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Rubinos C. Emergent Management of Status Epilepticus. Continuum (Minneap Minn) 2024; 30:682-720. [PMID: 38830068 DOI: 10.1212/con.0000000000001445] [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: 06/05/2024]
Abstract
OBJECTIVE Status epilepticus is a neurologic emergency that can be life- threatening. The key to effective management is recognition and prompt initiation of treatment. Management of status epilepticus requires a patient-specific-approach framework, consisting of four axes: (1) semiology, (2) etiology, (3) EEG correlate, and (4) age. This article provides a comprehensive overview of status epilepticus, highlighting the current treatment approaches and strategies for management and control. LATEST DEVELOPMENTS Administering appropriate doses of antiseizure medication in a timely manner is vital for halting seizure activity. Benzodiazepines are the first-line treatment, as demonstrated by three randomized controlled trials in the hospital and prehospital settings. Benzodiazepines can be administered through IV, intramuscular, rectal, or intranasal routes. If seizures persist, second-line treatments such as phenytoin and fosphenytoin, valproate, or levetiracetam are warranted. The recently published Established Status Epilepticus Treatment Trial found that all three of these drugs are similarly effective in achieving seizure cessation in approximately half of patients. For cases of refractory and super-refractory status epilepticus, IV anesthetics, including ketamine and γ-aminobutyric acid-mediated (GABA-ergic) medications, are necessary. There is an increasing body of evidence supporting the use of ketamine, not only in the early phases of stage 3 status epilepticus but also as a second-line treatment option. ESSENTIAL POINTS As with other neurologic emergencies, "time is brain" when treating status epilepticus. Antiseizure medication should be initiated quickly to achieve seizure cessation. There is a need to explore newer generations of antiseizure medications and nonpharmacologic modalities to treat status epilepticus.
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Orlandi N, Giovannini G, Cioclu MC, Biagioli N, Madrassi L, Vaudano AE, Pugnaghi M, Lattanzi S, Meletti S. Remote seizures and drug-resistant epilepsy after a first status epilepticus in adults. Eur J Neurol 2024; 31:e16177. [PMID: 38258477 DOI: 10.1111/ene.16177] [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: 09/10/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND AND PURPOSE Long-term consequences after status epilepticus (SE) represent an unsettled issue. We investigated the incidence of remote unprovoked seizures (RS) and drug-resistant epilepsy (DRE) in a cohort of first-ever SE survivors. METHODS A retrospective, observational, and monocentric study was conducted on adult patients (age ≥ 14 years) with first SE who were consecutively admitted to the Modena Academic Hospital, Italy (September 2013-March 2022). Kaplan-Meier survival analyses were used to calculate the probability of seizure freedom following the index event, whereas Cox proportional hazard regression models were used to identify outcome predictors. RESULTS A total of 279 patients were included, 57 of whom (20.4%) developed RS (mean follow-up = 32.4 months). Cumulative probability of seizure freedom was 85%, 78%, and 68% respectively at 12 months, 2 years, and 5 years. In 45 of 57 patients (81%), the first relapse occurred within 2 years after SE. The risk of RS was higher in the case of structural brain damage (hazard ratio [HR] = 2.1, 95% confidence interval [CI] = 1.06-4.01), progressive symptomatic etiology (HR = 2.7, 95% CI = 1.44-5.16), and occurrence of nonconvulsive evolution in the semiological sequence of SE (HR = 2.9, 95% CI = 1.37-6.37). Eighteen of 57 patients (32%) developed DRE; the risk was higher in the case of super-refractory (p = 0.006) and non-convulsive SE evolution (p = 0.008). CONCLUSIONS The overall risk of RS was moderate, temporally confined within 2 years after the index event, and driven by specific etiologies and SE semiology. Treatment super-refractoriness and non-convulsive SE evolution were associated with DRE development.
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Affiliation(s)
- Niccolò Orlandi
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Giada Giovannini
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
| | - Maria Cristina Cioclu
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolò Biagioli
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Laura Madrassi
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Anna Elisabetta Vaudano
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Matteo Pugnaghi
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Stefano Meletti
- Neurology Unit, Ospedale Civile, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
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Saroha D, Panda S, Deora S, Mohammed S. Cardiac Abnormalities in Refractory Status Epilepticus-an Exploratory Study. J Epilepsy Res 2023; 13:42-50. [PMID: 38223358 PMCID: PMC10783967 DOI: 10.14581/jer.23007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/06/2023] [Accepted: 12/16/2023] [Indexed: 01/16/2024] Open
Abstract
Background and Purpose Cardiac abnormalities have been reported during ongoing seizures and refractory status epilepticus (RSE). Reduced heart rate variability (HRV) and cardiac arrhythmias may contribute to sudden unexpected death in epilepsy. We sought to explore the utility of electrocardiographic and echocardiographic changes in patients with RSE prognosis and functional outcome. Methods Patients of RSE underwent electrocardiogram (ECG), holter, troponin-I (Trop I), N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and 2-dimensional echocardiogram (2D Echo) along with continuous electroencephalogram in first 24 hours and admission. Heart rate changes/arrhythmias, corrected QT interval (QTc) and HRV, ventricular dysfunction or regional motion wall abnormality were studied on 2D Echo. These parameters were also at baseline, at discharge or death and 30 days post discharge. Results This prospective observational study conducted over 18 months enrolled 20 patients with RSE, fulfilling the inclusion criteria. Mean age was 47.75±17.2 years with male: female ratio of 1:1. Mean time to presentation from seizure onset was 8.80±7.024 hours. Central nervous system infection (35.0%), autoimmune encephalitis (20.0%) and cerebrovascular disease (20.0%) were the common etiologies. Amongst cardiac injury markers, cardiac enzymes and QTc prolongation were the commonest abnormalities in RSE. Both reduced HRV and presence of cardiac injury markers had significant correlation with poor outcome along with poor Glasgow coma scale (GCS) and modified Rankin scale (mRS) at presentation, and presence of non convulsive status epilepticus (NCSE). Conclusions Presence of poor GCS, poor mRS, markers of cardiac injury, reduced HRV and occurrence of NCSE have a consistent correlation with mortality and poor clinical outcome. Therefore, routine assessment of cardiac abnormalities using affordable, easily accessible and non-invasive tools such as ECG, 2D Echo, holter NT-proBNP and Trop I is recommended in RSE patients.
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Affiliation(s)
- Deepika Saroha
- Department of Neurology, All India Institute of Medical Sciences (AIIMS), Jodhpur,
India
| | - Samhita Panda
- Department of Neurology, All India Institute of Medical Sciences (AIIMS), Jodhpur,
India
| | - Surender Deora
- Department of Cardiology, All India Institute of Medical Sciences (AIIMS), Jodhpur,
India
| | - Sadik Mohammed
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), Jodhpur,
India
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Liu G, Wang Y, Tian F, Jiang M, Huang H, Chen W, Zhang Y, Su Y. Long-term follow-up of phenobarbital versus valproate for generalized convulsive status epilepticus in adults: A randomized clinical trial. Epilepsy Res 2023; 195:107187. [PMID: 37467704 DOI: 10.1016/j.eplepsyres.2023.107187] [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: 03/09/2023] [Revised: 06/16/2023] [Accepted: 07/03/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE Intravenous phenobarbital is frequently offered to patients with generalized convulsive status epilepticus (GCSE) in China, but its long-term benefits are unclear. We aimed to evaluate the long-term effects of intravenous phenobarbital on adult patients with GCSE. METHODS This randomized clinical trial with a 12-month follow-up was performed in Xuanwu Hospital, Capital Medical University (Beijing, China) between February 2011 and December 2021. After the failure of intravenous diazepam treatment, adult patients with GCSE were randomized to receive either intravenous phenobarbital or valproate. Neurological outcome within 12-month was dichotomized as good (modified Rankin scale, mRS 0-2) or poor (mRS 3-6). Cognitive function was measured by mini-mental state examination (MMSE) and Montreal cognitive assessment (MoCA). Hamilton anxiety scale (HAMA) and Hamilton depression scale (HAMD) were tested for mood disorders. RESULTS We consecutively recruited 166 patients with GCSE. After excluding individuals with termination after intravenous diazepam (n = 61), and with other exclusion criteria (n = 7), 98 patients were included and 88.0% (66/75) of survivors achieved seizure freedom at 12-month. Forty-five patients (45.92%) had good outcomes at 3-month and 57 patients (58.16%) had good outcomes at 12-month. And 46.67% (35/75) of survivors showed mRS improvement at 12-month (phenobarbital group, n = 17 vs. valproate group, n = 18, P = 0.321). Despite there was no significant difference with respect to good outcomes at 3-month (54.0% vs. 37.5%, P = 0.101), the rate of good outcomes in phenobarbital group was higher than valproate group at 12-month (68.0% vs. 47.92%, P = 0.044). A total of 43 patients successfully participated cognitive and emotional tests. Mild cognitive impairment was found in 7.14% of phenobarbital group and 50.0% in valproate group (P = 0.026). In addition, there were no significant differences with respect to anxiety (36.36% vs. 38.10%) and depression (31.82% vs. 47.62%) between the phenobarbital and valproate groups. CONCLUSIONS Combined with long term conventional therapy, intravenous phenobarbital group had more good outcomes than intravenous valproate group in Chinese adult patients with GCSE up to 12-month follow-up. This finding may prompt the option of intravenous phenobarbital especially in patients with limited access to new antiseizure drugs.
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Affiliation(s)
- Gang Liu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Yuan Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Fei Tian
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Mengdi Jiang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Huijin Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Weibi Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China.
| | - Yingying Su
- Department of Neurology, Xuanwu Hospital, Capital Medical University, National Brain Injury Evaluation Quality Control Center, National Center for Neurological Disorders and National Clinical Research Center for Geriatric Diseases, Beijing 10053, China.
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Meletti S, Turchi G, Orlandi N, Vaudano AE, Cioclu MC, Pugnaghi M, Giovannini G. Electrographic seizure duration and inter-seizure intervals in focal status epilepticus. Epileptic Disord 2023; 25:519-527. [PMID: 37170072 DOI: 10.1002/epd2.20071] [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: 02/11/2023] [Revised: 05/07/2023] [Accepted: 05/08/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To characterize the duration of seizures and inter-seizure intervals in focal status epilepticus (SE). METHODS We reviewed consecutive scalp EEG recordings from adult patients who were admitted for a first episode of focal status epilepticus. We identified electrographic seizure duration and inter-seizure intervals in the first diagnostic pretreatment EEG. We also reviewed isolated focal self-limiting seizures in epilepsy patients, as a comparison group for seizure duration. RESULTS We recorded 307 focal seizures in 100 consecutive focal SE episodes, with a median seizure duration of 107 s (IQR: 54-186), and 134 isolated focal self-limiting seizures in 42 epilepsy patients, with a median duration of 59 s (IQR: 30-90; p < .001). The only clinical feature of SE that significantly increased seizure duration was acute symptomatic etiology. In SE, 15% and 7% of seizures lasted longer than 300 and 600 s, respectively (t1 of the actual definition for tonic-clonic and focal SE), while only 1% of self-limiting seizures lasted longer than 300 s, and none lasted longer than 600 s. The analysis of inter-seizure intervals in SE with multiple seizures showed that 50% of the inter-seizure periods were shorter than 60 s, and 95% were shorter than 540 s (9 min). Patients who had an increase in seizure duration (last versus first) of at least 1.4 times showed an increased 30-day mortality. SIGNIFICANCE Focal seizures within a SE episode showed a wide range of duration, partly overlapping with the duration of focal self-limiting seizures but with a longer median duration. Inter-seizure intervals within an episode of SE were shorter than 1 min in 50% of the seizures and never lasted more than 10 min. Finally, an increase in seizure duration could represent an "electrophysiological biomarker" of a more severe SE episode, which may require more aggressive and rapid treatment.
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Affiliation(s)
- Stefano Meletti
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy
| | - Giulia Turchi
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
| | - Niccolò Orlandi
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy
| | - Anna Elisabetta Vaudano
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy
| | - Maria Cristina Cioclu
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio-Emilia, Modena, Italy
| | - Matteo Pugnaghi
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
| | - Giada Giovannini
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, Modena, Italy
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio-Emilia, Modena, Italy
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Li H, Liu X, Wang R, Lu A, Ma Z, Wu S, Lu H, Du Y, Deng K, Wang L, Yuan F. Blood-brain barrier damage and new onset refractory status epilepticus: An exploratory study using dynamic contrast-enhanced magnetic resonance imaging. Epilepsia 2023. [PMID: 36892496 DOI: 10.1111/epi.17576] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 03/03/2023] [Accepted: 03/03/2023] [Indexed: 03/10/2023]
Abstract
OBJECTIVE This study was undertaken to characterize the blood-brain barrier (BBB) dysfunction in patients with new onset refractory status epilepticus (NORSE) using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). METHODS This study included three groups of adult participants: patients with NORSE, encephalitis patients without status epilepticus (SE), and healthy subjects. These participants were retrospectively included from a prospective DCE-MRI database of neurocritically ill patients and healthy subjects. The BBB permeability (Ktrans) in the hippocampus, basal ganglia, thalamus, claustrum, periventricular white matter, and cerebellum were measured and compared between these three groups. RESULTS A total of seven patients with NORSE, 14 encephalitis patients without SE, and nine healthy subjects were included in this study. Among seven patients with NORSE, only one had a definite etiology (autoimmune encephalitis), and the rest were cryptogenic. Etiology of encephalitis patients without SE included viral (n = 2), bacterial (n = 8), tuberculous (n = 1), cryptococcal (n = 1), and cryptic (n = 2) encephalitis. Of these 14 encephalitis patients without SE, three patients had seizures. Compared to healthy controls, NORSE patients had significantly increased Ktrans values in the hippocampus (.73 vs. .02 × 10-3 /min, p = .001) and basal ganglia (.61 vs. .003 × 10-3 /min, p = .007) and a trend in the thalamus (.24 vs. .08 × 10-3 /min, p = .017). Compared to encephalitis patients without SE, NORSE patients had significantly increased Ktrans values in the thalamus (.24 vs. .01 × 10-3 /min, p = .002) and basal ganglia (.61 vs. .004 × 10-3 /min, p = .013). SIGNIFICANCE This exploratory study demonstrates that BBBs of NORSE patients were impaired diffusely, and BBB dysfunction in the basal ganglia and thalamus plays an important role in the pathophysiology of NORSE.
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Affiliation(s)
- Huiping Li
- Department of Neurocritical Care, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xian Liu
- Department of Imaging, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ruihong Wang
- Department of Neurocritical Care, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Aili Lu
- Department of Neurocritical Care, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhaohui Ma
- Department of Neurocritical Care, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shibiao Wu
- Department of Neurocritical Care, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Hongji Lu
- Department of Neurocritical Care, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yaming Du
- Department of Neurocritical Care, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Kan Deng
- Philips Healthcare, Guangzhou, China
| | - Lixin Wang
- Department of Neurocritical Care, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong Provincial Key Laboratory of Chinese Medicine Emergency Research, Guangzhou, China
| | - Fang Yuan
- Department of Neurocritical Care, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Development and Validation of a Nomogram Based on the Epidemiology-Based Mortality Score in Status Epilepticus (EMSE) Parameters to Predict 30-day Mortality in Status Epilepticus. Neurocrit Care 2022; 37:754-760. [PMID: 35778648 DOI: 10.1007/s12028-022-01548-6] [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: 03/28/2022] [Accepted: 06/04/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND To develop a nomogram using the parameters of the Epidemiology-Based Mortality Score in Status Epilepticus (EMSE) and to evaluate its accuracy compared with the EMSE alone in the prediction of 30-day mortality in patients with status epilepticus (SE). METHODS We included a cohort of patients with SE aged ≥ 21 years admitted from 2013 to 2021. Regression coefficients from the multivariable logistic regression model were used to generate a nomogram predicting the risk of 30-day mortality. Discrimination of the nomogram was evaluated using the area under the receiver operating characteristic curve (AUCROC) with 95% confidence interval. Internal validation was performed by bootstrap resampling. RESULTS Among 698 patients with SE, the 30-day mortality rate was 28.9% (202 of 698). On the multivariable analysis, all EMSE parameters (except for the comorbidity group including metastatic solid tumor or AIDS) were associated with a significantly higher risk of 30-day mortality and were included in the nomogram. The discriminatory capability of the nomogram with bootstrap resampling (5000 resamples) had an AUCROC of 0.830 (95% confidence interval 0.798-0.862). Conversely, the AUCROC of the EMSE was 0.777 (95% confidence interval 0.742-0.813). Thus, the probability that a patient who died within 30 days from SE had a higher score than a patient who survived was 83%, indicating good discriminatory power of the nomogram. Conversely, the risk predicted using the EMSE alone was 77%. The nomogram was well calibrated. CONCLUSIONS A nomogram based on EMSE parameters appears superior to the EMSE in predicting the risk of 30-day mortality after SE. The discrimination and calibration of the nomogram shows a better predictive accuracy than the EMSE alone.
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Briassoulis G, Stefanogianni C, Zaganas I, Raissaki M, Briassoulis P, Ilia S. Specific characteristics and current diagnostic and treatment modalities performance of super refractory status epilepticus in children: A comparative study. Eur J Paediatr Neurol 2022; 37:32-39. [PMID: 35051734 DOI: 10.1016/j.ejpn.2022.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 07/28/2021] [Accepted: 01/02/2022] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Super-refractory status epilepticus (SRSE) is associated with significant morbidity and mortality in children. We explored the clinical spectrum, specific characteristics, and outcome in SRSE patients admitted in a pediatric intensive care unit (PICU) and investigated how well current diagnostic or treatment modalities perform compared to Status Epilepticus (SE) and Refractory SE (RSE) patients. METHODS Retrospective analysis of PICU patients admitted with convulsive SE during 2009-2019. Eighty-six patients were classified as SE, RSE, and SRSE. New-onset RSE (NORSE) and febrile infection-related epilepsy syndrome (FIRES) were also identified. Functional outcome was evaluated by the modified Rankin scale. RESULTS Patients with SRSE (n = 20) had longer weaning off anesthetics (p = 0.014), length of stay, mechanical ventilation duration, higher illness severity scores, and poorer outcome compared to SE (n = 13) or RSE (n = 53) patients (all p < 0.001). Diagnosis, mainly expressed by high prevalence of NORSE (n = 13) and FIRES (n = 9), was independently associated with SRSE (p = 0.024). Abnormal MRI findings (p = 0.005), and epilepsy-related pathogenic variants identified by whole-exome sequencing (WES) were mostly found in SRSE patients. Compared to intravenous immunoglobulins and steroid pulses, plasmapheresis and ketogenic diet, more often used in SRSE (p < 0.01), contributed better to seizure control. Only SRSE (AUROC > 0.80, 95% CI = 0.68-0.94, p < 0.001) and diagnosis (AUROC > 0.70, 95% CI = 0.55-0.83, p = 0.02) could predict a poor outcome. CONCLUSION The majority of SRSE patients are characterized by considerable functional decline and morbidity. WES analysis may reveal epilepsy-related pathogenic variants while early aggressive immunotherapy and/or ketogenic diet might prove beneficial. Multicenter studies for prediction models of outcome are needed.
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Affiliation(s)
- George Briassoulis
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, Heraklion, Crete, Greece.
| | - Chrysavgi Stefanogianni
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Ioannis Zaganas
- Neurology Department, Neurogenetics Laboratory, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Maria Raissaki
- Department of Radiology, University Hospital, School of Medicine, University of Crete, Greece
| | - Panagiotis Briassoulis
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Stavroula Ilia
- Pediatric Intensive Care Unit, University Hospital, School of Medicine, University of Crete, Heraklion, Crete, Greece
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Recurrent Status Epilepticus: clinical features and recurrence risk in an adult population. Seizure 2022; 97:1-7. [DOI: 10.1016/j.seizure.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 11/22/2022] Open
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Status Epilepticus and Neurosyphilis: A Case Report and a Narrative Review. NEUROSCI 2021. [DOI: 10.3390/neurosci2040031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Neurosyphilis is a rare but life-threatening complication of syphilis that can develop even decades after the primary infection and can be unrecognized. Seizures and status epilepticus (SE) may represent the first manifestation in a previously undiagnosed syphilitic patient. We present an exemplification case of a new onset refractory status epilepticus caused by neurosyphilis and we reviewed the existing literature. We selected all studies reporting cases of SE in the context both of patients with a known diagnosis of syphilis and as the first manifestation of neurosyphilis. We identified 50 patients, mostly composed of immunocompetent, middle-aged males. Thirty-nine patients (83%) presented a new onset SE. A history of subtle and rapidly progressive mood and/or cognitive impairment suggesting a limbic encephalitis-like presentation was frequently observed. Focal frontal or temporal SE was reported in 26. Brain MRI frequently showed T2/FLAIR hyperintensities widely involving the medial temporal structures and the frontal lobes. This review should increase the clinician’s awareness of neurosyphilis as a possible etiology of a new onset SE of unknown etiology, especially in the context of a “limbic encephalitis”-like clinical presentation. Prompt recognition and treatment for neurosyphilis partially or completely reverse neurologic sequelae, changing the natural history of the disease.
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Othman AS, El‐Tamawy MS, Amer H, Kishk NA, Nawito AM, Shaker E, Basheer MA, Alieldin N, Magdy R. Characteristics and outcome in an Egyptian Cohort with status epilepticus. Acta Neurol Scand 2021; 144:375-382. [PMID: 34042176 DOI: 10.1111/ane.13478] [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: 12/22/2020] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Status epilepticus (SE) is an important cause of mortality worldwide. Information regarding associations of mortality outcome in Egypt is limited. The main objective of this study was to describe the clinical characteristics and factors associated with mortality of patients with SE admitted to Cairo University Hospitals. METHODS A prospective observational hospital-based study was conducted from January 2017 to June 2018. Patients with SE aged ≥12 years old were followed with documentation of outcome on discharge as survival versus death. RESULTS The study cohort included 144 SE patients. The majority of episodes (96.5%) were with prominent motor features, while nonconvulsive SE occurred in 3.5%. There was a clear semiology evolution in 22.9% of episodes, 56.3% had unchanging semiology (e.g., just convulsive or just nonconvulsive) and the semiology evolution could not be discerned in 20.8%. In relation to treatment, the majority of cases were responsive (46.5%), whereas 43.1% were refractory and only 10.4% were super-refractory SE. Apart from seven patients who were referred to other hospitals, 99 patients survived whereas 38 (26.4%) died. After regression analysis, only absence of a history of epilepsy, semiology evolution and mechanical ventilator use were associated with mortality increasing its odds by 3.7, 5, 111 times, respectively. CONCLUSION Absence of a history of epilepsy, SE semiology evolution, and mechanical ventilator use was found to be associated with mortality outcome among Egyptian patients with SE.
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Affiliation(s)
- Alshimaa S. Othman
- Department of Neurology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Mohamed S. El‐Tamawy
- Department of Neurology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Hanan Amer
- Department of Neurology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Nirmeen A. Kishk
- Department of Neurology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Amani M. Nawito
- Department of Neurophysiology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Ehab Shaker
- Department of Neurology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Mye A. Basheer
- Department of Neurophysiology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
| | - Nelly Alieldin
- Department of Cancer Epidemiology National Cancer Institute Cairo University Cairo Egypt
| | - Rehab Magdy
- Department of Neurology Kasr Al‐Ainy Faculty of Medicine Cairo University Cairo Egypt
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12
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Giovannini G, Malagoli M, Turchi G, Miani A, Orlandi N, Vaudano AE, Meletti S. Cortical and thalamic hyper-perfusion in non-convulsive status epilepticus. Relationship between perfusion CT patterns and Salzburg EEG criteria. Seizure 2021; 92:10-17. [PMID: 34391029 DOI: 10.1016/j.seizure.2021.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Status epilepticus (SE) is a neurological emergency and in particular nonconvulsive SE (NCSE) represents a diagnostic challenge. To improve clinical decision-making, cerebral perfusion-computed tomography (PCT) has been shown as a helpful tool to support the diagnosis of focal NCSE. MATERIALS AND METHODS This is a monocentric retrospective study. Among the 602 cases of SE observed between September 2013 and April 2020 we included 21 patients that were studied with PCT. The perfusion maps were first visually analysed then a quantitative analysis (by regions of interest, ROI) was obtained. For each patient, the diagnostic EEG was reviewed and classified in accordance to the Salzburg Criteria for NCSE (SCC) as definite (D-NCSE) and possible (P-NCSE). Finally, we analysed the relationship between PCT and EEG patterns. RESULTS Hyper-perfusion was observed in 18 patients (86%), while in the remaining 3 (14%) a normo-perfused pattern was present. Hyper-perfusion was observed in 14 of the D-NCSE group (88%) and in the two patients with a P-NCSE (100%). No one among the patients with a P-NCSE had a thalamic hyper-perfusion, while among the 6 patients with continuous sustained epileptiform discharges > 2.5 Hz (pattern 1 of SCC), 4 (67%) showed cortical plus thalamic hyper-perfusion. CONCLUSIONS PCT could facilitate the differential diagnosis and speed-up the diagnostic process of NCSE in emergency situations. Finding cortical multi-lobar hyper-perfusion, especially if present together with homolateral thalamic hyper-perfusion in a patient with an acute-onset of motor/sensory/language deficits is highly suggestive for the presence of NCSE and is particularly related to continuous/sustained ictal patterns.
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Affiliation(s)
- Giada Giovannini
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy; PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Marcella Malagoli
- Neuroradiology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy
| | - Giulia Turchi
- Neurology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy
| | - Alice Miani
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolò Orlandi
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy
| | | | - Stefano Meletti
- Department of Biomedical, Metabolic, and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy; Neurology Unit, OCB Hospital, Azienda Ospedaliera Universitaria di Modena, Italy.
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13
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Lattanzi S, Giovannini G, Brigo F, Orlandi N, Trinka E, Meletti S. Status epilepticus with prominent motor symptoms clusters into distinct electroclinical phenotypes. Eur J Neurol 2021; 28:2694-2699. [PMID: 33932068 PMCID: PMC8359986 DOI: 10.1111/ene.14891] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/21/2021] [Accepted: 04/26/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Status epilepticus (SE) is a heterogeneous condition and considerable variability exists in its etiology, semiology, electroencephalographic correlates, and response to treatment. The aim of the present study was to explore whether distinct phenotypes may be identified within SE with prominent motor symptoms. METHODS Consecutive episodes of SE with prominent motor symptoms in patients aged ≥14 years were included. Etiology of SE was defined as symptomatic (acute, remote, progressive) or unknown. Electroencephalogram (EEG) recordings were searched for lateralized periodic discharges (LPDs), generalized sharply and/or triphasic periodic potentials (GPDs), and spontaneous burst suppression (BS). According to treatment response, SE was classified into responsive, refractory and super-refractory. Average linkage hierarchical cluster analysis was performed with Pearson's correlation as a similarity measure. RESULTS A total of 240 episodes of SE were identified. Three major clusters were found. The first cluster linked focal motor SE evolving into non-convulsive SE (NCSE), presence of LPDs/GPDs on EEG, unknown etiology and treatment refractoriness. The second cluster linked convulsive and myoclonic SE evolving into NCSE, presence of spontaneous BS on EEG, progressive symptomatic etiology and super-refractoriness. The third cluster linked convulsive and myoclonic SE not evolving into other semiologies, absence of LPDs/GPDs/spontaneous BS on EEG, acute symptomatic etiology and treatment responsiveness. CONCLUSIONS Distinct electroclinical phenotypes characterized by different response to pharmacological intervention can be identified within the heterogeneity of SE with prominent motor phenomena.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Giada Giovannini
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy.,PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Brigo
- Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Italy.,Division of Neurology, "Franz Tappeiner" Hospital, Merano, BZ, Italy
| | - Niccolò Orlandi
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy.,Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.,Center for Cognitive Neuroscience, Salzburg, Austria.,Public Health, Health Services Research and HTA, Medical Informatics and Technology, University for Health Sciences, Hall i.T, Austria
| | - Stefano Meletti
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy.,Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
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14
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Jose J, Keni RR, Hassan H, Menon R, Sukumaran S, Cherian A, Radhakrishnan A. Predictors of outcome in super refractory status epilepticus. Epilepsy Behav 2021; 118:107929. [PMID: 33775578 DOI: 10.1016/j.yebeh.2021.107929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/06/2021] [Accepted: 03/07/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE We conducted this study to determine the clinical, electrophysiological and radiological predictors of outcome in Super Refractory Status Epilepticus (SRSE). METHODS Data of patients treated for SRSE between January 2000 and November 2019, archived prospectively in our SE registry were analyzed. Functional outcome was measured by Glasgow outcome score (GOS) at the time of hospital discharge and was divided into: good i.e. GOS ≥ 3 and bad outcome i.e. GOS < 3. The predictors of outcome were determined using appropriate statistical tests by univariate and multivariate analysis, p < 0.05 was considered as statistically significant. RESULTS Of the 384 patients with status epilepticus (SE) identified during the study, 28 (8%) were diagnosed as SRSE and were included in the final analysis. Acute symptomatic SE comprising 15 (53.6%) patients was the most common etiology of SRSE. Thirteen patients (three patients with viral encephalitis and 10 patients with clinically possible autoimmune encephalitis) had New Onset Refractory Status Epilepticus (NORSE) like clinical presentation.12 patients (42.9%) had good outcome and 16 patients (57.1%) had bad outcome. Multivariate logistic regression analysis showed that independent predictors of poor outcome were: duration of ICU stay (p < 0.001); EEG findings such as non-convulsive SE in coma (0.032), spontaneous burst suppression (0.001) and postictal diffuse attenuation (<0.001); delay in starting anesthesia (0.002); and delay in starting immunotherapy in NORSE due to autoimmune encephalitis (0.002). CONCLUSION We could determine independent therapeutic and electrophysiological prognostic factors for SRSE. Early initiation of treatment and stringent management of these factors especially in an younger age-group, aided by continuous EEG monitoring and a thorough etiological work-up can result in good outcomes in more than one-third of cases.
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Affiliation(s)
- Jithu Jose
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ravish R Keni
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Haseeb Hassan
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ramshekhar Menon
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sajith Sukumaran
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ajith Cherian
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Ashalatha Radhakrishnan
- R. Madhavan Nayar Center for Comprehensive Epilepsy Care, Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India.
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15
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Yuan F, Lu A, Wu S, Wang L. Refractory Status Epilepticus Responsive to Electroacupuncture at Shuigou Acupoint: A Case Report. Front Neurol 2020; 11:580777. [PMID: 33329323 PMCID: PMC7734353 DOI: 10.3389/fneur.2020.580777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/04/2020] [Indexed: 11/30/2022] Open
Abstract
Refractory status epilepticus (RSE) is a critical and intractable neurological emergency. Around 55% of RSE episodes still persist despite high dose of continuous infusion of anesthetics. It's a clinical urgency and challenge to search for novel alternative treatments to control RSE as soon as possible. Here, we reported a case of RSE in a 67-year-old woman with varicella-zoster virus encephalitis. She had persistent non-convulsive SE despite the continuous infusion of midazolam. On the basis of fundamental treatments, she was given electroacupuncture at Shuigou acupoint for 10 min. An immediate EEG suppression was seen after the electroacupuncture treatment and lasted for 9 min, and lasting epileptic discharges (> 10 s) and clinical seizures were not observed any more. Midazolam was withdrawn gradually 24 h later. This case report may bring an alternative treatment for RSE.
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Affiliation(s)
- Fang Yuan
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Aili Lu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shibiao Wu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lixin Wang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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16
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Alkhachroum A, Der-Nigoghossian CA, Rubinos C, Claassen J. Markers in Status Epilepticus Prognosis. J Clin Neurophysiol 2020; 37:422-428. [PMID: 32890064 PMCID: PMC7864547 DOI: 10.1097/wnp.0000000000000761] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Status epilepticus (SE) is a neurologic emergency with high morbidity and mortality. The assessment of a patient's prognosis is crucial in making treatment decisions. In this review, we discuss various markers that have been used to prognosticate SE in terms of recurrence, mortality, and functional outcome. These markers include demographic, clinical, electrophysiological, biochemical, and structural data. The heterogeneity of SE etiology and semiology renders development of prognostic markers challenging. Currently, prognostication in SE is limited to a few clinical scores. Future research should integrate clinical, genetic and epigenetic, metabolic, inflammatory, and structural biomarkers into prognostication models to approach "personalized medicine" in prognostication of outcomes after SE.
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Affiliation(s)
- Ayham Alkhachroum
- Department of Neurology, Columbia University, New York, NY, USA
- Department of Neurology, University of Miami, Miami, FL, USA
| | | | - Clio Rubinos
- Department of Neurology, Columbia University, New York, NY, USA
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY, USA
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17
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Orlandi N, Giovannini G, Rossi J, Cioclu MC, Meletti S. Clinical outcomes and treatments effectiveness in status epilepticus resolved by antiepileptic drugs: A five-year observational study. Epilepsia Open 2020; 5:166-175. [PMID: 32524042 PMCID: PMC7278543 DOI: 10.1002/epi4.12383] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 02/09/2020] [Accepted: 02/11/2020] [Indexed: 12/29/2022] Open
Abstract
Objective To evaluate clinical outcomes and treatment effectiveness of status epilepticus finally resolved by nonbenzodiazepine antiepileptic drugs (AEDs). Methods All consecutive SE episodes observed from September 1, 2013, to September 1, 2018, and resolved by AEDs were considered. Diagnosis and classification of SE followed the 2015 ILAE proposal. Nonconvulsive status (NCSE) diagnosis was confirmed according to the Salzburg EEG criteria. The modified Rankin Scale and deaths at 30 days from onset were used to evaluate outcomes. Results A total of 277 status episodes (mean age 71 years; 61% female) were treated and resolved by antiepileptic drugs after 382 treatment trials. 68% of the SE resolved after AED use as first/second treatment line, while subsequent trials with AEDs gave an additional 32% resolution. A return to baseline conditions was observed in 48% of the patients, while overall mortality was 19% without significant changes across the study years. Mortality was higher in NCSE than in convulsive SE (22.5% vs 12.9%; P < .05), while mortality did not differ in SE episodes resolved by a first/second AED trial (17.2%) versus SE resolved by successive treatment trials (18.9%). The resolution rate of intravenous AEDs was 82% for valproate, 77% for lacosamide, 71% for phenytoin, and 62% for levetiracetam. No significant differences were found in head-to-head comparison, but for the valproate-levetiracetam one that was related to NCSE episodes in which valproate resulted to be effective in 86% of the trials while levetiracetam in 62% (P < .002). Significance A high short-term mortality, stable over time, was observed in SE despite resolution of seizures, especially in SE with nonconvulsive semiology. Comparative AED efficacy showed no significant differences except for higher resolution rate for valproate versus levetiracetam in NCSE.
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Affiliation(s)
- Niccolò Orlandi
- Neurology Unit OCB Hospital Azienda Ospedaliera-Universitaria Modena Italy.,Department of Biomedical, Metabolic and Neural Science University of Modena and Reggio Emilia Modena Italy
| | - Giada Giovannini
- Neurology Unit OCB Hospital Azienda Ospedaliera-Universitaria Modena Italy.,Department of Biomedical, Metabolic and Neural Science University of Modena and Reggio Emilia Modena Italy
| | - Jessica Rossi
- Neurology Unit OCB Hospital Azienda Ospedaliera-Universitaria Modena Italy.,Department of Biomedical, Metabolic and Neural Science University of Modena and Reggio Emilia Modena Italy
| | - Maria Cristina Cioclu
- Neurology Unit OCB Hospital Azienda Ospedaliera-Universitaria Modena Italy.,Department of Biomedical, Metabolic and Neural Science University of Modena and Reggio Emilia Modena Italy
| | - Stefano Meletti
- Neurology Unit OCB Hospital Azienda Ospedaliera-Universitaria Modena Italy.,Department of Biomedical, Metabolic and Neural Science University of Modena and Reggio Emilia Modena Italy
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18
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Prisco L, Ganau M, Aurangzeb S, Moswela O, Hallett C, Raby S, Fitzgibbon K, Kearns C, Sen A. A pragmatic approach to intravenous anaesthetics and electroencephalographic endpoints for the treatment of refractory and super-refractory status epilepticus in critical care. Seizure 2019; 75:153-164. [PMID: 31623937 DOI: 10.1016/j.seizure.2019.09.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/23/2019] [Indexed: 12/13/2022] Open
Abstract
Status epilepticus is a common neurological emergency, with overall mortality around 20%. Over half of cases are first time presentations of seizures. The pathological process by which spontaneous seizures are generated arises from an imbalance in excitatory and inhibitory neuronal networks, which if unchecked, can result in alterations in intracellular signalling pathways and electrolyte shifts, which bring about changes in the blood brain barrier, neuronal cell death and eventually cerebral atrophy. This narrative review focusses on the treatment of status epilepticus in adults. Anaesthetic agents interrupt neuronal activity by enhancing inhibitory or decreasing excitatory transmission, primarily via GABA and NMDA receptors. Intravenous anaesthetic agents are commonly used as second or third line drugs in the treatment of refractory status epilepticus, but the optimal timing and choice of anaesthetic drug has not yet been established by high quality evidence. Titration of antiepileptic and anaesthetic drugs in critically ill patients presents a particular challenge, due to alterations in drug absorbtion and metabolism as well as changes in drug distrubution, which arise from fluid shifts and altered protein binding. Furthermore, side effects associated with prolonged infusions of anaesthetic drugs can lead to multi-organ dysfunction and a need for critical care support. Electroencelography can identify patterns of burst suppression, which may be a target to guide weaning of intravenous therapy. Continuous elctroencephalography has the potential to directly impact clinical care, but despite its utility, major barriers exist which have limited its widespread use in clinical practice. A flow chart outlining the timing and dosage of anaesthetic agents used at our institution is provided.
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Affiliation(s)
- Lara Prisco
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Anaesthesia Neuroimaging Research Group, Wellcome Centre for Integrative Neuroimaging, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; Oxford Epilepsy Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, UK.
| | - Mario Ganau
- Department of Neurosurgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sidra Aurangzeb
- Oxford Epilepsy Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, UK; Department of Clinical Neurology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Department of Clinical Neurophysiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Olivia Moswela
- Pharmacy Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Claire Hallett
- Pharmacy Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Simon Raby
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Karina Fitzgibbon
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Christopher Kearns
- Neurosciences Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Arjune Sen
- Oxford Epilepsy Research Group, Nuffield Department of Clinical Neurosciences, University of Oxford, UK; Department of Clinical Neurology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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19
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Horváth L, Fekete I, Molnár M, Válóczy R, Márton S, Fekete K. The Outcome of Status Epilepticus and Long-Term Follow-Up. Front Neurol 2019; 10:427. [PMID: 31105639 PMCID: PMC6498966 DOI: 10.3389/fneur.2019.00427] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/08/2019] [Indexed: 12/17/2022] Open
Abstract
Objective: This study was to investigate the outcome of status epilepticus (SE) associated with antiepileptic therapy during SE and in follow-up period, risk factors including age, co-morbidities, pre-existing epilepsy, and etiology in the East-Hungarian region. Methods: A prospective cross-sectional database was compiled from outpatient files between 2013 and 2017. Follow-up ended on 30.06.2018. Results: One hundred and thirty five episodes (male: 68, 50.4%) were evaluated, mean age and follow-up time being 64.1 ± 13.9 years and 39.9 ± 14.2 months, respectively. Of the 89 patients with pre-existing epilepsy, 34 failed to visit the outpatient unit regularly. Case fatality rate was 25.2% and 31 patients (30.7%) died after discharge due to co-morbidities; their mean survival time was 10.44 ± 8 months. Focal, generalized and combined type epilepsies were diagnosed in 67 patients (49.6%), 47 patients (34.8%), and 21 patients (15.6%) of SE, respectively. Nine patients had non-convulsive SE (NCSE). Mean seizure-free period was 6.8 ± 6.9 months. Patients taking carbamazepine (20.9%; OR: 0.37, 95%CI: 0.16–0.82; p = 0.018), levetiracetam (27.5%; OR: 0.51, 95%CI: 0.27–0.97; p = 0.041), or valproate (11.1%; OR: 0.18, 95%CI: 0.05–0.61; p = 0.0043) were expected to achieve seizure freedom after SE. The worst outcome was linked to advanced age, etiology, new onset status epilepticus, NCSE, and focal status epilepsy. Conclusion: This study highlights the importance of regular care and patient follow-up.
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Affiliation(s)
- László Horváth
- Department of Pharmaceutical Surveillance and Economy, Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - István Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Márk Molnár
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Réka Válóczy
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Sándor Márton
- Faculty of Art, Institute of Political Science and Sociology, University of Debrecen, Debrecen, Hungary
| | - Klára Fekete
- Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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20
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Gofton TE, Gaspard N, Hocker SE, Loddenkemper T, Hirsch LJ. New onset refractory status epilepticus research: What is on the horizon? Neurology 2019; 92:802-810. [PMID: 30894443 DOI: 10.1212/wnl.0000000000007322] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 01/17/2019] [Indexed: 12/14/2022] Open
Abstract
New-onset refractory status epilepticus (NORSE) is a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurologic disorder, with new onset of refractory status epilepticus (RSE) that does not resolve after 2 or more rescue medications, without a clear acute or active structural, toxic, or metabolic cause. Febrile infection-related epilepsy syndrome is a subset of NORSE in which fever began at least 24 hours prior to the RSE. Both terms apply to all age groups. Until recently, NORSE was a poorly recognized entity without a consistent definition or approach to care. We review the current state of knowledge in NORSE and propose a roadmap for future collaborative research. Research investigating NORSE should prioritize the following 4 domains: (1) clinical features, etiology, and pathophysiology; (2) treatment; (3) adult and pediatric evaluation and management approaches; and (4) public advocacy, professional education, and family support. We consider international collaboration and multicenter research crucial in achieving these goals.
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Affiliation(s)
- Teneille E Gofton
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT.
| | - Nicolas Gaspard
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Sara E Hocker
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Tobias Loddenkemper
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
| | - Lawrence J Hirsch
- From the Schulich School of Medicine and Dentistry (T.E.G.), Western University, London, Canada; Service de Neurologie (N.G.), Université Libre de Bruxelles-Hôpital Erasme, Brussels, Belgium; Division of Critical Care Neurology, Department of Neurology (S.E.H.), Mayo Clinic, Rochester, MN; Division of Epilepsy and Clinical Neurophysiology, Department of Neurology (T.L.), Boston Children's Hospital & Harvard Medical School, MA; and Comprehensive Epilepsy Center, Department of Neurology (L.G.H.), Yale University, New Haven, CT
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Factors associated with refractoriness and outcome in an adult status epilepticus cohort. Seizure 2018; 61:111-118. [DOI: 10.1016/j.seizure.2018.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/25/2018] [Accepted: 07/27/2018] [Indexed: 11/20/2022] Open
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Marawar R, Basha M, Mahulikar A, Desai A, Suchdev K, Shah A. Updates in Refractory Status Epilepticus. Crit Care Res Pract 2018; 2018:9768949. [PMID: 29854452 PMCID: PMC5964484 DOI: 10.1155/2018/9768949] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/19/2018] [Indexed: 01/01/2023] Open
Abstract
Refractory status epilepticus is defined as persistent seizures despite appropriate use of two intravenous medications, one of which is a benzodiazepine. It can be seen in up to 40% of cases of status epilepticus with an acute symptomatic etiology as the most likely cause. New-onset refractory status epilepticus (NORSE) is a recently coined term for refractory status epilepticus where no apparent cause is found after initial testing. A large proportion of NORSE cases are eventually found to have an autoimmune etiology needing immunomodulatory treatment. Management of refractory status epilepticus involves treatment of an underlying etiology in addition to intravenous anesthetics and antiepileptic drugs. Alternative treatment options including diet therapies, electroconvulsive therapy, and surgical resection in case of a focal lesion should be considered. Short-term and long-term outcomes tend to be poor with significant morbidity and mortality with only one-third of patients reaching baseline neurological status.
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Affiliation(s)
- Rohit Marawar
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Maysaa Basha
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Advait Mahulikar
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Aaron Desai
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Kushak Suchdev
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
| | - Aashit Shah
- Department of Neurology, Detroit Medical Center and Wayne State University, Detroit, MI 48201, USA
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Leo A, Giovannini G, Russo E, Meletti S. The role of AMPA receptors and their antagonists in status epilepticus. Epilepsia 2018; 59:1098-1108. [DOI: 10.1111/epi.14082] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Antonio Leo
- Department of Science of Health; University Magna Graecia of Catanzaro; Catanzaro Italy
| | - Giada Giovannini
- Department of Biomedical Metabolic and Neural Sciences; University of Modena and Reggio Emilia; Modena Italy
| | - Emilio Russo
- Department of Science of Health; University Magna Graecia of Catanzaro; Catanzaro Italy
| | - Stefano Meletti
- Department of Biomedical Metabolic and Neural Sciences; University of Modena and Reggio Emilia; Modena Italy
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Masapu D, Gopala Krishna KN, Sanjib S, Chakrabarti D, Mundlamuri RC, Manohar N, Mariamma P, Satishchandra P, Umamaheswara Rao GS. A Comparative Study of Midazolam and Target-Controlled Propofol Infusion in the Treatment of Refractory Status Epilepticus. Indian J Crit Care Med 2018; 22:441-448. [PMID: 29962746 PMCID: PMC6020637 DOI: 10.4103/ijccm.ijccm_327_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: The recommended treatment for refractory status epilepticus (RSE) is the use of anesthetic agents, but evidence regarding the agent of choice is lacking. This study was designed to compare target-controlled infusion of propofol versus midazolam for the treatment of RSE regarding seizure control and complications. Methods: This prospective, randomized study recruited 23 adult patients with RSE due to any etiology and treated with either propofol or midazolam titrated to clinical seizure cessation and gradual tapering thereafter. The primary outcome measure was seizure control and the secondary outcomes were duration of the Intensive Care Unit stay and duration of mechanical ventilation, occurrence of super RSE (SRSE), and complications. Results: We recruited 23 patients (male:female = 18:5) into this study (propofol Group-11; midazolam Group-12). Overall, seizure control was noted in 34.8%, with successful seizure control in 45% of patients in the propofol group and 25% in midazolam group (P = 0.4). Mortality was similar in both the groups (propofol group [8/11; 72.7%] compared to the midazolam group [7/12; 58.3%] [P = 0.667]). The duration of hospital stay was significantly shorter in the propofol group compared to midazolam (P = 0.02). The overall incidence of SRSE was 69.5% in this study. The complication rate was not significantly different between the groups. Conclusions: The choice of anesthetic agent does not seem to affect the overall outcome in RSE and SRSE. Target-controlled propofol infusion was found to be equal in its efficacy to midazolam for the treatment of RSE. High mortality might be due to SRSE secondary to the underlying brain pathology.
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Affiliation(s)
- Dheeraj Masapu
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - K N Gopala Krishna
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Sinha Sanjib
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dhrithiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - R C Mundlamuri
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Nitin Manohar
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - P Mariamma
- Department of Biostatistics, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - P Satishchandra
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - G S Umamaheswara Rao
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Misra UK, Kalita J, Dubey D. A Study of Super Refractory Status Epilepticus from India. Front Neurol 2017; 8:636. [PMID: 29234303 PMCID: PMC5712310 DOI: 10.3389/fneur.2017.00636] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 11/14/2017] [Indexed: 11/13/2022] Open
Abstract
Background Super refractory status epilepticus (SRSE) is an important and recently recognized neurological emergency. Purpose In view of paucity of studies on SRSE, we report the frequency, etiology and outcome of SRSE. Methods In a hospital-based observational study during 2013 to 2016, consecutive patients with SRSE [persistence of status epilepticus (SE) for 24 h or more, or recurrence of SE on weaning of intravenous anesthetic] were included. The demographic, clinical, and laboratory data were obtained and the severity of SE was defined using Status Epilepticus Severity Score (STESS). The outcome was defined as control of SE, hospital death, and functional status at the time of discharge. Results Fourteen (13%) patients developed SRSE. Their median age was 27.5 (2–70) years and four were below 18 years of age. The etiology of SRSE was metabolic encephalopathy and encephalitis in five patients each, cerebral venous sinus thrombosis in one and miscellaneous disorders in three patients. Six (43%) patients died. The patients with SRSE had higher admission STESS (p = 0.04), and longer intensive care unit (p < 0.01) and hospital (p = 0.004) stay compared to non-SRSE group. The patients with treatable etiology had better outcome. Conclusion SRSE occurred in 13% patients with SE and 43% of them died. The SRSE patients with treatable etiology had a better outcome.
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Affiliation(s)
- Usha K Misra
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Deepanshu Dubey
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Strzelczyk A, Ansorge S, Hapfelmeier J, Bonthapally V, Erder MH, Rosenow F. Costs, length of stay, and mortality of super-refractory status epilepticus: A population-based study from Germany. Epilepsia 2017; 58:1533-1541. [PMID: 28681418 DOI: 10.1111/epi.13837] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Super-refractory status epilepticus (SRSE) is a severe condition in which a patient in status epilepticus (SE) for ≥24 h does not respond to first-, second-, or third-line therapy. The economic impact of SRSE treatment remains unclear. A health insurance research database was used for a population-based estimation of SRSE-associated inpatient costs, length of stay, and mortality in Germany. METHODS An algorithm using International Classification of Diseases, 10th Edition coding and treatment parameters identified and classified patients in a German statutory health insurance database covering admissions from 2008 to 2013 as having refractory SE (RSE) or SRSE. Admissions data in our study refer to these classifications. Associated patient data included costs, procedures, and demographics. RESULTS The algorithm identified 2,585 (all type) SE admissions, classified as 1,655 nonrefractory SE (64%), 592 (22.9%) RSE, and 338 (13.1%) SRSE, producing database incidence rates of 15.0 in 100,000, 5.2 in 100,000, and 3.0 in 100,000 per year, respectively. Median cost per admission was €4,063 for nonrefractory SE, €4,581 (p < 0.001) for RSE, and €32,706 (p < 0.001) for SRSE. Median length of stay varied significantly between 8 days (mean = 13.6) in nonrefractory SE, 14 days in RSE, and up to 37 days in SRSE. Discharge mortality increased from 9.6% in nonrefractory SE to 15.0% (p < 0.001) in RSE and 39.9% (p < 0.001) in SRSE. SIGNIFICANCE This study evaluated the hospital treatment costs associated with admissions classified by the algorithm as SRSE in Germany. SRSE represented 13% of all SE admissions, but resulted in 56% of all SE-related costs. The lack of approved treatments and limited number of evidence-based treatment guidelines highlight the need for further evaluations of the SRSE burden of illness and the potential for further optimization of treatments for SRSE.
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Affiliation(s)
- Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University, Frankfurt am Main, Germany.,Epilepsy Center Hessen and Department of Neurology, Philipps University, Marburg, Germany
| | | | | | | | - M Haim Erder
- M. Haim Erder Health Economics Consulting, Cambridge, Massachusetts, U.S.A
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe University, Frankfurt am Main, Germany.,Epilepsy Center Hessen and Department of Neurology, Philipps University, Marburg, Germany
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Kantanen AM, Reinikainen M, Parviainen I, Kälviäinen R. Long-term outcome of refractory status epilepticus in adults: A retrospective population-based study. Epilepsy Res 2017; 133:13-21. [DOI: 10.1016/j.eplepsyres.2017.03.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 02/07/2017] [Accepted: 03/28/2017] [Indexed: 01/21/2023]
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Challenges in the treatment of convulsive status epilepticus. Seizure 2017; 47:17-24. [DOI: 10.1016/j.seizure.2017.02.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 01/09/2023] Open
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Predictors of hospital and one-year mortality in intensive care patients with refractory status epilepticus: a population-based study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:71. [PMID: 28330483 PMCID: PMC5363025 DOI: 10.1186/s13054-017-1661-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 02/28/2017] [Indexed: 12/18/2022]
Abstract
Background The aim was to determine predictors of hospital and 1-year mortality in patients with intensive care unit (ICU)-treated refractory status epilepticus (RSE) in a population-based study. Methods This was a retrospective study of the Finnish Intensive Care Consortium (FICC) database of adult patients (16 years of age or older) with ICU-treated RSE in Finland during a 3-year period (2010–2012). The database consists of admissions to all 20 Finnish hospitals treating RSE in the ICU. All five university hospitals and 11 out of 15 central hospitals participated in the present study. The total adult referral population in the study hospitals was 3.92 million, representing 91% of the adult population of Finland. Patients whose condition had a post-anoxic aetiological basis were excluded. Results We identified 395 patients with ICU-treated RSE, corresponding to an annual incidence of 3.4/100,000 (95% confidence interval (CI) 3.04–3.71). Hospital mortality was 7.4% (95% CI 0–16.9%), and 1-year mortality was 25.4% (95% CI 21.2–29.8%). Mortality at hospital discharge was associated with severity of organ dysfunction. Mortality at 1 year was associated with older age (adjusted odds ratio (aOR) 1.033, 95% CI 1.104–1.051, p = 0.001), sequential organ failure assessment (SOFA) score (aOR 1.156, CI 1.051–1.271, p = 0.003), super-refractory status epilepticus (SRSE) (aOR 2.215, 95% CI 1.20–3.84, p = 0.010) and dependence in activities of daily living (ADL) (aOR 2.553, 95% CI 1.537–4.243, p < 0.0001). Conclusions Despite low hospital mortality, 25% of ICU-treated RSE patients die within a year. Super-refractoriness, dependence in ADL functions, severity of organ dysfunction at ICU admission and older age predict long-term mortality. Trial registration Retrospective registry study; no interventions on human participants.
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30
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Mortality, morbidity and refractoriness prediction in status epilepticus: Comparison of STESS and EMSE scores. Seizure 2017; 46:31-37. [DOI: 10.1016/j.seizure.2017.01.004] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/29/2017] [Accepted: 01/30/2017] [Indexed: 11/23/2022] Open
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31
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Beg JM, Anderson TD, Francis K, Meckley LM, Fitzhenry D, Foster T, Sukhtankar S, Kanes SJ, Moura LMVR. Burden of illness for super-refractory status epilepticus patients. J Med Econ 2017; 20:45-53. [PMID: 27556834 DOI: 10.1080/13696998.2016.1223680] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To provide an estimate of the annual number of super-refractory status epilepticus (SRSE) cases in the US and to evaluate utilization of hospital resources by these patients. METHODS The Premier Hospital Database was utilized to estimate the number of SRSE cases based on hospital discharges during 2012. Discharges were classified as SRSE cases based on an algorithm using seizure-related International Classification of Diseases-9 (ICD-9) codes, Intensive Care Unit (ICU) length of stay (LOS), and treatment protocols (e.g. benzodiazepines, anti-epileptic drugs (AEDs), and ventilator use). Secondary analyses were conducted using more restrictive algorithms for SRSE. RESULTS A total of 6,325 hospital discharges were classified as SRSE cases from a total of 5,300,000 hospital discharges. Applying a weighting based on hospital characteristics and 2012 US demographics, this projected to an estimated 41,156 cases of SRSE in the US during 2012, an estimated incidence rate of ∼13/100,000 annually for SRSE in the US. Secondary analyses using stricter SRSE algorithms resulted in estimated incidence rates of ∼11/100,000 and 8/100,000 annually. The mean LOS for SRSE hospitalizations was 16.5 days (median =11; interquartile range [IQR] = 6-20), and the mean ICU LOS was 9.3 days (median =6; IQR =3-12). The mean cost of an SRSE hospitalization was $51,247 (median = $33,294; 95% CI = $49,634-$52,861). LIMITATIONS The analysis uses ICD-9 diagnostic codes and claims information, and there are inherent limitations in any methodology based on treatment protocol, which created challenges in distinguishing with complete accuracy between SRSE, RSE, and SE on the basis of care patterns in the database. CONCLUSION SRSE is associated with high mortality and morbidity, which place a high burden on healthcare resources. Projections based upon the findings of this study suggest an estimated 25,821-41,959 cases of SRSE may occur in the US each year, but more in-depth studies are required.
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Affiliation(s)
- Jamil M Beg
- a Sage Therapeutics, Inc. , Cambridge , MA , USA
| | | | | | | | | | | | | | | | - Lidia M V R Moura
- c Department of Neurology , Massachusetts General Hospital , Boston , MA , USA
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Delaj L, Novy J, Ryvlin P, Marchi NA, Rossetti AO. Refractory and super-refractory status epilepticus in adults: a 9-year cohort study. Acta Neurol Scand 2017; 135:92-99. [PMID: 27080243 DOI: 10.1111/ane.12605] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE While status epilepticus (SE) persisting after two antiseizure agents is called refractory (RSE), super-refractory status epilepticus (SRSE) defines SE continuing after general anaesthesia. Its prevalence and related clinical profiles have received limited attention, and most studies were restricted to intensive care facilities. We therefore aimed at describing RSE and SRSE frequencies and identifying associated clinical variables. METHODS Between 2006 and 2015, consecutive adult SE episodes were prospectively recorded in a registry. Occurrence of RSE and SRSE and their relationship to clinical variables of interest, including outcome, were analysed. RESULTS Of 804 SE episodes, 268 (33.3%) were RSE and 33 (4%) SRSE. Coma induction for SE treatment occurred in 79 (9.8%) episodes. Severe consciousness impairment (OR 1.67; 95% CI 1.24-2.46; P = 0.001), increasing age (OR 1.01, 95% CI 1.01-1.02), and lack of remote symptomatic SE aetiology (OR 0.48; 95% CI 0.32-0.72) were independently associated with RSE, while severe consciousness impairment (OR 4.26; 95% CI 1.44-12.60) and younger age (OR 0.96; 95% CI 0.95-0.99) correlated with SRSE; however, most SRSE episodes were not predicted by these variables. Mortality was 15.5% overall, higher in RSE (24.5%) and SRSE (37.9%) than in non-refractory SE (9.8%) (P < 0.001). SIGNIFICANCE Super-refractory status epilepticus appears clearly less prevalent in this cohort than previously reported, probably as it is not restricted to intensive care unit. SRSE emerges in younger patients with marked consciousness impairment, pointing to the underlying severe clinical background, but these variables do not predict most SRSE developments. There is currently a knowledge gap for prediction of SRSE occurrence that needs to be filled.
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Affiliation(s)
- L. Delaj
- Service de Neurologie; Département des Neurosciences Cliniques; CHUV and University of Lausanne; Lausanne Switzerland
- Unità operativa di Neurologia; Dipartimento Emergenza-Urgenza; Medicina Generale e Specialistica; Azienda Ospedaliero-Universitaria di Parma; Parma Italy
| | - J. Novy
- Service de Neurologie; Département des Neurosciences Cliniques; CHUV and University of Lausanne; Lausanne Switzerland
| | - P. Ryvlin
- Service de Neurologie; Département des Neurosciences Cliniques; CHUV and University of Lausanne; Lausanne Switzerland
| | - N. A. Marchi
- Service de Neurologie; Département des Neurosciences Cliniques; CHUV and University of Lausanne; Lausanne Switzerland
| | - A. O. Rossetti
- Service de Neurologie; Département des Neurosciences Cliniques; CHUV and University of Lausanne; Lausanne Switzerland
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Kortland LM, Alfter A, Bähr O, Carl B, Dodel R, Freiman TM, Hubert K, Jahnke K, Knake S, von Podewils F, Reese JP, Runge U, Senft C, Steinmetz H, Rosenow F, Strzelczyk A. Costs and cost-driving factors for acute treatment of adults with status epilepticus: A multicenter cohort study from Germany. Epilepsia 2016; 57:2056-2066. [DOI: 10.1111/epi.13584] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Lena-Marie Kortland
- Department of Neurology; Epilepsy Center Frankfurt Rhine-Main; Goethe-University; Frankfurt am Main Germany
- Epilepsy Center Hessen and Department of Neurology; Philipps-University; Marburg Germany
| | - Anne Alfter
- Department of Neurology; Epilepsy Center Frankfurt Rhine-Main; Goethe-University; Frankfurt am Main Germany
| | - Oliver Bähr
- Senckenberg Institute of Neurooncology; Goethe-University; Frankfurt am Main Germany
| | - Barbara Carl
- Department of Neurosurgery; Philipps-University; Marburg Germany
| | - Richard Dodel
- Epilepsy Center Hessen and Department of Neurology; Philipps-University; Marburg Germany
- Department of Geriatrics; University Duisburg-Essen; Essen Germany
| | - Thomas M. Freiman
- Department of Neurosurgery; Goethe-University; Frankfurt am Main Germany
| | - Kristina Hubert
- Department of Neurology; Epilepsy Center Frankfurt Rhine-Main; Goethe-University; Frankfurt am Main Germany
| | - Kolja Jahnke
- Department of Neurology; Epilepsy Center Frankfurt Rhine-Main; Goethe-University; Frankfurt am Main Germany
| | - Susanne Knake
- Epilepsy Center Hessen and Department of Neurology; Philipps-University; Marburg Germany
| | - Felix von Podewils
- Department of Neurology and Epilepsy Center; Ernst-Moritz-Arndt-University; Greifswald Germany
| | - Jens-Peter Reese
- Institute of Health Service Research and Clinical Epidemiolgy and Coordinating Center for Clinical Trials; Philipps-University; Marburg Germany
| | - Uwe Runge
- Department of Neurology and Epilepsy Center; Ernst-Moritz-Arndt-University; Greifswald Germany
| | - Christian Senft
- Department of Neurosurgery; Goethe-University; Frankfurt am Main Germany
| | - Helmuth Steinmetz
- Department of Neurology; Epilepsy Center Frankfurt Rhine-Main; Goethe-University; Frankfurt am Main Germany
| | - Felix Rosenow
- Department of Neurology; Epilepsy Center Frankfurt Rhine-Main; Goethe-University; Frankfurt am Main Germany
- Epilepsy Center Hessen and Department of Neurology; Philipps-University; Marburg Germany
| | - Adam Strzelczyk
- Department of Neurology; Epilepsy Center Frankfurt Rhine-Main; Goethe-University; Frankfurt am Main Germany
- Epilepsy Center Hessen and Department of Neurology; Philipps-University; Marburg Germany
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