu Jia
- Shanxi Provincial People's Hospital, Taiyuan, Shanxi, China
| | - Desheng Jia
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Andrew Faramand
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Weelic Chong
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yuan Fang
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Fang Fang
- West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Clinical pathways of epileptic seizures and status epilepticus: results from a survey in Italy. Neurol Sci 2020; 41:1571-1575. [PMID: 31989348 PMCID: PMC7275936 DOI: 10.1007/s10072-020-04270-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/20/2020] [Indexed: 11/26/2022]
Abstract
Objective Patients with seizures or status epilepticus (SE) access the hospital through emergency departments and may be admitted into different wards according to the level of care required. Clinicians with different expertise are in charge of taking critical therapeutic decisions. To date, very few studies have investigated the stage at which these patients are referred to neurologists or epileptologists and how guideline recommendations are applied in clinical practice. Methods A survey was used to investigate how patients with epileptic seizures or SE are managed in emergency and in subsequent hospital pathways in Italy. Results One hundred and seventy-seven physicians (mainly neurologists) from all parts of Italy filled in a questionnaire. Less than half of the participants (35%) answered that, in their hospital, patients with epilepsy were managed by epileptologists. The percentages were lower for patients presenting with acute seizures (21%) or SE (16%). Diagnostic, therapeutic, and assistance pathways (PDTA) for patients presenting with seizure(s) or SE were available for both conditions in about 50% of cases, while, in the rest of the hospitals, participants indicated informal agreements (about 25% of cases) or lack of any agreement (about 25% of cases) between clinicians. Professionals more often involved in PDTA were epileptologists/neurologists, emergency physicians, and intensivists. More than half ot the participants (55%) thought that organizational issues are the most important criticalities for such patients and need to be improved (61%). Significance There is a high variability in hospital clinical pathways for epilepsy in Italy. Electronic supplementary material The online version of this article (10.1007/s10072-020-04270-3) contains supplementary material, which is available to authorized users.
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Abstract
Convulsive status epilepticus (CSE) is one of the most common pediatric neurological emergencies. Ongoing seizure activity is a dynamic process and may be associated with progressive impairment of gamma-aminobutyric acid (GABA)-mediated inhibition due to rapid internalization of GABAA receptors. Further hyperexcitability may be caused by AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid) and NMDA (N-methyl-D-aspartic acid) receptors moving from subsynaptic sites to the synaptic membrane. Receptor trafficking during prolonged seizures may contribute to difficulties treating seizures of longer duration and may provide some of the pathophysiological underpinnings of established and refractory SE (RSE). Simultaneously, a practice change toward more rapid initiation of first-line benzodiazepine (BZD) treatment and faster escalation to second-line non-BZD treatment for established SE is in progress. Early administration of the recommended BZD dose is suggested. For second-line treatment, non-BZD anti-seizure medications (ASMs) include valproate, fosphenytoin, or levetiracetam, among others, and at this point there is no clear evidence that any one of these options is better than the others. If seizures continue after second-line ASMs, RSE is manifested. RSE treatment consists of bolus doses and titration of continuous infusions under continuous electro-encephalography (EEG) guidance until electrographic seizure cessation or burst-suppression. Ultimately, etiological workup and related treatment of CSE, including broad spectrum immunotherapies as clinically indicated, is crucial. A potential therapeutic approach for future studies may entail consideration of interventions that may accelerate diagnosis and treatment of SE, as well as rational and early polytherapy based on synergism between ASMs by utilizing medications targeting different mechanisms of epileptogenesis and epileptogenicity.
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Pires PC, Peixoto D, Teixeira I, Rodrigues M, Alves G, Santos AO. Nanoemulsions and thermosensitive nanoemulgels of phenytoin and fosphenytoin for intranasal administration: Formulation development and in vitro characterization. Eur J Pharm Sci 2019; 141:105099. [PMID: 31672614 DOI: 10.1016/j.ejps.2019.105099] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/10/2019] [Accepted: 10/01/2019] [Indexed: 10/25/2022]
Abstract
Phenytoin is a low solubility anticonvulsant drug. It has, nonetheless, other possible therapeutic indications, such as neuropathic pain, including trigeminal neuralgia, or wound healing. Its use has decreased due to side effects, but nasal/intranasal administration could significantly increase drug safety and efficacy. The aim of this work was to develop and study nanoemulsions and thermosensitive nanoemulgels of phenytoin and fosphenytoin, in combination, for intranasal administration, with immediate and sustained release profiles. Nanoemulsions were prepared by adding the aqueous phase, containing gelling polymers in the case of nanoemulgels, to emulsion preconcentrates, followed, in the optimized procedure, by premix membrane emulsification. Formulation design and optimization was guided by drug strength, rheological behavior, osmolality, mean droplet size and polydispersity. Fosphenytoin interfered significantly with Carbopol but not with Pluronic's gelation, and allowed to achieve drug strengths equivalent to 22 or 27 mg/g of phenytoin in lead nanoemulsions, and 16.7 mg/g of phenytoin in the lead nanoemulgel. The final selected low viscosity nanoemulsions had an immediate or prolonged fosphenytoin release profile, depending of anhydrous phase proportion (10% or 40%, respectively). The thermosensitive nanoemulgel, with 10% anhydrous phase, showed prolonged drug release. Future studies will establish whether they are more suited for topical effects or therapeutic brain delivery.
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Affiliation(s)
- Patrícia C Pires
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Diana Peixoto
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Isaura Teixeira
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Márcio Rodrigues
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Research Unit for Inland Development (UDI-IPG), Polytechnic Institute of Guarda, 6300-749 Guarda, Portugal.
| | - Gilberto Alves
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
| | - Adriana O Santos
- Health Sciences Research Centre (CICS-UBI), University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal; Faculty of Health Sciences, University of Beira Interior, Av. Infante D. Henrique, 6200-506 Covilhã, Portugal.
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Theusinger OM, Schenk P, Dette-Oltmann K, Mariotti S, Baulig W. Treatment of Seizures in Children and Adults in the Emergency Medical System of the City of Zurich, Switzerland - Midazolam vs. Diazepam - A Retrospective Analysis. J Emerg Med 2019; 57:345-353. [PMID: 31296354 DOI: 10.1016/j.jemermed.2019.05.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 05/10/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Seizures count to critical situations emergency medical systems (EMS) are confronted with. OBJECTIVES Evaluation of a modified treatment algorithm (MTAS-EMS) using diazepam and midazolam due to a supply bottleneck of iv lorazepam in 2012. METHODS Retrospective study where data from patients treated for seizures by the EMS of the city of Zurich were analyzed. Effectiveness of the MTAS-EMS and i.v. diazepam in children and adults was compared with respect of cessation of seizure without recurrence over the period until arrival at the hospital. The chi-square and Fisher's exact test were used to compare categorical data. The Student's t-test and Mann Whitney test were used to compare numerical data. p-values < 0.05 are considered significant. RESULTS Of 584 documented missions, 165 treated patients (126 adults and 39 children) were included. 115 patients (80 adults and 35 children) were treated according the MTAS-EMS. Cessation of seizure was achieved in 85% of the adults and in 97% of the children, if all options of the MTAS-EMS were used. The first dose of nasal midazolam was more successful in children compared to adults (p = 0.012). In adults, the single dose of i.v. diazepam terminated the seizure in 98% (p = 0.001) compared to 57% for the single dose of iv and 64% for nasal midazolam. CONCLUSIONS The treatment success of the MTAS-EMS is high. However, in adults the single dose of i.v. diazepam is as successful as the completely used MTAS-EMS and seems to be superior to the single dose iv and nasal midazolam.
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Affiliation(s)
- Oliver M Theusinger
- Blood Transfusion Service Zürich, SRC, Schlieren, Switzerland; University of Zurich, Zurich, Switzerland
| | - Peter Schenk
- Institute of Anesthesiology, University and University Hospital, Zurich, Switzerland
| | - Katharina Dette-Oltmann
- Alster-Klinik Hamburg, Department of Plastic, Hand and Restorative Surgery, Hamburg, Germany
| | - Sergio Mariotti
- Schutz und Rettung Zurich, Zurich, Switzerland; City Hospital Triemli, Zurich, Switzerland
| | - Werner Baulig
- Department of Anesthesiology and Intensive Care Medicine, Klinik Im Park, Zurich, Switzerland
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Huertas González N, Barros González A, Hernando Requejo V, Díaz Díaz J. Focal status epilepticus: a review of pharmacological treatment. Neurologia 2019; 37:S0213-4853(19)30044-1. [PMID: 31072691 DOI: 10.1016/j.nrl.2019.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/29/2019] [Accepted: 02/27/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Status epilepticus (SE) is a neurological emergency associated with high morbidity and mortality. One prognostic factor is the type of SE. The purpose of this review is to analyse the most recent recommendations of different scientific societies and expert groups on the treatment of SE, and the latest studies, to assess the literature on the management of focal SE. METHODS We searched PubMed for studies published between 1 August 2008 and 1 August 2018 on the pharmacological treatment of focal SE and its different types in adults. RESULTS We identified 29 publications among reviews, treatment guidelines, meta-analyses, clinical trials, and case series on the treatment of SE. Only 3 of them accounted for whether SE was focal or generalised; 4 focused exclusively on focal SE, and 7 differentiated between convulsive and non-convulsive SE and also record the presence of focal seizures. Treatment recommendations for focal SE do not differ from those of generalised SE in stages I and II: initially intravenous lorazepam or diazepam, if the intravenous route is available, and otherwise intramuscular midazolam, followed by intravenous phenytoin, valproate, levetiracetam, or lacosamide if seizures persist. Use of anaesthetic drugs should be delayed for as long as possible in patients with refractory focal SE. CONCLUSIONS The available scientific evidence is insufficient to claim that pharmacological treatment of focal SE should be different from treatment for generalised SE. More studies with a greater number of patients are needed.
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Affiliation(s)
- N Huertas González
- Servicio de Neurología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España.
| | - A Barros González
- Servicio de Neurología, Sankt Katharinen Hospital, Frechen, Alemania
| | - V Hernando Requejo
- Servicio de Neurología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España
| | - J Díaz Díaz
- Servicio de Neurología, Hospital Universitario Severo Ochoa, Leganés, Madrid, España
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28
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[Diagnosis and treatment of status epilepticus in the intensive care unit]. Med Klin Intensivmed Notfmed 2019; 114:475-484. [PMID: 31053866 DOI: 10.1007/s00063-019-0581-8] [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: 08/04/2018] [Revised: 02/09/2019] [Accepted: 03/07/2019] [Indexed: 10/26/2022]
Abstract
Both convulsive and nonconvulsive status epilepticus are associated with a high risk of morbidity and mortality. To limit brain damage, emergency investigation of etiology and treatment must be done synchronously. This review presents the general rules for treatment. The steps of pharmacologic escalation with benzodiazepines, antiepileptics, and anesthetics are discussed together with their advantages and disadvantages.
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Zhang Q, Yu Y, Lu Y, Yue H. Systematic review and meta-analysis of propofol versus barbiturates for controlling refractory status epilepticus. BMC Neurol 2019; 19:55. [PMID: 30954065 PMCID: PMC6451279 DOI: 10.1186/s12883-019-1281-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 03/22/2019] [Indexed: 11/28/2022] Open
Abstract
Background Several studies have compared the efficacy and safety of propofol and barbiturates in the treatment of refractory status epilepticus (RSE). This study aims to quantitatively assess the advantages and disadvantages of propofol and barbiturates in controlling RSE. Methods We searched for studies with relevant data from the PubMed, Embase, Ovid, Cochrane Library, Springer Link, Web of Science, and China National Knowledge Infrastructure databases. By calculating odds ratios and standardized mean differences with 95% confidence intervals, we assessed the disease control rate (DCR), case fatality rate (CFR), average control time (ACT), average tracheal intubation placement time (ATIPT), and incidence of hypotension between propofol and barbiturates in treating RSE. Results Seven studies with 261 patients were included in this analysis. Meta-analysis revealed that the DCR of propofol was higher than that of barbiturates (p < 0.001) and that the CFR (p = 0.382) between the two treatment did not significantly differ in controlling RSE. Propofol shortened the ACT (p < 0.001) of RSE and reduced the ATIPT (p < 0.001) of patients with RSE more extensively than did barbiturates and did not increase the incidence of hypotension (p = 0.737). Conclusions In comparison with barbiturates, propofol can control RSE and shorten ATIPT in a more efficient and timely manner. Moreover, the drug does not increase the incidence of hypotension and CFR.
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Affiliation(s)
- Qing Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No.119, Nansihuanxi Road, Fengtai District, Beijing, 100070, China
| | - Yun Yu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No.119, Nansihuanxi Road, Fengtai District, Beijing, 100070, China
| | - Yu Lu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No.119, Nansihuanxi Road, Fengtai District, Beijing, 100070, China
| | - Hongli Yue
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No.119, Nansihuanxi Road, Fengtai District, Beijing, 100070, China.
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30
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Marawar R, Basha M, Mahulikar A, Desai A, Suchdev K, Shah A. Updates in Refractory Status Epilepticus. Crit Care Res Pract 2018; 2018:9768949. [PMID: 29854452 PMCID: PMC5964484 DOI: 10.1155/2018/9768949] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/19/2018] [Indexed: 01/01/2023] Open
Abstract
Refractory status epilepticus is defined as persistent seizures despite appropriate use of two intravenous medications, one of which is a benzodiazepine. It can be seen in up to 40% of cases of status epilepticus with an acute symptomatic etiology as the most likely cause. New-onset refractory status epilepticus (NORSE) is a recently coined term for refractory status epilepticus where no apparent cause is found after initial testing. A large proportion of NORSE cases are eventually found to have an autoimmune etiology needing immunomodulatory treatment. Management of refractory status epilepticus involves treatment of an underlying etiology in addition to intravenous anesthetics and antiepileptic drugs. Alternative treatment options including diet therapies, electroconvulsive therapy, and surgical resection in case of a focal lesion should be considered. Short-term and long-term outcomes tend to be poor with significant morbidity and mortality with only one-third of patients reaching baseline neurological status.
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Affiliation(s)
- Rohit Marawar
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Maysaa Basha
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Advait Mahulikar
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Aaron Desai
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Kushak Suchdev
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Aashit Shah
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
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Hussein AM, Adel M, El-Mesery M, Abbas KM, Ali AN, Abulseoud OA. l-Carnitine Modulates Epileptic Seizures in Pentylenetetrazole-Kindled Rats via Suppression of Apoptosis and Autophagy and Upregulation of Hsp70. Brain Sci 2018. [PMID: 29538301 PMCID: PMC5870363 DOI: 10.3390/brainsci8030045] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
l-Carnitine is a unique nutritional supplement for athletes that has been recently studied as a potential treatment for certain neuropsychiatric disorders. However, its efficacy in seizure control has not been investigated. Sprague Dawley rats were randomly assigned to receive either saline (Sal) (negative control) or pentylenetetrazole (PTZ) 40 mg/kg i.p. × 3 times/week × 3 weeks. The PTZ group was further subdivided into two groups, the first received oral l-carnitine (l-Car) (100 mg/kg/day × 4 weeks) (PTZ + l-Car), while the second group received saline (PTZ + Sal). Daily identification and quantification of seizure scores, time to the first seizure and the duration of seizures were performed in each animal. Molecular oxidative markers were examined in the animal brains. l-Car treatment was associated with marked reduction in seizure score (p = 0.0002) that was indicated as early as Day 2 of treatment and continued throughout treatment duration. Furthermore, l-Car significantly prolonged the time to the first seizure (p < 0.0001) and shortened seizure duration (p = 0.028). In addition, l-Car administration for four weeks attenuated PTZ-induced increase in the level of oxidative stress marker malondialdehyde (MDA) (p < 0.0001) and reduced the activity of catalase enzyme (p = 0.0006) and increased antioxidant GSH activity (p < 0.0001). Moreover, l-Car significantly reduced PTZ-induced elevation in protein expression of caspase-3 (p < 0.0001) and β-catenin (p < 0.0001). Overall, our results suggest a potential therapeutic role of l-Car in seizure control and call for testing these preclinical results in a proof of concept pilot clinical study.
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Affiliation(s)
- Abdelaziz M Hussein
- Department of Medical Physiology, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt.
| | - Mohamed Adel
- Department of Medical Physiology, Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt.
| | - Mohamed El-Mesery
- Department of Biochemistry, Faculty of Pharmacy, Mansoura University, Mansoura 35516, Egypt.
| | - Khaled M Abbas
- Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt.
| | - Amr N Ali
- Faculty of Medicine, Mansoura University, Mansoura 35516, Egypt.
| | - Osama A Abulseoud
- Neuroimaging Research Branch, IRP, National Institute on Drug Abuse, National Institutes of Health, Biomedical Research Center, 251 Bayview Blvd, Baltimore, MD 21224, USA.
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Mahroum N, Watad A, Bragazzi NL, Amital H, Sharif K, Watad S, Adavastro G, Canepa G, Brigo F, Adawi M. On status epilepticus and pins: A systematic content analysis. Epilepsy Behav 2017; 74:130-134. [PMID: 28734196 DOI: 10.1016/j.yebeh.2017.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 06/06/2017] [Accepted: 06/12/2017] [Indexed: 10/19/2022]
Abstract
Status epilepticus (SE) can be defined as abnormally prolonged, persistent, or recurrent clinical and/or electrographic epileptic activity and, as such, is a challenging medical emergency requiring an aggressive treatment aimed at promptly terminating the seizures. It imposes a relevant clinical burden, both in terms of comorbidity and mortality. In the era of the Web 2.0, most people search the Web to obtain SE-related information. The current investigation aimed at qualitatively characterizing the pins related to SE: Pinterest, "the world's catalog of ideas", is a visual social networking site that enables users to freely upload visual material, to bookmark, and to share it (repin). Using SE as a keyword, 192 pins were extracted and analyzed on the basis of their content. Fifty-five were found to meet the inclusion criteria. Fifty-six point four percent of the pins reported at least one cause of SE, the most quoted of which being remote brain injuries (47.3% of the pins); 54.5% and 45.5% of the included pins reported SE symptoms and diagnosis, respectively; 72.7% and 40.0% of pins focused on SE treatment and on prognosis, respectively; and 50.9%, 30.9%, and 40.0% of the pins were intended for physicians, medical/nursing students, and lay people, respectively. Only 12.7% of pins were patient-centered and devoted to fund-raising and advocacy. In the field of neurological diseases, Pinterest, despite being a "pinstructive" tool, is too much overlooked and underused for advocacy purposes. Healthcare workers and stakeholders should be aware of the opportunities offered by Pinterest and exploit this visual social networking site for raising awareness of the life-threatening condition of SE, promoting fund-raising campaigns.
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Affiliation(s)
- Naim Mahroum
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Abdulla Watad
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nicola Luigi Bragazzi
- Post-graduate School of Public Health Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy; Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy.
| | - Howard Amital
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Kassem Sharif
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel; Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Samaa Watad
- Department of Statistics and Operations Research, Tel-Aviv University, Tel-Aviv, Israel
| | - Giulia Adavastro
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Giovanna Canepa
- Section of Psychiatry, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement, University of Verona, Verona, Italy
| | - Mohammad Adawi
- Padeh and Ziv Hospitals, Bar-Ilan Faculty of Medicine, Ramat Gan, Israel
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