Incidences and outcomes of status epilepticus: A 9-year longitudinal national study

Burden of status epilepticus: prognosis and cost driving factors, insight from a nationwide retrospective cohort study of the French health insurance database

BACKGROUND

Status epilepticus (SE) imposes a significant burden in terms of in-hospital mortality and costs, but the relationship between SE causes, patient comorbidities, mortality, and cost remains insufficiently understood. We determined the in-hospital mortality and cost-driving factors of SE using a large and comprehensive database.

METHODS

We conducted a retrospective cohort study involving patients experiencing their first hospitalization with an ICD-10 code diagnosis of SE, spanning from January 1, 2015, to December 31, 2019, using the French health insurance database which covers 99% of population. Patient characteristics, SE causes, Intensive Care Unit (ICU) admissions, mechanical ventilation, discharge status, and health insurance costs were extracted for each hospitalization.

RESULTS

We identified 52,487 patients hospitalized for a first SE. In-hospital mortality occurred in 11,464 patients (21.8%), with associated factors including age (Odds Ratio [OR], 10.3, 95% Confidence Interval [CI] 7.87-13.8 for ages over 80 compared to 10-19), acute causes (OR, 15.3, 95% CI 13.9-16.8 for hypoxic cause), tumors (OR, 1.75, 95% CI 1.63-1.8), comorbidities (OR, 3.00, 95% CI 2.79-3.24 for 3 or more comorbidities compared to 0), and prolonged mechanical ventilation (OR, 2.61, 95% CI 2.42-2.82). The median reimbursed cost for each SE hospitalization was 6517€ (3364-13,354), with cost factors mirroring those of in-hospital mortality.

CONCLUSION

Causes and co-morbidities are major determinants of mortality and hospital costs in status epilepticus, and factors associated with higher mortality are also often associated with higher costs. Further studies are needed to identify their long-term effects.

Incidence of First-Episode Status Epilepticus and Risk Factors in Ontario, Canada

BACKGROUND

Status epilepticus (SE) is a neurological emergency characterized by prolonged seizures. However, the incidence of first-episode SE is unclear, as estimates vary greatly among studies. Additionally, SE risk factors have been insufficiently explored. Therefore, the objectives of this study were to estimate the incidence of first-episode SE in Ontario, Canada, and estimate the associations between potential sociodemographic and health-related risk factors and first-episode SE.

METHODS

We conducted a population-based retrospective cohort study using linked health administrative datasets. We included individuals who completed Canada's 2006 Census long-form questionnaire, lived in Ontario, were between 18 and 105, and had no history of SE. A Cox proportional hazards regression model was used to estimate the hazard ratios for SE within three years associated with each potential risk factor.

RESULTS

The final sample included 1,301,700 participants, 140 of whom were hospitalized or had an emergency department visit for first-episode SE during follow-up (3.5 per 100,000 person-years). Older age was the only significant sociodemographic SE risk factor (HR = 1.35, 95% CI = 1.33, 1.37), while health-related risk factors included alcohol or drug abuse (HR = 1.05, 95% CI = 1.02, 1.08), brain tumour or cancer (HR = 1.14, 95% CI = 1.12, 1.15), chronic kidney disease (HR = 1.32, 95% CI = 1.29, 1.36), dementia (HR = 1.42, 95% CI = 1.36, 1.48), diabetes (HR = 1.11, 95% CI = 1.09, 1.12), epilepsy or seizures (HR = 1.05, 95% CI = 1.01, 1.09) and stroke (HR = 1.08, 95% CI = 1.05, 1.11).

CONCLUSION

The estimated incidence of SE in a sample of Ontario residents was 3.5 per 100,000 person-years. Older age and several comorbid conditions were associated with higher first-episode SE risk.

Comparing Patients With Isolated Seizures and Status Epilepticus in Intensive Care Units: An Observational Cohort Study

BACKGROUND AND OBJECTIVES

To assess the frequency of status epilepticus (SE) among seizing critically ill adult patients and to determine clinical differences between patients with isolated seizures and patients with SE in the intensive care unit (ICU).

METHODS

From 2015 to 2020, all consecutive adult ICU patients at a Swiss tertiary care center with isolated seizures or SE as reported by intensivists and/or consulting neurologists were identified by screening of all digital medical, ICU, and EEG records. Patients aged <18 years and patients with myoclonus due to hypoxic-ischemic encephalopathy but without seizures on EEG were excluded. The frequency of isolated seizures, SE, and clinical characteristics at seizure onset associated with SE were the primary outcomes. Uni- and multivariable logistic regression was performed to identify associations with the emergence of SE.

RESULTS

Among 404 patients with seizures, 51% had SE. Compared with patients with isolated seizures, patients with SE had a lower median Charlson Comorbidity Index (CCI) (3 vs 5, p < 0.001), fewer fatal etiologies (43.6% vs 80.5%, p < 0.001), higher median Glasgow coma scores (7 vs 5, p < 0.001), fever more frequently (27.5% vs 7.5%, p < 0.001), shorter median ICU and hospital stay (ICU: 4 vs 5 days, p = 0.039; hospital stay: 13 vs 15 days, p = 0.045), and recovered to premorbid function more often (36.8% vs 17%, p < 0.001). Multivariable analyses revealed decreased odds ratios (ORs) for SE with increasing CCI (OR 0.91, 95% CI 0.83-0.99), fatal etiology (OR 0.15, 95% CI 0.08-0.29), and epilepsy (OR 0.32, 95% CI 0.16-0.63). Systemic inflammation was an additional association with SE after excluding patients with seizures as the reason for ICU admission (ORfor CRP 1.01, 95% CI 1.00-1.01; ORfor fever 7.35, 95% CI 2.84-19.0). Although fatal etiologies and increasing CCI remained associated with low odds for SE after excluding anesthetized patients and hypoxic-ischemic encephalopathy, inflammation remained associated in all subgroups except patients with epilepsy.

DISCUSSION

Among all ICU patients with seizures, SE emerged frequently and seen in every second patient. Besides the unexpected low odds for SE with higher CCI, fatal etiology, and epilepsy, the association of inflammation with SE in the critically ill without epilepsy represents a potential treatment target and deserves further attention.

Mortality, and life expectancy in Epilepsy and Status epilepticus-current trends and future aspects

Patients with epilepsy carry a risk of premature death which is on average two to three times higher than in the general population. The risk of death is not homogenously distributed over all ages, etiologies, and epilepsy syndromes. People with drug resistant seizures carry the highest risk of death compared to those who are seizure free, whose risk is similar as in the general population. Most of the increased risk is directly related to the cause of epilepsy itself. Sudden unexplained death in epilepsy patients (SUDEP) is the most important cause of epilepsy-related deaths especially in the young and middle-aged groups. Population based studies with long-term follow up demonstrated that the first years after diagnosis carry the highest risk of death, while in the later years the mortality decreases. Improved seizure control and being exposed to a specialized comprehensive care centre may help to reduce the risk of death in patients with epilepsy. The mortality of status epilepticus is substantially increased with case fatality rates between 4.6% and 39%, depending on its cause and duration, and the age of the population studied. The epidemiological data on overall and cause specific mortality as well as their determinants and risk factors are critically reviewed and methodological issues pertinent to the studies on mortality of epilepsy and Status epilepticus are discussed.

Insight into Drug Resistance in Status Epilepticus: Evidence from Animal Models

Status epilepticus (SE), a condition with abnormally prolonged seizures, is a severe type of epilepsy. At present, SE is not well controlled by clinical treatments. Antiepileptic drugs (AEDs) are the main therapeutic approaches, but they are effective for SE only with a narrow intervening window, and they easily induce resistance. Thus, in this review, we provide an updated summary for an insight into drug-resistant SE, hoping to add to the understanding of the mechanism of refractory SE and the development of active compounds. Firstly, we briefly outline the limitations of current drug treatments for SE by summarizing the extensive experimental literature and clinical data through a search of the PubMed database, and then summarize the common animal models of refractory SE with their advantages and disadvantages. Notably, we also briefly review some of the hypotheses about drug resistance in SE that are well accepted in the field, and furthermore, put forward future perspectives for follow-up research on SE.

Association between status epilepticus and cardiorespiratory comorbidity in patients with epilepsy: A population-based study

PURPOSE

This study aimed to evaluate the relationship between status epilepticus (SE) and cardiorespiratory comorbidity in patients with epilepsy.

METHODS

We conducted a population-based study using cloud-based aggregated electronic medical records from >53 million patients in the US (Explorys, IBM Watson; January 1999 to November 2020). During the study period, we identified patients with epilepsy with SE. Patients with a history of cardiac arrest, anoxic encephalopathy, and/or cerebrovascular disease were excluded. We reported the prevalences and prevalence ratios of cardiorespiratory and medical comorbidities using age- and sex-adjusted standardization.

RESULTS

We identified 494,790 patients with epilepsy and 19,190 had SE. Cardiovascular and respiratory diseases were statistically significantly more prevalent in patients with epilepsy with SE than in those without SE (adjusted prevalence ratio (APR) 1.13, prevalence 68.7% [95% confidence interval (CI): 67.6-69.9] vs 60.9% [95% CI: 60.7-61.1]) and (APR 1.25, 73.1% [95% CI: 71.8-74.3] vs 58.4% [95% CI: 58.1-58.6]), respectively. Aspiration pneumonia (APR 3.12, 0.47% [95% CI: 0.37-0.57] vs 0.15% [95% CI: 0.14-0.16]) and acute respiratory distress syndrome (APR 2.40, 0.47% [95% CI: 0.37-0.57] vs 0.20% [95% CI: 0.18-0.21]) were more prevalent in patients with epilepsy with SE. Common cardiovascular risk factors such as diabetes mellitus (APR 1.13, 17.1% [95% CI: 16.5-17.6] vs 15.1% [95% CI: 1.50-15.2]) and hypertension (APR 1.28, 10.6% [95% CI: 10.2-11.0] vs 8.31% [95% CI: 8.23-8.39]) were also more common in patients with epilepsy with SE.

CONCLUSION

In this population-based study, patients with epilepsy with SE had a statistically significantly higher prevalence of cardiorespiratory comorbidities than in those without SE.

The Next Frontier in Neurocritical Care in Resource-Constrained Settings

Neurocritical care (NCC) is an emerging field within critical care medicine, reflecting the widespread prevalence of neurologic injury in critically ill patients. Morbidity and mortality from neurocritical illness (NCI) have been reduced substantially in resource-rich settings (RRS), owing to the development of advanced technologies, neuro-specific units, and subspecialized medical training. Despite shouldering much of the burden of NCI worldwide, resource-limited settings (RLS) face immense hurdles when implementing guidelines generated in RRS. This review summarizes the current epidemiology, management, and outcomes of the most common NCIs in RLS and offers commentary on future directions in NCC practiced in RLS.

Why won't it stop? The dynamics of benzodiazepine resistance in status epilepticus

Status epilepticus is a life-threatening neurological emergency that affects both adults and children. Approximately 36% of episodes of status epilepticus do not respond to the current preferred first-line treatment, benzodiazepines. The proportion of episodes that are refractory to benzodiazepines is higher in low-income and middle-income countries (LMICs) than in high-income countries (HICs). Evidence suggests that longer episodes of status epilepticus alter brain physiology, thereby contributing to the emergence of benzodiazepine resistance. Such changes include alterations in GABA_A receptor function and in the transmembrane gradient for chloride, both of which erode the ability of benzodiazepines to enhance inhibitory synaptic signalling. Often, current management guidelines for status epilepticus do not account for these duration-related changes in pathophysiology, which might differentially impact individuals in LMICs, where the average time taken to reach medical attention is longer than in HICs. In this Perspective article, we aim to combine clinical insights and the latest evidence from basic science to inspire a new, context-specific approach to efficiently managing status epilepticus.

Management of Status Epilepticus, Refractory Status Epilepticus, and Super-refractory Status Epilepticus

PURPOSE OF REVIEW

Status epilepticus is a serious condition caused by disorders and diseases that affect the central nervous system. In status epilepticus, hypersynchronous epileptic activity lasts longer than the usual duration of isolated self-limited seizures (time t1), which causes neuronal damage or alteration of neuronal networks at a certain time point (time t2), depending on the type of and duration of status epilepticus. The successful management of status epilepticus includes both the early termination of seizure activity and the earliest possible identification of a causative etiology, which may require independent acute treatment. In nonconvulsive status epilepticus, patients present only with subtle clinical signs or even without any visible clinical manifestations. In these cases, EEG allows for the assessment of cerebral function and identification of patterns in need of urgent treatment.

RECENT FINDINGS

In 2015, the International League Against Epilepsy proposed a new definition and classification of status epilepticus, encompassing four axes: symptomatology, etiology, EEG, and age. Various validation studies determined the practical usefulness of EEG criteria to identify nonconvulsive status epilepticus. The American Clinical Neurophysiology Society has incorporated these criteria into their most recent critical care EEG terminology in 2021. Etiology, age, symptomatology, and the metabolic demand associated with an increasing duration of status epilepticus are the most important determinants of prognosis. The consequences of status epilepticus can be visualized in vivo by MRI studies.

SUMMARY

The current knowledge about status epilepticus allows for a more reliable diagnosis, earlier treatment, and improved cerebral imaging of its consequences. Outcome prediction is a soft tool for estimating the need for intensive care resources.

The Outcome of Status Epilepticus Among Adults in Aseer Region of Saudi Arabia

Introduction

Epileptic seizure episodes can vary from brief and nearly undetectable to long periods of vigorous shaking. These episodes can result in physical injuries, occasionally including broken bones. With epilepsy, seizures tend to recur and, as a rule, have no immediate underlying cause. Status epilepticus (SE) is an attack of a seizure lasting for more than five minutes or two or more seizures without the person returning to normal between the attacks. Previous definitions used a 30-minute time limit. This study aimed to assess the clinical outcome of SE among adult patients in the Aseer region.

Materials and methods

A retrospective record-based cohort study design was conducted, targeting all accessible medical files of adult patients with SE who were admitted to the Aseer central hospital and military hospital from 2010 to 2017. Data were extracted from all complete and accessible files. Records with missing data were excluded. Clinical outcomes for the cases included were assessed and categorized into cases of complete recovery (without sequelae), cases with incomplete recovery, and death.

Results

The study included 19 adult patients with SE whose ages ranged from seven to 87 years with a mean age of 33.4 ± 22.5 years. Men made up 63.2% of the cases. Infection was the most recorded risk factor among the cases, followed by anti-epileptic drug withdrawal. Only two cases recovered with sequelae, while the remaining 17 cases recovered completely. There were no deaths.

Conclusions

The study revealed that nearly all cases recovered completely with no complications, particularly men who immediately received IV treatment. Early diagnosis and receiving treatment under careful observation via follow-up are recommended.

Management of status epilepticus: a narrative review

Status epilepticus causes prolonged or repetitive seizures that, if left untreated, can lead to neuronal injury, severe disability, coma and death in paediatric and adult populations. While convulsive status epilepticus can be diagnosed using clinical features alone, non-convulsive status epilepticus requires confirmation by electroencephalogram. Early seizure control remains key in preventing the complications of status epilepticus. This is especially true for convulsive status epilepticus, which has stronger evidence supporting the benefit of treatment on outcomes. When status epilepticus becomes refractory, often due to gamma-aminobutyric acid and N-methyl-D-aspartate receptor modulation, anaesthetic drugs are needed to suppress seizure activity, of which there is limited evidence regarding the selection, dose or duration of their use. Seizure monitoring with electroencephalogram is often needed when patients do not return to baseline or during anaesthetic wean; however, it is resource-intensive, costly, only available in highly specialised centres and has not been shown to improve functional outcomes. Thus, the treatment goals and aggressiveness of therapy remain under debate, especially for non-convulsive status epilepticus, where prolonged therapeutic coma can lead to severe complications. This review presents an evidence-based, clinically-oriented and comprehensive review of status epilepticus and its definitions, aetiologies, treatments, outcomes and prognosis at different stages of the patient's journey.

Super-Refractory Status Epilepticus: Prognosis and Recent Advances in Management

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.

Epidemiology and Outcomes of Status Epilepticus

Status epilepticus (SE) is a neurological and medical emergency, defined as a condition resulting either from the failure of the mechanisms responsible of seizure self-limitation or from the initiation of mechanisms which lead to atypically prolonged seizures. Further than death, SE can have long-term consequences, including neuronal injury, depending on the type, cause and duration of seizures with severe associated disabilities. In Europe, SE shows an incidence rate ranging about 9 to 40/100,000/y. In adults, mortality of patients with SE is ~30%, and even higher (up to 40%) in refractory status epilepticus. To date, etiology, duration, presence of comorbidity, level of consciousness, semiology and age are the main clinical predictors of SE outcome.

Epidemiology of status epilepticus in a non-urban area in Switzerland

OBJECTIVE

The aim of this study is to provide a precise population-based data on incidence, types, and causes of SE according to the 2015 ILAE definition and classification using a prospectively cohort in an adult population of a non-urban area.

MATERIALS & METHODS

Prospective observational SE cohort in a single large community hospital. The center is the only one in the region (French-speaking Valais canton), with all available resources to treat SE (including neurologist available 24/7, EEG monitoring and ICU). Every adult patient with SE is included (except post-anoxic SE). All variables are collected prospectively using the 2015 ILAE status epilepticus classification.

RESULTS

We identified 103 patients with SE in the study period between 1st of May 2015 and 30th of June 2019 for a population of 260,855 people. The incidence is 8.6 per 100,000 adults per year with an overall case-fatality rate of 7.8%. SE was generalized convulsive in 52% of cases and nonconvulsive SE in coma in 34%.

CONCLUSIONS

Using a prospective reliable data collection with strict inclusion criteria, we found an incidence of 8.6 per 100,000 persons per year, in line with previous report using similar methods. The most severe forms-generalized convulsive and nonconvulsive SE in coma-represent the majority of cases. These data might be important for resources allocation in non-urban area with non-university healthcare system.

Knockout of Transient Receptor Potential Melastatin 4 Channel Mitigates Cerebral Edema and Neuronal Injury After Status Epilepticus in Mice

This study aimed to evaluate whether the knockout of transient receptor potential melastatin 4 (TRPM4) could reduce cerebral edema and improve neurologic outcome in a mouse model of status epilepticus (SE). Wild-type (WT) (n = 61) and Trpm4-/- mice (n = 61) with behavioral seizures induced by lithium (10 mEq/kg) and pilocarpine (30-40 mg/kg) were terminated 2.5 hours after the onset of SE. After SE, 28 WT-SE and 27 Trpm4-/--SE mice were observed for 28 days and assessed for survival and cognitive function; the others were killed after 24 hours, 72 hours, or 7 days, and evaluated for cerebral edema and histological injury. In comparison to WT-SE mice, the mortality and cognitive deficit for Trpm4-/--SE mice following SE after 28 days were significantly ameliorated. Trpm4-/--SE mice also showed less water content and cerebral edema assessed by magnetic resonance imaging, and decreased blood-brain barrier breakdown after SE. Moreover, Trpm4 deficiency significantly mitigated neuronal loss, cellular necrosis and apoptosis in the hippocampus and piriform cortex and mitigated astrocytosis and microgliosis. In conclusion, this study suggests that Trmp4 may represent a new target for improving outcomes after SE.

A Fast-Track Care by a Nursing Case Management Concept Improved Status Epilepticus Outcomes

BACKGROUND

Status epilepticus (SE) is an emergency neurological condition, which is life-threatening, results in high morbidity and mortality rates, and needs to be diagnosed and promptly cared for. This study aimed to develop and evaluate the SE fast-track care using a nursing case management concept on SE outcomes.

METHODS

Quasi-experimental study conducted in adult patients with SE admitted in 15 emergency and intensive critical/intermediate care wards. SE outcomes were evaluated and compared between preintervention and postintervention.

RESULTS

Time to treatment was reduced from 30 minutes to 3.5 minutes (P < .001). Similarly, the seizure control rate increased from 65.7% to 94.4% (P = .009). The mortality rate was reduced but did not reach statistical significance (8.6% vs 0%; P = .115). The intervention also reduced average waiting time for receiving antiepileptic drugs from the pharmacy department from 13.09 minutes to < 1 minute.

CONCLUSION

The development of the fast-track care system for SE patients by nursing case management is at the core of management for coordinating multidisciplinary teams. This can improve outcomes by reducing the time to diagnosis and treatment time, therefore reducing mortality rates in SE patients.

Outcomes of status epilepticus and their predictors in the elderly-A systematic review

Status epilepticus (SE) is associated with high mortality and morbidity. Although SE is frequently seen in elderly patients, there is a lack of a cohesive report of outcome measures and associated factors within this population. Our aim was to systematically review studies reporting outcomes of SE among elderly patients and factors influencing these outcomes. A literature search was conducted in PubMed/MEDLINE, EMBASE, CINAHL Complete, and Cochrane Library from database conception to April 22, 2018. A total of 85 studies were included in this systematic review. The included studies show that mortality is higher in elderly patients than in adult patients. Lesional etiologies, higher number of comorbidities, NCSE, RSE, longer hospital and intensive care unit stays, and infection during hospitalization are associated with poor outcome. Future studies should consider measuring functional outcomes, comparative studies between elderly and adults and AED clinical trials specific for elderly with SE.

Cardiovascular complications of epileptic seizures

Seizure disorders are associated with multisystem complications. Cardiovascular complications account for a significant proportion of morbidity and mortality in these patients. As such, particular attention must be paid to the incidence of cardiovascular complications especially in populations at increased risk. The background for cardiac dysfunction lies in the interplay of genetic/molecular, autonomic, and iatrogenic factors that contribute to its onset. The purpose of this review was to summarize the state of literature in the last decade with regard to cardiac complications of epileptic seizures in order to increase awareness of short- and long-term debilitating cardiac complications as well as facilitate informed clinical decision-making. Taken together, the evidence provided in this review suggests that cardiac dysfunction following seizures should not be viewed as a separate entity but as an important complication of epileptic seizures. Appropriate cardiac therapy should be instituted in the postictal medical management of epileptic seizures. In acute states, postictal cardiac troponinemia (elevated cTn) should be worked up. Longer-term, monitoring for the development of cardiac structural and functional abnormalities is prudent.

Epidemiology of status epilepticus in adults: Apples, pears, and oranges - A critical review

OBJECTIVE

Status epilepticus (SE) is a severe neurologic condition associated with high morbidity and mortality. Population-based studies in adults have found a wide range of incidences in various regions in the world. Although the incidence of SE increases almost exponentially in the elderly, data on census-based population statistics in these studies are scarce. This study provides a critical review with an emphasis on census-based population statistics and study characteristics in adults.

METHODS

We performed a systematic search of population-based studies on SE in adults in PubMed using "status epilepticus" in combination with "epidemiology", "population", and "incidence" as search terms, and also screened references. For each identified study, we assessed and extracted the respective population pyramids of study and reference population, and study characteristics.

RESULTS

We identified 22 population-based studies (eleven from Europe, six from North America, three from Asia, one from Africa, and one from Australasia). Incidence rates of patients with SE ranged from 1.29 to 73.7/100,000 adults (95% confidence interval (CI): 76.6-80.3) and of SE episodes up to 81.1/100,000 adults (95% CI: 75.8-87.0). The proportions of elderly and very old patients varied by a factor of 2.6 and 8.5, respectively, depending on study period and place. Further major reasons for heterogeneity were retrospective or prospective study design, definition of time to diagnose SE, variable detection of nonconvulsive SE (NCSE), different etiologies, inclusion of children, recurrent episodes, postanoxic patients, exclusion of patients with preexisting epilepsy or patients identified outside the emergency department, and choice of reference population for age- and gender adjustment. The most recent definition and classification of SE by the International League Against Epilepsy (ILAE) 2015 was used in two studies. Four studies (18.2%) reported incidences per ten-year age strata necessary for age adjustment to various reference populations.

CONCLUSIONS

This critical review reveals a marked heterogeneity among population-based studies on SE in adults. It provides comprehensive details on census-based population statistics in study and reference populations and various study designs and characteristics essential for direct comparisons between studies. Reporting on these essential key features should be improved in population-based studies on SE.

Incidence of the different stages of status epilepticus in Eastern Finland: A population-based study

OBJECTIVE

The objective of this study was to determine the incidence in Eastern Finland of the different stages of status epilepticus (SE): 1) at the early stage of SE (a prolonged seizure lasting over 5 min);, 2) refractory SE (RSE), and 3) super-refractory SE (SRSE).

METHODS

Firstly, we conducted a retrospective study on the incidence and outcome of intensive care unit (ICU)-treated RSE and SRSE in the adult population (≥16 years) in Kuopio University Hospital (KUH)'s special care responsibility area (840,000 inhabitants). Secondly, we conducted a prospective study using the International League Against Epilepsy (ILAE)'s new definition for SE (prolonged seizures lasting over 5 min), in adult (≥16 years) patients in the KUH municipality district (North Savo, 248,000 inhabitants).

RESULTS

The retrospective study on ICU-treated RSE and SRSE from 2010 to 2012 identified 75 patients with RSE, of whom 21% were treated as SRSE, resulting in an annual age-adjusted incidence of ICU-treated RSE of 3.0/100,000 (95% confidence interval [CI]: 2.4-3.8) and 0.6/100,000 (95% CI: 0.4-1.0) for SRSE. In the prospective study of early stage SE (seizures lasting over 5 min), we identified 151 consecutive episodes during the 9-month study period in 2015, corresponding to an annual age-adjusted incidence of 81.1/100,000 (95% CI: 75.8-87.0). In this study, 11 seizure episodes became refractory, resulting in an age-adjusted incidence of RSE of 6.0/100,000 (95% CI: 3.4-10.4), of which seven were treated in the ICU [3.8/100,000 (95% CI: 1.8-7.8)], four were treated palliatively [2.2/100,000 (95% CI: 0.82-5.7)], and two evolved to SRSE [1.1/100,000 (95% CI: 0.3-4.3)].

CONCLUSIONS

The new ILAE 2015 definition of SE resulted in a four-fold increase in incidence of SE compared to the earlier 30-min definition reported earlier in Europe. In the epidemiology of RSE, the incidence of ICU-treated RSE, palliatively treated RSE, and SRSE needs to be separated. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures.

Causes of death in patients with status epilepticus

BACKGROUND

Status epilepticus (SE) is a neurological disorder that affects to the high mortality risk. Several studies reported predictors of mortality in SE; actual causes of death in hospital and out of hospital are limited. This study aimed to describe the case fatality and the causes of death in patients with SE.

METHODS

This was a descriptive study using the data collected in the national data of the Universal Coverage Scheme in Thailand during the fiscal year 2005 to 2015. Patients who admitted to hospitals and diagnosed as SE were included. The vital status of patients with SE was linked with the Ministry of the Interior and was classified into three phases: in-hospital, short-term, and long-term.

RESULTS

Among 24,802 patients with SE, 1861 (7.5%) died in hospital, 1910 (7.7%) died within 30 days after hospital discharge, and 4906 (19.8%) died after 30 days. In-hospital death, SE complications (45.9%), seizure (19.6%), and comorbidities (15.4%) were the three common causes of death. While the common causes in short-term and long-term mortality were SE complications (27.7% and 31.0%), comorbidities (28.1% and 26.7%), and other causes (22.4% and 21.9%).

CONCLUSION

Status epilepticus complications and comorbidities were the common cause of death in patients with SE for all of three periods. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".

In-hospital mortality of status epilepticus in China: Results from a nationwide survey

PURPOSE

We attempted to determine the nationwide in-hospital mortality rate in people with status epilepticus (SE) in China.

METHODS

Using the database of the Chinese Hospital Quality Monitoring System (HQMS), we identified people hospitalised from 2013 to 2017 with an ICD-10 code G41 for SE as the primary diagnosis. HQMS was developed by the National Health Commission of the People's Republic of China. Demographics, outcomes at discharge, and financial information were extracted automatically from the medical records.

RESULTS

We identified 29,031 cases with SE as the primary diagnosis from 585 tertiary centres during the five-year period. Among those included, there was a preponderance of men (61 %), and the mean age was 40.4 ± 25.2 years (range: 0-98). The in-hospital mortality rate was 1.46 % over the whole time period, while the overall mortality ranged from 1.80 % in 2013 to 1.20 % in 2017. The mean cost of treatment was 14517.81 RMB ($ 2147.92) per individual, and the mean duration of hospital stay was 9.25 days.

CONCLUSION

We provide an overview of mortality related to SE in China as the HQMS database covers a large number of cases of SE in China, making it one of the most efficient tools for mortality investigation. The use of electronic medical records in China creates several challenges and here we discuss lessons learned. The methodology will be improved and will be used in future studies.

Budget Impact Analysis of Extended-Release Phenytoin Capsules Compared With Immediate-Release Phenytoin Capsules for Patients With Epilepsy in Thailand

OBJECTIVES

There was higher frequency of breakthrough seizures during immediate-release phenytoin capsule usage than during extended-release phenytoin capsule usage by epilepsy patients. This study aimed to estimate the total budget of using extended-release phenytoin compared with immediate-release phenytoin capsules.

METHODS

A decision tree model was developed for 3 scenarios in Thailand where (1) extended-release phenytoin, (2) immediate-release phenytoin, and (3) both forms, as per the market share, were prescribed. All parameters were derived from the literature reviews and hospital database and analyzed from payer and societal perspectives.

RESULTS

Of 95 613 patients receiving phenytoin, the total budget impact of scenarios 1 to 3 ranged from $45 214 915 to $50 209 357, $104 298 093 to $111 846 317, and $61 167 373 to $66 851 336 from payer and societal perspectives, respectively.

CONCLUSION

Prescribing extended-release phenytoin showed the lowest total budget impact in Thailand. A healthcare policy recommendation developed from this research would help in solving the antiepileptic drug issue.

Status Epilepticus, Refractory Status Epilepticus, and Super-refractory Status Epilepticus

PURPOSE OF REVIEW

Status epilepticus, refractory status epilepticus, and super-refractory status epilepticus can be life-threatening conditions. This article presents an overview of the three conditions and discusses their management and outcomes.

RECENT FINDINGS

Status epilepticus was previously defined as lasting for 30 minutes or longer but now is more often defined as lasting 5 minutes or longer. A variety of potential causes exist for status epilepticus, refractory status epilepticus, and super-refractory status epilepticus, but all three ultimately involve changes at the cellular and molecular level. Management of patients with status epilepticus generally requires several studies, with EEG of utmost importance given the pathophysiologic changes that can occur during the course of status epilepticus. Status epilepticus is treated with benzodiazepines as first-line antiepileptic drugs, followed by phenytoin, valproic acid, or levetiracetam. If status epilepticus does not resolve, these are followed by an IV anesthetic and then alternative therapies based on limited data/evidence, such as repetitive transcranial magnetic stimulation, therapeutic hypothermia, immunomodulatory agents, and the ketogenic diet. Scores have been developed to help predict the outcome of status epilepticus. Neurologic injury and outcome seem to worsen as the duration of status epilepticus increases, with outcomes generally worse in super-refractory status epilepticus compared to status epilepticus and sometimes also to refractory status epilepticus.

SUMMARY

Status epilepticus can be a life-threatening condition associated with multiple complications, including death, and can progress to refractory status epilepticus and super-refractory status epilepticus. More studies are needed to delineate the best management of these three entities.

Epidemiology of status epilepticus in adults: A population-based study on incidence, causes, and outcomes

Objective

In 2015, the International League Against Epilepsy (ILAE) proposed a new definition of status epilepticus (SE): 5 minutes of ongoing seizure activity to diagnose convulsive SE (CSE, ie, bilateral tonic–clonic SE) and 10 minutes for focal SE and absence SE, rather than the earlier criterion of 30 minutes. Based on semiology, several types of SE with prominent motor phenomena at any time (including CSE) were distinguished from those without (ie, nonconvulsive SE, NCSE). We present the first population‐based incidence study applying the new 2015 ILAE definition and classification of SE and report the impact of the evolution of semiology and level of consciousness (LOC) on outcome.

Methods

We conducted a retrospective population‐based incidence study of all adult patients with SE residing in the city of Salzburg between January 2011 and December 2015. Patients with hypoxic encephalopathy were excluded. SE was defined and classified according to the ILAE 2015.

Results

We identified 221 patients with a median age of 69 years (range 20‐99 years). The age‐ and sex‐adjusted incidence of a first episode of SE, NCSE, and SE with prominent motor phenomena (including CSE) was 36.1 (95% confidence interval [CI] 26.2‐48.5), 12.1 (95% CI 6.8‐20.0), and 24.0 (95% CI 16.0‐34.5; including CSE 15.8 [95% CI 9.4‐24.8]) per 100 000 adults per year, respectively. None of the patients whose SE ended with or consisted of only bilateral tonic–clonic activity died. In all other clinical presentations, case fatality was lower in awake patients (8.2%) compared with patients with impaired consciousness (33%).

Significance

This first population‐based study using the ILAE 2015 definition and classification of SE found an increase of incidence of 10% compared to previous definitions. We also provide epidemiologic evidence that different patterns of status evolution and LOCs have strong prognostic implications.

Treatment gap for convulsive status epilepticus in resource-poor countries

The magnitude of the treatment gap (TG) for convulsive status epilepticus (CSE) in resource-poor countries is unknown. Hospital-based cohort studies from developing countries revealed that the management of CSE was usually suboptimal due to lack of advanced diagnostic and treatment facilities, significant delay in patient's presentation at hospital, and shortages of essential antiepileptic drugs (AEDs). However, there were no significant differences in the proportion of refractory status epilepticus, short-term mortalities, and morbidities of CSE between the developed and the developing countries. Therefore, the presence of significant TG for CSE in developing countries is still an assumption without evidence. We conducted an expert survey in Asia for potential sources of TG. Experts from 16 Asian countries responded to the questionnaire. An injectable form of diazepam was available in all 16 countries even at the primary care level, but intravenous lorazepam was available only in four countries. Second-line AEDs were widely available at tertiary care hospitals, but not at primary care hospitals. Lack of second-line AEDs at primary care hospitals, significant delay in patient transportation to the hospital, shortages of intensive care unit facilities, and absence of trained physicians were important contributing factors to TG in Asia.

Risk score predictive of mortality in status epilepticus according to a national database

Status epilepticus (SE) is a serious neurologic condition with high morbidity and mortality rates. This study aimed to develop and validate a risk score that is predictive of mortality in patients with SE using clinical factors without electrocardiography. The inclusion criteria of this study were all patients diagnosed with SE and treated between 2005 and 2015. We retrospectively searched for eligible patients using the International Classification of Diseases, Tenth Revision (ICD-10) code for SE (G41) in the national Universal Health Coverage database. The outcome was death at discharge or within 30 days after discharge. Factors-associated death was analyzed using stepwise logistic regression analysis. Risk scores were developed based on the final logistic regression model. The final model was also validated. There were 10 924 patients used for model development and 10 808 used for model validation. The formula to determine the risk score for SE mortality was 5 × shock + 4 × age over 60 years old + 3.5 × heart diseases + 3 × acute renal failure + 3 × septicemia + 2.5 × central nervous system infection + 2.5 × age 41-60 years old + 2 × cancer + 2 × chronic renal failure + 1.5 × age 21-40 years old + 1 × pneumonia + 1 × respiratory failure + 1 × anemia. The risk scores of greater than 4 indicated risk for mortality with a sensitivity of 78.20% and specificity of 75.38%. The area under the receiver-operating characteristic (ROC) curve for death in the final model was 83.59%. The area under the ROC curve for the model validation group was 83.52%. SE patients who had a risk score of 4 or more were at high risk for death. Physicians should be aware of the high mortality rate in these particular patients.

Systemic Complications Following Status Epilepticus

PURPOSE OF REVIEW

Status epilepticus (SE) is a multisystem disorder. Initially, complications of a massive catecholamine release followed by the side effects of medical therapies, impact patients' outcomes. The aim of this article is to provide an updated summary of the systemic complications following SE.

RECENT FINDINGS

In recent years, the importance of the multifaceted nature of SE and its relationship with clinical outcomes has been increasingly recognized. The cumulative systemic effects of prolonged seizures and their treatment contribute to morbidity and mortality in this condition. Most systemic complications after SE are predictable. Anticipating their occurrence and respecting a number of simple guidelines may improve the prognosis of these patients.

Status epilepticus in the elderly patients: A national data study in Thailand

There are limited data in terms of incidence, clinical features, and outcomes in elderly patients with status epilepticus (SE) in national level. We retrospectively explored national data in Thailand for reimbursement of all SE in elderly patients admitted in the fiscal year 2004-2012. SE in elderly patients (age>60years old) were diagnosed and searched based on ICD 10 (G41) from the national database of from the National Health and Security Office. There were 3326 SE in elderly patients. The national incidence of SE was highest at 8.78patients/100,000/year in 2012. The average age was 72.02years and most were males (1379 patients; 58.8%). At discharge, 66% of patients had improved and in-hospital mortality rate was 14.5%. Predictors of poor outcomes were older age≥80years, being female, hospital levels, chronic renal failure, central nervous system infection, respiratory failure, pneumonia, septicemia, shock, acute renal failure, and hyperkalemia. In conclusion, the number of cases of SE in elderly patients in Thailand has been increasing annually. Increasing age was associated with poor outcome in admitted elderly SE patients.

Infodemiology of status epilepticus: A systematic validation of the Google Trends-based search queries

People increasingly use Google looking for health-related information. We previously demonstrated that in English-speaking countries most people use this search engine to obtain information on status epilepticus (SE) definition, types/subtypes, and treatment. Now, we aimed at providing a quantitative analysis of SE-related web queries. This analysis represents an advancement, with respect to what was already previously discussed, in that the Google Trends (GT) algorithm has been further refined and correlational analyses have been carried out to validate the GT-based query volumes. Google Trends-based SE-related query volumes were well correlated with information concerning causes and pharmacological and nonpharmacological treatments. Google Trends can provide both researchers and clinicians with data on realities and contexts that are generally overlooked and underexplored by classic epidemiology. In this way, GT can foster new epidemiological studies in the field and can complement traditional epidemiological tools.