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Rickel JK, Zeeb D, Knake S, Urban H, Konczalla J, Weber KJ, Zeiner PS, Pagenstecher A, Hattingen E, Kemmling A, Fokas E, Adeberg S, Wolff R, Sebastian M, Rusch T, Ronellenfitsch MW, Menzler K, Habermehl L, Möller L, Czabanka M, Nimsky C, Timmermann L, Grefkes C, Steinbach JP, Rosenow F, Kämppi L, Strzelczyk A. Status epilepticus in patients with brain tumors and metastases: A multicenter cohort study of 208 patients and literature review. Neurol Res Pract 2024; 6:19. [PMID: 38570823 PMCID: PMC10993483 DOI: 10.1186/s42466-024-00314-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/13/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE Brain tumors and metastases account for approximately 10% of all status epilepticus (SE) cases. This study described the clinical characteristics, treatment, and short- and long-term outcomes of this population. METHODS This retrospective, multi-center cohort study analyzed all brain tumor patients treated for SE at the university hospitals of Frankfurt and Marburg between 2011 and 2017. RESULTS The 208 patients (mean 61.5 ± 14.7 years of age; 51% male) presented with adult-type diffuse gliomas (55.8%), metastatic entities (25.5%), intracranial extradural tumors (14.4%), or other tumors (4.3%). The radiological criteria for tumor progression were evidenced in 128 (61.5%) patients, while 57 (27.4%) were newly diagnosed with tumor at admission and 113 (54.3%) had refractory SE. The mean hospital length of stay (LOS) was 14.8 days (median 12.0, range 1-57), 171 (82.2%) patients required intensive care (mean LOS 8.9 days, median 5, range 1-46), and 44 (21.2%) were administered mechanical ventilation. All patients exhibited significant functional status decline (modified Rankin Scale) post-SE at discharge (p < 0.001). Mortality at discharge was 17.3% (n = 36), with the greatest occurring in patients with metastatic disease (26.4%, p = 0.031) and those that met the radiological criteria for tumor progression (25%, p < 0.001). Long-term mortality at one year (65.9%) was highest in those diagnosed with adult-type diffuse gliomas (68.1%) and metastatic disease (79.2%). Refractory status epilepticus cases showed lower survival rates than non-refractory SE patients (log-rank p = 0.02) and those with signs of tumor progression (log-rank p = 0.001). CONCLUSIONS SE occurrence contributed to a decline in functional status in all cases, regardless of tumor type, tumor progression status, and SE refractoriness, while long-term mortality was increased in those with malignant tumor entities, tumor progressions, and refractory SE. SE prevention may preserve functional status and improve survival in individuals with brain tumors.
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Affiliation(s)
- Johanna K Rickel
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt, Germany
| | - Daria Zeeb
- Department of Neurology and Epilepsy Center Hessen, Philipps-University Marburg, Marburg, Germany
- Department of Neurosurgery, Philipps-University Marburg, Marburg, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Susanne Knake
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt, Germany
- Department of Neurology and Epilepsy Center Hessen, Philipps-University Marburg, Marburg, Germany
| | - Hans Urban
- Dr Senckenberg Institute of Neurooncology, University Hospital and Goethe-University Frankfurt, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Jürgen Konczalla
- Department of Neurosurgery, Goethe-University Frankfurt, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Katharina J Weber
- Frankturt Cancer Institute (FCI), Goethe-University Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ) Heidelberg, Germany and German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Frankfurt, Germany
- Institute of Neurology (Edinger-Institute), Goethe-University Frankfurt, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Pia S Zeiner
- Dr Senckenberg Institute of Neurooncology, University Hospital and Goethe-University Frankfurt, Frankfurt, Germany
- Frankturt Cancer Institute (FCI), Goethe-University Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ) Heidelberg, Germany and German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Axel Pagenstecher
- Institute of Neuropathology, Philipps-University Marburg, Marburg, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Elke Hattingen
- Institute of Neuroradiology, Goethe-University Frankfurt, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - André Kemmling
- Department of Neuroradiology, Philipps-University Marburg, Marburg, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Emmanouil Fokas
- Frankturt Cancer Institute (FCI), Goethe-University Frankfurt, Frankfurt, Germany
- Department of Radiotherapy and Oncology, Goethe-University Frankfurt, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Sebastian Adeberg
- Department of Radiation Oncology, UKGM Marburg, Marburg, Germany
- Marburg Ion-Beam Therapy Center (MIT), Department of Radiation Oncology, UKGM Marburg, Marburg, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Robert Wolff
- Gamma Knife Frankfurt, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Martin Sebastian
- Hematology/Oncology, Department of Medicine II, University Hospital Frankfurt, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Tillmann Rusch
- Department of Hematology, Oncology & Immunology, Philipps-University Marburg, Marburg, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Michael W Ronellenfitsch
- Dr Senckenberg Institute of Neurooncology, University Hospital and Goethe-University Frankfurt, Frankfurt, Germany
- Frankturt Cancer Institute (FCI), Goethe-University Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ) Heidelberg, Germany and German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Katja Menzler
- Department of Neurology and Epilepsy Center Hessen, Philipps-University Marburg, Marburg, Germany
| | - Lena Habermehl
- Department of Neurology and Epilepsy Center Hessen, Philipps-University Marburg, Marburg, Germany
| | - Leona Möller
- Department of Neurology and Epilepsy Center Hessen, Philipps-University Marburg, Marburg, Germany
| | - Marcus Czabanka
- Department of Neurosurgery, Goethe-University Frankfurt, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, Philipps-University Marburg, Marburg, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Lars Timmermann
- Department of Neurology and Epilepsy Center Hessen, Philipps-University Marburg, Marburg, Germany
| | - Christian Grefkes
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Joachim P Steinbach
- Dr Senckenberg Institute of Neurooncology, University Hospital and Goethe-University Frankfurt, Frankfurt, Germany
- Frankturt Cancer Institute (FCI), Goethe-University Frankfurt, Frankfurt, Germany
- German Cancer Research Center (DKFZ) Heidelberg, Germany and German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, Frankfurt, Germany
- University Cancer Center (UCT) Frankfurt-Marburg, Frankfurt, Marburg, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt, Germany
| | - Leena Kämppi
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
- Epilepsia Helsinki, European Reference Network EpiCARE, Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, Goethe-University and University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany.
- Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt, Germany.
- Department of Neurology and Epilepsy Center Hessen, Philipps-University Marburg, Marburg, Germany.
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Haanpää A, Laakso SM, Kinnunen A, Kämppi L, Forss N. Early clinical features of new-onset refractory status epilepticus (NORSE) in adults. BMC Neurol 2022; 22:495. [PMID: 36539824 PMCID: PMC9764533 DOI: 10.1186/s12883-022-03028-y] [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: 07/16/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND The aim of this study was to identify early clinical features of patients with new-onset refractory status epilepticus (NORSE) that could direct the treatment in the first days of hospitalisation. METHODS A retrospective cohort study of adult NORSE patients treated in the intensive care units of Helsinki University Hospital 2007-2018. RESULTS We found 19 adult NORSE patients who divided into three subgroups on the basis of their clinical features: viral encephalitis (n = 5, 26%), febrile infection-related epilepsy syndrome (FIRES) (n = 6, 32%) and afebrile NORSE (n = 8, 42%). FIRES and afebrile NORSE patients remained without confirmed etiology, but retrospectively two paraneoplastic and two neurodegenerative causes were suspected in the afebrile NORSE group. Viral encephalitis patients were median 64 years old (IQR 55-64), and four (80%) had prodromal fever and abnormal findings in the first brain imaging. FIRES patients were median 21 years old (IQR 19-24), all febrile and had normal brain imaging at onset. In the afebrile NORSE group, median age was 67 (IQR 59-71) and 50% had prodromal cognitive or psychiatric symptoms. FIRES patients differed from other NORSE patients by younger age (p = 0.001), respiratory prodromal symptoms (p = 0.004), normal brain MRI (p = 0.044) and lack of comorbidities (p = 0.011). They needed more antiseizure medications (p = 0.001) and anesthetics (p = 0.002), had a longer hospital stay (p = 0.017) and more complications (p < 0.001). CONCLUSIONS Among febrile NORSE patients, FIRES group was distinctive due to patients' young age, prodromal respiratory symptoms and normal first brain imaging. These features should be confirmed by subsequent studies as basis for selecting patients for early intensive immunotherapy.
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Affiliation(s)
- Anna Haanpää
- grid.15485.3d0000 0000 9950 5666Department of Neurology, Neurocenter, Helsinki University Hospital, PB 372, 00029 HUS Helsinki, Finland ,grid.7737.40000 0004 0410 2071Department of Clinical Neurosciences, University of Helsinki, PB 22, 00014 University of Helsinki Helsinki, Finland
| | - Sini M. Laakso
- grid.15485.3d0000 0000 9950 5666Department of Neurology, Neurocenter, Helsinki University Hospital, PB 372, 00029 HUS Helsinki, Finland ,grid.7737.40000 0004 0410 2071Department of Clinical Neurosciences, University of Helsinki, PB 22, 00014 University of Helsinki Helsinki, Finland
| | - Antti Kinnunen
- grid.15485.3d0000 0000 9950 5666Department of Clinical Neurophysiology, Helsinki University Hospital, PB 340, 00029 HUS Helsinki, Finland
| | - Leena Kämppi
- grid.7737.40000 0004 0410 2071Department of Clinical Neurosciences, University of Helsinki, PB 22, 00014 University of Helsinki Helsinki, Finland ,grid.15485.3d0000 0000 9950 5666Epilepsia Helsinki, Department of Neurology, Neurocenter, Helsinki University Hospital, PB 372, 00029 HUS Helsinki, Finland
| | - Nina Forss
- grid.15485.3d0000 0000 9950 5666Department of Neurology, Neurocenter, Helsinki University Hospital, PB 372, 00029 HUS Helsinki, Finland ,grid.7737.40000 0004 0410 2071Department of Clinical Neurosciences, University of Helsinki, PB 22, 00014 University of Helsinki Helsinki, Finland
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Jin MC, Parker JJ, Zhang M, Medress ZA, Halpern CH, Li G, Ratliff JK, Grant GA, Fisher RS, Skirboll S. Status epilepticus after intracranial neurosurgery: incidence and risk stratification by perioperative clinical features. J Neurosurg 2021; 135:1752-1764. [PMID: 33990087 PMCID: PMC8665824 DOI: 10.3171/2020.10.jns202895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Status epilepticus (SE) is associated with significant mortality, cost, and risk of future seizures. In one of the first studies of SE after neurosurgery, the authors assess the incidence, risk factors, and outcome of postneurosurgical SE (PNSE). METHODS Neurosurgical admissions from the MarketScan Claims and Encounters database (2007 through 2015) were assessed in a longitudinal cross-sectional sample of privately insured patients who underwent qualifying cranial procedures in the US and were older than 18 years of age. The incidence of early (in-hospital) and late (postdischarge readmission) SE and associated mortality was assessed. Procedural, pathological, demographic, and anatomical covariates parameterized multivariable logistic regression and Cox models. Multivariable logistic regression and Cox proportional hazards models were used to study the incidence of early and late PNSE. A risk-stratification simulation was performed, combining individual predictors into singular risk estimates. RESULTS A total of 197,218 admissions (218,217 procedures) were identified. Early PNSE occurred during 637 (0.32%) of 197,218 admissions for cranial neurosurgical procedures. A total of 1045 (0.56%) cases of late PNSE were identified after 187,771 procedure admissions with nonhospice postdischarge follow-up. After correction for comorbidities, craniotomy for trauma, hematoma, or elevated intracranial pressure was associated with increased risk of early PNSE (adjusted OR [aOR] 1.538, 95% CI 1.183-1.999). Craniotomy for meningioma resection was associated with an increased risk of early PNSE compared with resection of metastases and parenchymal primary brain tumors (aOR 2.701, 95% CI 1.388-5.255). Craniotomies for infection or abscess (aHR 1.447, 95% CI 1.016-2.061) and CSF diversion (aHR 1.307, 95% CI 1.076-1.587) were associated with highest risk of late PNSE. Use of continuous electroencephalography in patients with early (p < 0.005) and late (p < 0.001) PNSE rose significantly over the study time period. The simulation regression model predicted that patients at high risk for early PNSE experienced a 1.10% event rate compared with those at low risk (0.07%). Similarly, patients predicted to be at highest risk for late PNSE were significantly more likely to eventually develop late PNSE than those at lowest risk (HR 54.16, 95% CI 24.99-104.80). CONCLUSIONS Occurrence of early and late PNSE was associated with discrete neurosurgical pathologies and increased mortality. These data provide a framework for prospective validation of clinical and perioperative risk factors and indicate patients for heightened diagnostic suspicion of PNSE.
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Affiliation(s)
- Michael C. Jin
- Department of Neurosurgery, Neurology, Stanford University School of Medicine
| | - Jonathon J. Parker
- Department of Neurosurgery, Neurology, Stanford University School of Medicine
| | - Michael Zhang
- Department of Neurosurgery, Neurology, Stanford University School of Medicine
| | - Zack A. Medress
- Department of Neurosurgery, Neurology, Stanford University School of Medicine
| | - Casey H. Halpern
- Department of Neurosurgery, Neurology, Stanford University School of Medicine
| | - Gordon Li
- Department of Neurosurgery, Neurology, Stanford University School of Medicine
| | - John K. Ratliff
- Department of Neurosurgery, Neurology, Stanford University School of Medicine
| | - Gerald A. Grant
- Department of Neurosurgery, Neurology, Stanford University School of Medicine
| | - Robert S. Fisher
- Department of Neurology, Stanford University School of Medicine, Stanford
| | - Stephen Skirboll
- Department of Neurosurgery, Neurology, Stanford University School of Medicine
- Department of Section of Neurosurgery, VA Palo Alto Healthcare System, Palo Alto, California
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Maier S, Godau J, Bösel J, Rösche J. Recognition and treatment of status epilepticus in the prehospital setting. Seizure 2021; 86:1-5. [DOI: 10.1016/j.seizure.2020.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/28/2020] [Accepted: 12/16/2020] [Indexed: 11/27/2022] Open
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Llauradó A, Quintana M, Ballvé A, Campos D, Fonseca E, Abraira L, Toledo M, Santamarina E. Factors associated with resistance to benzodiazepines in status epilepticus. J Neurol Sci 2021; 423:117368. [PMID: 33652289 DOI: 10.1016/j.jns.2021.117368] [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: 11/05/2020] [Revised: 02/18/2021] [Accepted: 02/20/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate factors related to benzodiazepine (BZD) resistance in status epilepticus (SE) with a focus on their relationship with the etiology of the episode. METHODS All SE cases in patients aged >16 years treated with BZDs were prospectively collected in our center from February 2011 to April 2019. The registry included demographics, SE type and etiology, the timing and duration of BZD administration, and the outcome. In total, 371 episodes were analyzed. RESULTS Median age at SE onset was 61.3 years; the most frequent etiology was acute symptomatic (55.8%). SE with prominent motor symptoms occurred in 63.3%. Median time to BZD administration was 2 h. We studied the correlation between two-time variables: time from SE onset to BZD administration and time from BZD administration to resolution of SE (response); we observed that timely administration correlated with a faster response in patients with prominent motor symptoms (p = 0.017), SE due to a chronic structural cerebral lesion (p = 0.004), and patients with a history of seizures (p = 0.013). In these subgroups (prominent motor symptoms or chronic structural lesion) BZD administration within the first 4.5 h was highly associated with shorter post-BZD SE duration (p < 0.001). SIGNIFICANCE The relationship between prompt BZD administration and subsequent duration of SE was found to depend to some extent on the etiology of the episode: patients with chronic structural lesions and those with previous epilepsy responded faster to BZDs. Semiology may have also its impact, as the presence of prominent motor symptoms showed also a faster response.
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Affiliation(s)
- Arnau Llauradó
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Manuel Quintana
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Alejandro Ballvé
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Daniel Campos
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Elena Fonseca
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Laura Abraira
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Manuel Toledo
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain
| | - Estevo Santamarina
- Epilepsy Unit, Neurology Department, Vall de Hebron University Hospital, Barcelona, Spain.
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Kim HJ, Lee SA, Kim HW, Kim SJ, Jeon SB, Koo YS. The timelines of MRI findings related to outcomes in adult patients with new-onset refractory status epilepticus. Epilepsia 2020; 61:1735-1748. [PMID: 32715470 DOI: 10.1111/epi.16620] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/25/2020] [Accepted: 06/25/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To identify the timelines of magnetic resonance imaging (MRI) abnormalities and their relationships with the clinical outcomes of patients with new-onset refractory status epilepticus (NORSE). METHODS This retrospective observational study enrolled patients with NORSE who were admitted from March 2008 to July 2018. MRI abnormalities were analyzed visually with the readers blinded to the clinical characteristics of the patients. Poor functional outcome was defined as a Glasgow Outcome Scale score ≤ 3 at discharge. Subsequent pharmacoresistant epilepsy was defined as seizures not controlled by two or more anti-seizure medications 6 months after discharge. RESULTS Among 39 patients with NORSE, 32 (82.1%) exhibited an MRI abnormality. The most common abnormalities were persisting mesial temporal lobe signal abnormality (51.3%); initial diffuse leptomeningeal enhancement within 16 days from seizure onset (15/35, 42.9%); and hippocampal atrophy, which started to appear 26 days after seizure onset (15/26, 57.7%). Only three patients had claustrum abnormalities. Patients with insular involvement had longer treatment delay than those without (24.0 vs 5.5 hours, respectively, P = .02). Duration of status epilepticus (SE) tended to have a linear association with hippocampal atrophy (P = .055). Patients with diffuse leptomeningeal enhancement were more likely to have a poor functional outcome and to develop subsequent pharmacoresistant epilepsy than those without this finding (93.3% vs 15.0%, P < .001; 75.0% vs 22.2%, P = .004, respectively); the results were significant even after adjusting for age, sex, and duration of SE. Hippocampal atrophy and diffuse cortical atrophy were also significantly associated with poor functional outcomes (P = .001 and P = .002, respectively), and patients with these conditions were more likely to develop subsequent pharmacoresistant epilepsy than those without these conditions, after adjusting for age and sex (P = .035 and P = .048, respectively), but not after adjusting for duration of SE. SIGNIFICANCE Initial diffuse leptomeningeal enhancement and later hippocampal atrophy were associated with a poor functional outcome and subsequent pharmacoresistant epilepsy.
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Affiliation(s)
- Hyo Jae Kim
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Sang-Ahm Lee
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Hyun-Woo Kim
- Department of Neurology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Soo Jeong Kim
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Sang-Beom Jeon
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Yong Seo Koo
- Department of Neurology, Asan Medical Center, Seoul, South Korea
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Tuppurainen KM, Ritvanen JG, Mustonen H, Kämppi LS. Predictors of mortality at one year after generalized convulsive status epilepticus. Epilepsy Behav 2019; 101:106411. [PMID: 31668580 DOI: 10.1016/j.yebeh.2019.07.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 07/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Status epilepticus (SE) is a life-threatening neurologic emergency, which requires prompt medical treatment. Little is known of the long-term survival of SE. The aim of this study was to investigate which factors influence 90 days and 1-year mortality after SE. MATERIALS AND METHODS This retrospective study includes all consecutive adult (>16 years) patients (N = 70) diagnosed with generalized convulsive SE (GCSE) in Helsinki University Central Hospital (HUCH) emergency department (ED) over 2 years. We defined specific factors including patient demographics, GCSE characteristics, treatment, complications, delays in treatment, and outcome at hospital discharge and determined their relation to 90 days and 1-year mortality after GCSE by using logistic regression models. Survival analyses at 1 year after GCSE were performed with Cox proportional hazards regression analysis. RESULTS In-hospital mortality was 7.1%. Mortality rate was 14.3% at 90 days and 24.3% at 1 year after GCSE. In the univariate logistic regression analysis, Status Epilepticus Severity Score > 4 (STESS) (ODDS = 7.30, p = 0.012), worse-than-baseline condition at hospital discharge (ODDS = 3.5, p = 0.006), long delays in attaining seizure freedom (ODDS = 2.2, p = 0.041), and consciousness (ODDS = 3.4, p = 0.014) were risk factors for mortality at 90 days whereas epilepsy (ODDS = 0.2, p = 0.014) and Glasgow Outcome Scale (GOS) >3 at hospital discharge (ODDS = 0.05, p = 0.006) were protective factors. Risk factors for mortality at 1 year were STESS >4 (ODDS = 5.1, p = 0.028), use of vasopressors (ODDS = 8.2, p = 0.049), and worse-than-baseline condition at discharge (ODDS = 7.8, p = 0.010) while GOS >3 (ODDS = 0.2, p = 0.005) was protective. The univariate survival analysis at 1 year confirmed the significant findings regarding parameters STESS >4 (Hazard ratio (HR) = 4.1, p = 0.009), worse-than-baseline condition (HR = 6.2, p = 0.015), GOS >3 (HR = 0.2, p = 0.004) at hospital discharge and epilepsy (HR = 0.4, p = 0.044). Additionally, diagnostic delay over 6 h (HR = 3.8, p = 0.022) and Complication Burden Index (CBI) as an ordinal variable (0-2, 3-6, >6) (HR = 2.7, p = 0.027) were predictive for mortality. In the multivariate survival analysis, STESS > 4 (HR = 5.1, p = 0.007), CBI (HR = 3.2, p = 0.025, ordinal variable), diagnostic delay over 6 h (HR = 7.2, p = 0.003), and worse-than-baseline condition at hospital discharge (HR = 5.8, p = 0.027) were all independent risk factors for mortality at 1 year. CONCLUSIONS Severe form of SE, delayed recognition of GCSE, high number of complications during treatment period, and poor condition at hospital discharge are all independent predictors of long-term mortality. Most of these factors are also associated with mortality at 90 days, though at that point, delays in treatment seem to have a greater impact on prognosis than at 1 year. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures.
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Affiliation(s)
- Kati Marjatta Tuppurainen
- Clinical Neurosciences, Neurology, University of Helsinki and Department of Neurology, Helsinki University Central Hospital, Finland.
| | - Jaakko Gabriel Ritvanen
- Clinical Neurosciences, Neurology, University of Helsinki and Department of Neurology, Helsinki University Central Hospital, Finland.
| | - Harri Mustonen
- Department of Surgery, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland.
| | - Leena Sinikka Kämppi
- Clinical Neurosciences, Neurology, University of Helsinki and Department of Neurology, Helsinki University Central Hospital, Finland.
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Gaínza-Lein M, Fernández IS, Ulate-Campos A, Loddenkemper T, Ostendorf AP. Timing in the treatment of status epilepticus: From basics to the clinic. Seizure 2019; 68:22-30. [DOI: 10.1016/j.seizure.2018.05.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/18/2018] [Accepted: 05/29/2018] [Indexed: 02/07/2023] Open
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Muhlhofer WG, Layfield S, Lowenstein D, Lin CP, Johnson RD, Saini S, Szaflarski JP. Duration of therapeutic coma and outcome of refractory status epilepticus. Epilepsia 2019; 60:921-934. [PMID: 30957219 DOI: 10.1111/epi.14706] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 03/09/2019] [Accepted: 03/11/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Examine the association of duration of therapeutic coma (TC) with seizure recurrence, morbidity, and mortality in refractory status epilepticus (RSE). Define an optimal window for TC that provides sustained seizure control and minimizes complications. METHODS Retrospective, observational cohort study involving patients who presented with RSE to the University of Alabama at Birmingham or the University of California at San Francisco from 2010 to 2016. Relationship of duration of TC with primary and secondary outcomes was evaluated using two-sample t tests, simple linear regression, and chi-square tests. Multivariable linear and logistic regression models were used to identify independent predictors. Predictive ability of TC for seizure recurrence was quantified using a receiver-operating characteristic curve. Youden index was used to determine an optimal cutoff value. RESULTS Multivariable analysis of clinical and treatment characteristics of 182 patients who were treated predominantly with propofol as anesthetic agent showed that longer duration of the first trial of TC (27.2 vs 15.6 hours) was independently associated with a higher chance of seizure recurrence following the first weaning attempt (P = 0.038) but not with poor functional neurologic outcome upon discharge, in-hospital complications, or mortality. Furthermore, higher doses of anesthetic utilized during the first trial of TC were independently associated with fewer in-hospital complications (P = 0.003) and associated with a shorter duration of mechanical ventilation and total length of stay. Duration of TC was identified as an independent predictor of seizure recurrence with an optimal cutoff point at 35 hours. SIGNIFICANCE This study suggests that a shorter duration yet deeper TC as treatment for RSE may be more effective and safer than the currently recommended TC duration of 24-48 hours. Prospective and randomized trials should be conducted to validate these assertions.
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Affiliation(s)
- Wolfgang G Muhlhofer
- Department of Neurology/Epilepsy Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stephen Layfield
- Department of Neurology, Case Western Reserve University Hospitals, Cleveland, Ohio
| | - Daniel Lowenstein
- Department of Neurology, University of California San Francisco, San Francisco, California
| | - Chee Paul Lin
- Center for Clinical and Translational Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert D Johnson
- Informatics Institute, Center for Clinical and Translational Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Shalini Saini
- Information Technology Department at School of Medicine Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jerzy P Szaflarski
- Department of Neurology/Epilepsy Center, University of Alabama at Birmingham, Birmingham, Alabama
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10
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Requena M, Fonseca E, Olivé M, Abraira L, Quintana M, Mazuela G, Toledo M, Salas‐Puig X, Santamarina E. The ADAN scale: a proposed scale for pre‐hospital use to identify status epilepticus. Eur J Neurol 2019; 26:760-e55. [DOI: 10.1111/ene.13885] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 12/06/2018] [Indexed: 12/20/2022]
Affiliation(s)
- M. Requena
- Epilepsy Unit Hospital Universitario Vall d'Hebron Barcelona Spain
| | - E. Fonseca
- Epilepsy Unit Hospital Universitario Vall d'Hebron Barcelona Spain
| | - M. Olivé
- Epilepsy Unit Hospital Universitario Vall d'Hebron Barcelona Spain
| | - L. Abraira
- Epilepsy Unit Hospital Universitario Vall d'Hebron Barcelona Spain
| | - M. Quintana
- Epilepsy Unit Hospital Universitario Vall d'Hebron Barcelona Spain
| | - G. Mazuela
- Epilepsy Unit Hospital Universitario Vall d'Hebron Barcelona Spain
| | - M. Toledo
- Epilepsy Unit Hospital Universitario Vall d'Hebron Barcelona Spain
| | - X. Salas‐Puig
- Epilepsy Unit Hospital Universitario Vall d'Hebron Barcelona Spain
| | - E. Santamarina
- Epilepsy Unit Hospital Universitario Vall d'Hebron Barcelona Spain
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11
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Villamar MF, Cook AM, Ke C, Xu Y, Clay JL, Dolbec KS, Ward-Mitchell R, Goldstein LB, Bensalem-Owen M. Status epilepticus alert reduces time to administration of second-line antiseizure medications. Neurol Clin Pract 2018; 8:486-491. [PMID: 30588378 DOI: 10.1212/cpj.0000000000000544] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 08/17/2018] [Indexed: 11/15/2022]
Abstract
Background Status epilepticus (SE) is a neurologic emergency with high morbidity and mortality. Delays in SE treatment are common in clinical practice and can be associated with poorer outcomes. Our goal was to determine whether the implementation of an SE alert protocol improves time to administration of a second-line antiseizure medication (ASM) in hospitalized adults. Methods We developed and implemented an inpatient SE alert system. A quasiexperimental cohort study was performed. We analyzed all patients aged 18-85 years who were managed at the University of Kentucky Medical Center using the SE alert protocol between March 2015 and June 2017 (n = 19). Controls were the first 20 consecutive patients treated for SE over the same time period, but who were managed with usual care (i.e., without SE alert protocol). Results Time to administration of a second-line ASM was shorter with the use of the SE alert system (22.21 ± 3.44 minutes) compared to usual care (58.30 ± 6.72 minutes; p < 0.0001). Conclusion Implementation of an SE alert system led to a marked improvement in time to administration of a second-line ASM. Classification of evidence This study provides Class III evidence that for adult inpatients treated for SE, implementation of an SE alert protocol reduces time to administration of second-line ASM.
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Affiliation(s)
- Mauricio F Villamar
- Departments of Neurology (MFV, JLC, KSD, RW-M, LBG, MB-O) and Statistics (CK, YX), University of Kentucky, Lexington; Department of Neurology (MFV), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and UK HealthCare Pharmacy Services (AMC), Lexington, KY
| | - Aaron M Cook
- Departments of Neurology (MFV, JLC, KSD, RW-M, LBG, MB-O) and Statistics (CK, YX), University of Kentucky, Lexington; Department of Neurology (MFV), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and UK HealthCare Pharmacy Services (AMC), Lexington, KY
| | - Chenlu Ke
- Departments of Neurology (MFV, JLC, KSD, RW-M, LBG, MB-O) and Statistics (CK, YX), University of Kentucky, Lexington; Department of Neurology (MFV), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and UK HealthCare Pharmacy Services (AMC), Lexington, KY
| | - Yan Xu
- Departments of Neurology (MFV, JLC, KSD, RW-M, LBG, MB-O) and Statistics (CK, YX), University of Kentucky, Lexington; Department of Neurology (MFV), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and UK HealthCare Pharmacy Services (AMC), Lexington, KY
| | - Jordan L Clay
- Departments of Neurology (MFV, JLC, KSD, RW-M, LBG, MB-O) and Statistics (CK, YX), University of Kentucky, Lexington; Department of Neurology (MFV), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and UK HealthCare Pharmacy Services (AMC), Lexington, KY
| | - Katelyn S Dolbec
- Departments of Neurology (MFV, JLC, KSD, RW-M, LBG, MB-O) and Statistics (CK, YX), University of Kentucky, Lexington; Department of Neurology (MFV), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and UK HealthCare Pharmacy Services (AMC), Lexington, KY
| | - Rachel Ward-Mitchell
- Departments of Neurology (MFV, JLC, KSD, RW-M, LBG, MB-O) and Statistics (CK, YX), University of Kentucky, Lexington; Department of Neurology (MFV), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and UK HealthCare Pharmacy Services (AMC), Lexington, KY
| | - Larry B Goldstein
- Departments of Neurology (MFV, JLC, KSD, RW-M, LBG, MB-O) and Statistics (CK, YX), University of Kentucky, Lexington; Department of Neurology (MFV), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and UK HealthCare Pharmacy Services (AMC), Lexington, KY
| | - Meriem Bensalem-Owen
- Departments of Neurology (MFV, JLC, KSD, RW-M, LBG, MB-O) and Statistics (CK, YX), University of Kentucky, Lexington; Department of Neurology (MFV), Brigham and Women's Hospital, Harvard Medical School, Boston, MA; and UK HealthCare Pharmacy Services (AMC), Lexington, KY
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