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Au YK, Kananeh MF, Rahangdale R, Moore TE, Panza GA, Gaspard N, Hirsch LJ, Fernandez A, Shah SO. Treatment of Refractory Status Epilepticus With Continuous Intravenous Anesthetic Drugs: A Systematic Review. JAMA Neurol 2024; 81:534-548. [PMID: 38466294 DOI: 10.1001/jamaneurol.2024.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Importance Multiple continuous intravenous anesthetic drugs (CIVADs) are available for the treatment of refractory status epilepticus (RSE). There is a paucity of data comparing the different types of CIVADs used for RSE. Objective To systematically review and compare outcome measures associated with the initial CIVAD choice in RSE in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Evidence Review Data sources included English and non-English articles using Embase, MEDLINE, PubMed, and Web of Science (January 1994-June 2023) as well as manual search. Study selection included peer-reviewed studies of 5 or more patients and at least 1 patient older than 12 years with status epilepticus refractory to a benzodiazepine and at least 1 standard antiseizure medication, treated with continuously infused midazolam, ketamine, propofol, pentobarbital, or thiopental. Independent extraction of articles was performed using prespecified data items. The association between outcome variables and CIVAD was examined with an analysis of variance or χ2 test where appropriate. Binary logistic regressions were used to examine the association between outcome variables and CIVAD with etiology, change in mortality over time, electroencephalography (EEG) monitoring (continuous vs intermittent), and treatment goal (seizure vs burst suppression) included as covariates. Risk of bias was addressed by listing the population and type of each study. Findings A total of 66 studies with 1637 patients were included. Significant differences among CIVAD groups in short-term failure, hypotension, and CIVAD substitution during treatment were observed. Non-epilepsy-related RSE (vs epilepsy-related RSE) was associated with a higher rate of CIVAD substitution (60 of 120 [50.0%] vs 11 of 43 [25.6%]; odds ratio [OR], 3.11; 95% CI, 1.44-7.11; P = .006) and mortality (98 of 227 [43.2%] vs 7 of 63 [11.1%]; OR, 17.0; 95% CI, 4.71-109.35; P < .001). Seizure suppression was associated with mortality (OR, 7.72; 95% CI, 1.77-39.23; P = .005), but only a small subgroup was available for analysis (seizure suppression: 17 of 22 [77.3%] from 3 publications vs burst suppression: 25 of 98 [25.5%] from 12 publications). CIVAD choice and EEG type were not predictors of mortality. Earlier publication year was associated with mortality, although the observation was no longer statistically significant after adjusting SEs for clustering. Conclusions and Relevance Epilepsy-related RSE was associated with lower mortality compared with other RSE etiologies. A trend of decreasing mortality over time was observed, which may suggest an effect of advances in neurocritical care. The overall data are heterogeneous, which limits definitive conclusions on the choice of optimal initial CIVAD in RSE treatment.
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Affiliation(s)
- Yu Kan Au
- Department of Neurosciences, Hartford Hospital, University of Connecticut, Hartford, Connecticut
- Department of Neurology, University of Connecticut, Farmington
| | - Mohammed F Kananeh
- Department of Neurology, Hackensack University Medical Center, Hackensack, New Jersey
- Department of Neurology, Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | - Rahul Rahangdale
- Neuroscience Institute, Ascension St John Medical Center, Tulsa, Oklahoma
| | - Timothy Eoin Moore
- Statistical Consulting Services, Center for Open Research Resources & Equipment, University of Connecticut, Storrs
| | - Gregory A Panza
- Department of Research, Hartford HealthCare, Hartford, Connecticut
| | - Nicolas Gaspard
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
- Université Libre de Bruxelles and Service de Neurologie, Hôpital Universitaire de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Lawrence J Hirsch
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Andres Fernandez
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Syed Omar Shah
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Hidalgo de la Cruz M, Miranda Acuña JA, Luque Buzo E, Chavarria Cano B, Esteban de Antonio E, Prieto Montalvo J, Galiano Fragua ML, Massot-Tarrús A. Status epilepticus management and mortality risk factors: A retrospective study. Neurologia 2022; 37:532-542. [PMID: 31771778 DOI: 10.1016/j.nrl.2019.06.004] [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: 02/14/2019] [Revised: 05/28/2019] [Accepted: 06/20/2019] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Status epilepticus (SE) is a neurological emergency with relatively high mortality rates. In this study, we analysed the management of SE and identified mortality risk factors that may be addressed with educational interventions or modifications to hospital protocols. METHODS In this retrospective study, we analysed demographic, treatment, and outcome data from 65 patients (mean age, 59 years [range, 44.5-77]; 53.8% women) who were admitted to our tertiary hospital during an 18-month period and met the 2015 International League Against Epilepsy criteria for SE. RESULTS Thirty patients (46.2%) had history of epilepsy. The most frequent causes of SE were cerebrovascular disease (27.7%) and systemic infection (16.9%). The following deviations were observed in the administration of the antiepileptic drugs: benzodiazepines were used as first option in only 33 (50.8%) patients; the combination of 2 benzodiazepines was recorded in 7 cases (10.8%); and lacosamide was used as an off-label drug in 5 patients (7.7%). Electroencephalography studies were performed in only 26 patients (40%); and only 5 studies (7.7% of patients) were performed within 12 hours of seizure onset. The mortality rate was 21.5%. Acute stroke and cerebrovascular complications were associated with higher mortality rates, while previous history of epilepsy and admission to intensive care were related to better prognosis (P <.05). CONCLUSIONS To improve SE management and reduce mortality rates, training activities targeting emergency department physicians should be implemented, together with elective intensive care admission for patients with multiple mortality risk factors (eg, absence of history of epilepsy, acute stroke, or cardiovascular complications).
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Affiliation(s)
- M Hidalgo de la Cruz
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España.
| | - J A Miranda Acuña
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - E Luque Buzo
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - B Chavarria Cano
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - E Esteban de Antonio
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J Prieto Montalvo
- Servicio de Neurofisiología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - M L Galiano Fragua
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - A Massot-Tarrús
- Servicio de Neurología, Hospital General Universitario Gregorio Marañón, Madrid, España
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Hidalgo de la Cruz M, Miranda Acuña J, Luque Buzo E, Chavarria Cano B, Esteban de Antonio E, Prieto Montalvo J, Galiano Fragua M, Massot-Tarrús A. Status epilepticus management and mortality risk factors: a retrospective study. NEUROLOGÍA (ENGLISH EDITION) 2022; 37:532-542. [DOI: 10.1016/j.nrleng.2019.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 06/20/2019] [Indexed: 10/20/2022] Open
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Gams Massi D, Endougou Owona CD, Magnerou AM, Kana AJ, Mojoko Eko S, Doumbe J, Mapoure NY. Convulsive status epilepticus in an emergency department in Cameroon. Epilepsy Behav Rep 2021; 16:100440. [PMID: 33997758 PMCID: PMC8099500 DOI: 10.1016/j.ebr.2021.100440] [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: 11/29/2020] [Revised: 02/20/2021] [Accepted: 02/22/2021] [Indexed: 11/05/2022] Open
Abstract
•In Cameroon, the most common cause of CSE was stroke followed by infection.•Despite resource limitations, developing countries can effect protocols for CSE.•Despite limited antiseizure medications, outcomes were similar in Cameroon to multicenter outcomes.
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Affiliation(s)
- Daniel Gams Massi
- Douala General Hospital, PO Box: 4856, Douala, Cameroon
- Faculty of Health Sciences, University of Buea, PO Box: 63, Buea, Cameroon
| | | | - Annick Mélanie Magnerou
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, PO Box: 2701, Douala, Cameroon
| | | | | | - Jacques Doumbe
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, PO Box: 2701, Douala, Cameroon
| | - Njankouo Yacouba Mapoure
- Douala General Hospital, PO Box: 4856, Douala, Cameroon
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, PO Box: 2701, Douala, Cameroon
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Gutiérrez‐Viedma Á, Parejo‐Carbonell B, Romeral‐Jiménez M, Sanz‐Graciani I, Serrano‐García I, Cuadrado M, García‐Morales I. Therapy delay in status epilepticus extends its duration and worsens its prognosis. Acta Neurol Scand 2021; 143:281-289. [PMID: 33075155 DOI: 10.1111/ane.13363] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/03/2020] [Accepted: 10/09/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Timing in status epilepticus (SE) attention is probably the most relevant modifiable prognostic factor and may influence SE duration and prognosis. We aimed to describe the precise relationship between management timing, duration, and prognosis of SE. METHODS Observational longitudinal prospective study on a cohort of all patients diagnosed with SE admitted to our tertiary hospital from September 2017 to August 2019, with a 3-month follow-up. Univariate and multivariable analyses were performed to identify clinical and timing variables associated with SE duration and prognosis. RESULTS Eighty-three SE affecting 76 patients were included. Median age was 73 years, 61.4% were women, median baseline modified Rankin Scale (mRS) was 2, and 55.4% had prior epilepsy. In the out-of-hospital group (n = 50), median time to emergencies was 1.3 h and to hospital admission 2.8 h. In the global series, median time to neurologist was 4.3 h, and median time to therapy initiation was 4.5 h. These four times positively correlated with SE duration (all Spearman's rho coefficient >0.5, all p < .001). SE median duration was 24 h and was extended 1.2 h for each hour of treatment delay. A longer SE duration was associated with increased mortality and morbidity, both at hospital discharge and at 3-month follow-up (both p < .05). After 3 months, mortality was 30.1%, while recovery to baseline mRS occurred in 39.5%, with an overall median mRS of 4. CONCLUSIONS There were pervasive delays in all phases of SE attention, which conditioned a longer SE duration, and this led to increased long-term morbimortality.
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Affiliation(s)
- Álvaro Gutiérrez‐Viedma
- Servicio de Neurología Hospital Universitario Fundación Jiménez Díaz Madrid Spain
- Departamento de Medicina Facultad de Medicina Universidad Complutense de Madrid Madrid Spain
- Instituto de Investigación Sanitaria Fundación Jiménez Díaz Madrid Spain
- Unidad de Epilepsia Servicio de Neurología Hospital Clínico San Carlos Madrid Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
| | - Beatriz Parejo‐Carbonell
- Unidad de Epilepsia Servicio de Neurología Hospital Clínico San Carlos Madrid Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
| | - María Romeral‐Jiménez
- Unidad de Epilepsia Servicio de Neurología Hospital Clínico San Carlos Madrid Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
| | - Isabel Sanz‐Graciani
- Unidad de Epilepsia Servicio de Neurología Hospital Clínico San Carlos Madrid Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
| | - Irene Serrano‐García
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
- Unidad de Metodología de Investigación y Epidemiología Clínica Servicio de Medicina Preventiva Hospital Clínico San Carlos Madrid Spain
| | - María‐Luz Cuadrado
- Departamento de Medicina Facultad de Medicina Universidad Complutense de Madrid Madrid Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
- Servicio de Neurología Hospital Clínico San Carlos Madrid Spain
| | - Irene García‐Morales
- Departamento de Medicina Facultad de Medicina Universidad Complutense de Madrid Madrid Spain
- Unidad de Epilepsia Servicio de Neurología Hospital Clínico San Carlos Madrid Spain
- Instituto de Investigación Sanitaria Hospital Clínico San Carlos Madrid Spain
- Programa de Epilepsia Servicio de Neurología Hospital Ruber Internacional Madrid Spain
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Traenka C, De Marchis GM, Hert L, Seiffge DJ, Polymeris A, Peters N, Bonati LH, Engelter S, Lyrer P, Rüegg S, Sutter R. Acute Ischemic Stroke in Nonconvulsive Status Epilepticus-Underestimated? Results from an Eight-Year Cohort Study. J Stroke 2017; 19:236-238. [PMID: 28460495 PMCID: PMC5466282 DOI: 10.5853/jos.2016.01669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/13/2016] [Accepted: 01/22/2017] [Indexed: 12/23/2022] Open
Affiliation(s)
- Christopher Traenka
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Lisa Hert
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - David J Seiffge
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alexandros Polymeris
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nils Peters
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Leo H Bonati
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stefan Engelter
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philippe Lyrer
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Raoul Sutter
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland.,Department of Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
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Status Epilepticus: Epidemiology and Public Health Needs. J Clin Med 2016; 5:jcm5080071. [PMID: 27537921 PMCID: PMC4999791 DOI: 10.3390/jcm5080071] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Revised: 08/08/2016] [Accepted: 08/10/2016] [Indexed: 11/17/2022] Open
Abstract
Status epilepticus (SE) is defined as a continuous clinical and/or electrographic seizure activity lasting five minutes or more or recurrent seizure activity without return to baseline. There is a paucity of epidemiological studies of SE, as most research is derived from small population studies. The overall incidence of SE is 9.9 to 41 per 100,000/year, with peaks in children and the elderly and with febrile seizures and strokes as its main etiologies. The etiology is the major determinant of mortality. Governments and the academic community should predominantly focus on the primary prevention of etiologies linked to SE, as these are the most important risk factors for its development. This review describes the incidence, prevalence, etiology, risk factors, outcomes and costs of SE and aims to identify future research and public health needs.
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Delays and Factors Related to Cessation of Generalized Convulsive Status Epilepticus. EPILEPSY RESEARCH AND TREATMENT 2015; 2015:591279. [PMID: 26347816 PMCID: PMC4546976 DOI: 10.1155/2015/591279] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Accepted: 07/13/2015] [Indexed: 11/17/2022]
Abstract
Introduction. This study was designed to identify the delays and factors related to and predicting the cessation of generalized convulsive SE (GCSE). Methods. This retrospective study includes 70 consecutive patients (>16 years) diagnosed with GCSE and treated in the emergency department of a tertiary hospital over 2 years. We defined cessation of SE stepwise using clinical seizure freedom, achievement of burst-suppression, and return of consciousness as endpoints and calculated delays for these cessation markers. In addition 10 treatment delay parameters and 7 prognostic and GCSE episode related factors were defined. Multiple statistical analyses were performed on their relation to cessation markers. Results. Onset-to-second-stage-medication (p = 0.027), onset-to-burst-suppression (p = 0.005), and onset-to-clinical-seizure-freedom (p = 0.035) delays correlated with the onset-to-consciousness delay. We detected no correlation between age, epilepsy, STESS, prestatus period, type of SE onset, effect of the first medication, and cessation of SE. Conclusion. Our study demonstrates that rapid administration of second-stage medication and early obtainment of clinical seizure freedom and burst-suppression predict early return of consciousness, an unambiguous marker for the end of SE. We propose that delays in treatment chain may be more significant determinants of SE cessation than the previously established outcome predictors. Thus, streamlining the treatment chain is advocated.
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Abstract
PURPOSE OF REVIEW Status epilepticus is an acute neurologic emergency, the incidence of which is increasing in the United States as the definition evolves and our detection abilities improve. We will present the current definition of status epilepticus, including a recently modified operational definition for use in the clinical setting. We will also provide updates on identifying children in status epilepticus, etiologic considerations, and the rationale for diagnostic testing. RECENT FINDINGS Recent data reveal the benefits of MRI vs. computed tomography in new-onset status epilepticus, as well as high rates of identification of electrographic seizures in patients with unexplained acute encephalopathy in pediatric ICU settings. Genetic testing should be considered in young children with recurrent status epilepticus. SUMMARY Prompt recognition and diagnostic evaluation of the child in status epilepticus will help identify causes, which may require specific treatment, and help in the management of this life-threatening condition. Laboratory work, neuroimaging, electroencephalogram or continuous video electroencephalogram, lumbar puncture, and genetic testing may be considered in the evaluation of the child in status epilepticus.
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