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Dono F, Evangelista G, Rodorigo D, Rollo E, Romozzi M, Corniello C, Liviello D, Dasara M, Capriati L, Quintieri P, Servidei S, Della Marca G, Calabresi P, Sensi SL, Vollono C. Clinical characteristics and treatment approach of established New-Onset status epilepticus (eNOSE): A Real-World multicenter experience. Epilepsy Behav 2024; 159:109951. [PMID: 39111103 DOI: 10.1016/j.yebeh.2024.109951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 07/11/2024] [Accepted: 07/14/2024] [Indexed: 09/13/2024]
Abstract
INTRODUCTION Status Epilepticus (SE) can occur in patients without a previous epilepsy diagnosis, a condition identified as "new-onset status epilepticus" (NOSE). Treatment with benzodiazepine may fail in NOSE termination, requiring anti-seizure medication (ASM) employment. The term "established NOSE" (eNOSE) is generally employed in this context. This study aims to describe the main clinical characteristics of a large sample of patients suffering from eNOSE, compare the ASM efficacy, and explore the risk factors associated with ASM treatment unresponsiveness and eNOSE-associated mortality. METHODS Adult patients diagnosed with eNOSE were retrospectively selected between January 2016 and December 2022. We reviewed demographics, clinical data, diagnostic work-up, and treatment. We considered the last ASM introduced before the eNOSE termination as effective. RESULTS 123 patients were included (age: 67.9 ± 17.3). eNOSE acute etiology was mostly reported. In the overall cohort, phenytoin showed the highest response rate (p = 0.01). In the pairwise comparisons, valproate was superior to levetiracetam (p = 0.02) but not to lacosamide (p = 0.50). Phenytoin had a significantly higher resolution rate than levetiracetam (p = 0.001) but not lacosamide (p = 0.14). Thirty patients were refractory to ASM treatment. No predictors of refractoriness were identified. Thirty-nine patients died. Age and GCS were identified as eNOSE-related mortality risk factors. CONCLUSION eNOSE frequently has an acute etiology with several associated syndromes. Phenytoin is more effective in managing eNOSE, even though lacosamide, valproate, and levetiracetam can represent further therapeutic options. Age and GCS are the main risk factors for eNOSE-associated mortality.
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Affiliation(s)
- Fedele Dono
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy; Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST-, University G. D'Annunzio of Chieti-Pescara, Italy.
| | - Giacomo Evangelista
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy; Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST-, University G. D'Annunzio of Chieti-Pescara, Italy
| | - Davide Rodorigo
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Eleonora Rollo
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marina Romozzi
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Clarissa Corniello
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Davide Liviello
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Michelangelo Dasara
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy; Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST-, University G. D'Annunzio of Chieti-Pescara, Italy
| | - Luca Capriati
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Università Cattolica del Sacro Cuore, Rome, Italy; Neurofisiopatologia, Dipartimento di Neuroscienze, Organi di Senso e Torace, Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Paolo Quintieri
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Serenella Servidei
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Università Cattolica del Sacro Cuore, Rome, Italy; Neurofisiopatologia, Dipartimento di Neuroscienze, Organi di Senso e Torace, Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
| | - Giacomo Della Marca
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Università Cattolica del Sacro Cuore, Rome, Italy; Neurofisiopatologia, Dipartimento di Neuroscienze, Organi di Senso e Torace, Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
| | - Paolo Calabresi
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Università Cattolica del Sacro Cuore, Rome, Italy; Neurologia, Dipartimento di Neuroscienze, Organi di Senso e Torace, Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
| | - Stefano L Sensi
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy; Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology-CAST-, University G. D'Annunzio of Chieti-Pescara, Italy.
| | - Catello Vollono
- Dipartimento di Neuroscienze, Organi di Senso e Torace, Università Cattolica del Sacro Cuore, Rome, Italy; Neurofisiopatologia, Dipartimento di Neuroscienze, Organi di Senso e Torace, Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.
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Desai M, Kalkach-Aparicio M, Sheikh IS, Cormier J, Gallagher K, Hussein OM, Cespedes J, Hirsch LJ, Westover B, Struck AF. Evaluating the Impact of Point-of-Care Electroencephalography on Length of Stay in the Intensive Care Unit: Subanalysis of the SAFER-EEG Trial. Neurocrit Care 2024:10.1007/s12028-024-02039-6. [PMID: 38981999 DOI: 10.1007/s12028-024-02039-6] [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: 01/29/2024] [Accepted: 06/05/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Electroencephalography (EEG) is needed to diagnose nonconvulsive seizures. Prolonged nonconvulsive seizures are associated with neuronal injuries and deleterious clinical outcomes. However, it is uncertain whether the rapid identification of these seizures using point-of-care EEG (POC-EEG) can have a positive impact on clinical outcomes. METHODS In a retrospective subanalysis of the recently completed multicenter Seizure Assessment and Forecasting with Efficient Rapid-EEG (SAFER-EEG) trial, we compared intensive care unit (ICU) length of stay (LOS), unfavorable functional outcome (modified Rankin Scale score ≥ 4), and time to EEG between adult patients receiving a US Food and Drug Administration-cleared POC-EEG (Ceribell, Inc.) and those receiving conventional EEG (conv-EEG). Patient records from January 2018 to June 2022 at three different academic centers were reviewed, focusing on EEG timing and clinical outcomes. Propensity score matching was applied using key clinical covariates to control for confounders. Medians and interquartile ranges (IQRs) were calculated for descriptive statistics. Nonparametric tests (Mann-Whitney U-test) were used for the continuous variables, and the χ2 test was used for the proportions. RESULTS A total of 283 ICU patients (62 conv-EEG, 221 POC-EEG) were included. The two populations were matched using demographic and clinical characteristics. We found that the ICU LOS was significantly shorter in the POC-EEG cohort compared to the conv-EEG cohort (3.9 [IQR 1.9-8.8] vs. 8.0 [IQR 3.0-16.0] days, p = 0.003). Moreover, modified Rankin Scale functional outcomes were also different between the two EEG cohorts (p = 0.047). CONCLUSIONS This study reveals a significant association between early POC-EEG detection of nonconvulsive seizures and decreased ICU LOS. The POC-EEG differed from conv-EEG, demonstrating better functional outcomes compared with the latter in a matched analysis. These findings corroborate previous research advocating the benefit of early diagnosis of nonconvulsive seizure. The causal relationship between the type of EEG and metrics of interest, such as ICU LOS and functional/clinical outcomes, needs to be confirmed in future prospective randomized studies.
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Affiliation(s)
- Masoom Desai
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA.
| | | | - Irfan S Sheikh
- Epilepsy Division, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Justine Cormier
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, CT, USA
| | - Kaileigh Gallagher
- Epilepsy Division, Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Omar M Hussein
- Comprehensive Epilepsy Team, Neurology Department, University of New Mexico, Albuquerque, NM, USA
| | - Jorge Cespedes
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, CT, USA
| | - Lawrence J Hirsch
- Comprehensive Epilepsy Center, Department of Neurology, Yale University, New Haven, CT, USA
| | - Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Aaron F Struck
- Department of Neurology, University of Wisconsin, Madison, WI, USA
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Adhikari A, Yadav SK, Nepal G, Aryal R, Baral P, Neupane P, Paudel A, Pantha B, Acharya S, Shrestha GS, Khadayat R. Use of ketamine in Super Refractory Status Epilepticus: a systematic review. Neurol Res Pract 2024; 6:33. [PMID: 38926769 PMCID: PMC11210084 DOI: 10.1186/s42466-024-00322-7] [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: 01/18/2024] [Accepted: 04/03/2024] [Indexed: 06/28/2024] Open
Abstract
OBJECTIVE This review specifically investigates ketamine's role in SRSE management. METHODS PubMed, EMBASE, and Google Scholar databases were searched from inception to May 1st, 2023, for English-language literature. Inclusion criteria encompassed studies on SRSE in humans of all ages and genders treated with ketamine. RESULTS In this systematic review encompassing 19 studies with 336 participants, age ranged from 9 months to 86 years. Infections, anoxia, and metabolic issues emerged as the common causes of SRSE, while some cases had unknown origins, termed as NORSE (New Onset RSE) or FIRESs (Febrile Infection-Related Epilepsy Syndrome). Most studies categorized SRSE cases into convulsive (N = 105) and non-convulsive (N = 197). Ketamine was used after failed antiepileptics and anesthetics in 17 studies, while in others, it was a first or second line of treatment. Dosages varied from 0.5 mg/kg (bolus) and 0.2-15 mg/kg/hour (maintenance) in adults and 1-3 mg/kg (bolus) and 0.5-3 mg/kg/hour (maintenance) in pediatrics, lasting one to 30 days. Ketamine was concurrently used with other drugs in 40-100% of cases, most frequently propofol and midazolam. Seizure resolution rate varied from 53.3 to 91% and 40-100% in larger (N = 42-68) and smaller case series (N = 5-20) respectively. Seizure resolution occurred in every case of case report except in one in which the patient died. Burst suppression in EEG was reported in 12 patients from two case series and two case reports. Recurrence was reported in 11 patients from five studies. The reported all-cause mortality varied from 38.8 to 59.5% and 0-36.4% in larger and smaller case series., unrelated directly to ketamine dosage or duration. SIGNIFICANCE Ketamine demonstrates safety and effectiveness in SRSE, offering advantages over GABAergic drugs by acting on NMDA receptors, providing neuroprotection, and reducing vasopressor requirement.
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Affiliation(s)
| | - Sushil Kumar Yadav
- Intern, Institute of Medicine, Tribhuvan University Teaching Hospital, 44600, Kathmandu, Nepal.
| | - Gaurav Nepal
- Intern, Institute of Medicine, Tribhuvan University Teaching Hospital, 44600, Kathmandu, Nepal
| | - Roshan Aryal
- Intern, Institute of Medicine, Tribhuvan University Teaching Hospital, 44600, Kathmandu, Nepal
| | - Pratik Baral
- Intern, Institute of Medicine, Tribhuvan University Teaching Hospital, 44600, Kathmandu, Nepal
| | - Peter Neupane
- Jibjibe Primary Health Care Centre, 45003, Dhaibung, Rasuwa, Nepal
| | | | - Barsha Pantha
- Post Graduate Institute of Medical Education and Research, 160012, Chandigarh, India
| | - Sulav Acharya
- Intern, Institute of Medicine, Tribhuvan University Teaching Hospital, 44600, Kathmandu, Nepal
| | - Gentle Sunder Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, 44600, Maharajgunj, Kathmandu, Nepal
| | - Ramesh Khadayat
- Intern, Institute of Medicine, Tribhuvan University Teaching Hospital, 44600, Kathmandu, Nepal
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Willert AC, Kowski AB. Emerging Trends in Neuropalliative Care: A Palliative Approach to Epilepsy and Seizure Management in Adults. Semin Neurol 2024. [PMID: 38914127 DOI: 10.1055/s-0044-1787808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Abstract
Management of severe (drug-resistant) epilepsy and epilepsy in other serious illnesses is multidimensional and requires consideration of both physical symptoms and psychosocial distress that require individualized treatment. Palliative care offers a holistic approach to disease that focuses on all dimensions of suffering to maintain quality of life. Integration of a palliative care mind- and skillset in the management of severe epilepsy and epilepsy in other serious illnesses can provide person-centered care and support for families and caregivers.
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Affiliation(s)
- Anna-Christin Willert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
| | - Alexander Bernhard Kowski
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Neurology with Experimental Neurology, Berlin, Germany
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Bode CM, Kristensen SB, Olsen HT, Cornwall CD, Roberg L, Monsson O, Krøigård T, Toft P, Beier CP. Postictal Encephalopathy After Status Epilepticus: Outcome and Risk Factors. Neurocrit Care 2024; 40:1025-1035. [PMID: 37940836 PMCID: PMC11147838 DOI: 10.1007/s12028-023-01868-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/22/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Postictal encephalopathy is well known after status epilepticus (SE), but its prognostic impact and triggers are unknown. Here, we aimed to establish risk factors for the development of postictal encephalopathy and to study its impact on survival after discharge. METHODS This retrospective cohort study comprised adult patients diagnosed with first nonanoxic SE at Odense University Hospital between January 2008 and December 2017. Patients with ongoing SE at discharge or unknown treatment success were excluded. Postictal symptoms of encephalopathy were estimated retrospectively using the West Haven Criteria (WHC). WHC grade was determined for postictal day 1 to 14 or until the patient died or was discharged from the hospital. Cumulative postictal WHC during 14 days after SE-cessation was used to quantify postictal encephalopathy. Clinical characteristics, patient demographics, electroencephalographic and imaging features, and details on intensive care treatment were assessed from medical records. RESULTS Of all eligible patients (n = 232), 198 (85.3%) had at least WHC grade 2 postictal encephalopathy that lasted for > 14 days in 24.5% of the surviving patients. WHC grade at discharge was strongly associated with poor long-term survival (p < 0.001). Postictal encephalopathy was not associated with nonconvulsive SE, postictal changes on magnetic resonance imaging, or distinct ictal patterns on electroencephalography. Although duration of SE and treatment in the intensive care unit showed an association with cumulative postictal WHC grade, they were not independently associated with the degree of encephalopathy when controlling for confounders. In a linear regression model, etiology, duration of sedation, age, and premorbid modified Rankin Scale were significant and consistent predictors for higher cumulative postictal WHC grade. Exploratory analyses showed an association of a cumulative midazolam dosage (mg/kg/h) with higher cumulative postictal WHC grade. DISCUSSION In this cohort, postictal encephalopathy after SE was common and associated with poor long-term survival. Seizure characteristics were not independently associated with postictal encephalopathy; the underlying etiology, long (high-dose midazolam) sedation, high age, and poor premorbid condition were the major risk factors for its development.
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Affiliation(s)
- Clara Marie Bode
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
| | - Simon Bruun Kristensen
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
| | | | - Camilla Dyremose Cornwall
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Lars Roberg
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
| | - Olav Monsson
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
| | - Thomas Krøigård
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Neurophysiology, Odense University Hospital, Odense, Denmark
| | - Palle Toft
- Department of Anesthesiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christoph P Beier
- Department of Neurology, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense, Denmark.
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- OPEN, Odense Patient Data Explorative Network, Odense University Hospital, Odense, Denmark.
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Tedrus GMAS. Ictal EEG: Etiology and Mortality in Older Adults With Nonconvulsive Status Epilepticus. Clin EEG Neurosci 2024; 55:278-282. [PMID: 37498994 DOI: 10.1177/15500594231183554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Clinical-electroencephalogram (EEG), as well as etiological and prognostic data on subtypes of nonconvulsive status epilepticus (NCSE) are yet to be established. Objective: Evaluate the clinical semiology and EEG findings and prognostic data of older adults with NCSE. Methodology: Characterize the clinical-EEG and prognostic data in the subtypes of NCSE in older adults consecutively admitted to the emergency room of the Pontifícia Universidade Católica de Campinas (PUC-Campinas) University Hospital. Results: When evaluating 105 older adults with altered consciousness, it was possible to diagnose NCSE in 50 (47.6%) older adults, with a mean age of 72.8 ± 8.8 years. NCSE-coma occurred in 6 cases, with NCSE-without coma in 44 cases. The etiology was structural in 41(82%) cases, metabolic in 5 cases, and unknown etiology in 4 cases. Twelve cases had a history of epileptic seizures. On the EEG, epileptiform discharges (EDs > 2.5 Hz) were present in 34(68%) cases and rhythmic delta activity /lateralized periodic patterns occurred in 35(70%) cases. There was clinical improvement after the initial pharmacological treatment in 36 cases and, within 30 days, 18 cases died. The better prognosis was associated with a good response to initial pharmacological treatment (n = 14) and with EDs > 2.5 Hz on EEG (Fisher's exact test; 26 vs 8; P = .012). Conclusion: Focal NCSE with impaired consciousness was the most frequent subtype. The most frequent finding on the EEG was the recording of focal/regional seizures. A high number of cases showed initial clinical improvement, but mortality was high. The favorable prognosis was associated with initial clinical improvement and the presence of EDs > 2.5 Hz. There was no relationship between EEG patterns and the etiology and subtypes of NCSE in older adults.
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Affiliation(s)
- Glória M A S Tedrus
- Postgraduate Program in Health Sciences, Pontifícia Universidade Católica de Campinas, Campinas, SP, Brasil
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Beuchat I, Novy J, Rosenow F, Kellinghaus C, Rüegg S, Tilz C, Trinka E, Unterberger I, Uzelac Z, Strzelczyk A, Rossetti AO. Staged treatment response in status epilepticus: Lessons from the SENSE registry. Epilepsia 2024; 65:338-349. [PMID: 37914525 DOI: 10.1111/epi.17817] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/20/2023] [Accepted: 10/31/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVES Although in epilepsy patients the likelihood of becoming seizure-free decreases substantially with each unsuccessful treatment, to our knowledge this has been poorly investigated in status epilepticus (SE). We aimed to evaluate the proportion of SE cessation and functional outcome after successive treatment steps. METHODS We conducted a post hoc analysis of a prospective, observational, multicenter cohort (Sustained Effort Network for treatment of Status Epilepticus [SENSE]), in which 1049 incident adult SE episodes were prospectively recorded at nine European centers. We analyzed 996 SE episodes without coma induction before the third treatment step. Rates of SE cessation, mortality (in ongoing SE or after SE control), and favorable functional outcome (assessed with modified Rankin scale) were evaluated after each step. RESULTS SE was treated successfully in 838 patients (84.1%), 147 (14.8%) had a fatal outcome (36% of them died while still in SE), and 11 patients were transferred to palliative care while still in SE. Patients were treated with a median of three treatment steps (range 1-13), with 540 (54.2%) receiving more than two steps (refractory SE [RSE]) and 95 (9.5%) more than five steps. SE was controlled after the first two steps in 45%, with an additional 21% treated after the third, and 14% after the fourth step. Likelihood of SE cessation (p < 0.001), survival (p = 0.003), and reaching good functional outcome (p < 0.001) decreased significantly between the first two treatment lines and the third, especially in patients not experiencing generalized convulsive SE, but remained relatively stable afterwards. SIGNIFICANCE The significant worsening of SE prognosis after the second step clinically supports the concept of RSE. However, and differing from findings in human epilepsy, RSE remains treatable in about one third of patients, even after several failed treatment steps. Clinical judgment remains essential to determine the aggressiveness and duration of SE treatment, and to avoid premature treatment cessation in patients with SE.
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Affiliation(s)
- Isabelle Beuchat
- Department of Neurology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Jan Novy
- Department of Neurology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University, Frankfurt am Main, Germany
| | - Christoph Kellinghaus
- Department of Neurology, Klinikum Osnabrück, Osnabrück, Germany
- Epilepsy Center, Münster-Osnabrück, Campus Osnabrück, Osnabrück, Germany
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel, and University of Basel, Basel, Switzerland
| | - Christian Tilz
- Department of Neurology, Krankenhaus Barmherzige Brüder, Regensburg, Germany
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Member of the European Reference Network EpiCARE, Salzburg, Austria
- Neuroscience Institute, Christian Doppler University Hospital, Paracelsus Medical University, Centre for Cognitive Neuroscience, Salzburg, Austria
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology, Salzburg, Austria
| | - Iris Unterberger
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Zeljko Uzelac
- Department of Neurology, University Hospital Ulm, Ulm, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, Goethe-University, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University, Frankfurt am Main, Germany
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Andrea O Rossetti
- Department of Neurology, Centre Hospitalier Universitaire Vaudois (CHUV) and University of Lausanne, Lausanne, Switzerland
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Fisch U, Jünger AL, Baumann SM, Semmlack S, De Marchis GM, Rüegg SJ, Hunziker S, Marsch S, Sutter R. Association Between Dose Escalation of Anesthetics and Outcomes in Patients With Refractory Status Epilepticus. Neurology 2024; 102:e207995. [PMID: 38165316 DOI: 10.1212/wnl.0000000000207995] [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: 01/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES To investigate the association between dose escalation of continuously administered IV anesthetics and its duration with short-term outcomes in adult patients treated for refractory status epilepticus (RSE). METHODS Clinical and electroencephalographic data of patients with RSE without hypoxic-ischemic encephalopathy who were treated with anesthetics at a Swiss academic medical center from 2011 to 2019 were assessed. The frequency of anesthetic dose escalation (i.e., dose increase) and its associations with in-hospital death or return to premorbid neurologic function were primary endpoints. Multivariable logistic regression analysis was performed to identify associations with endpoints. RESULTS Among 111 patients with RSE, doses of anesthetics were escalated in 57%. Despite patients with dose escalation having a higher morbidity (lower Glasgow Coma Scale [GCS] score at status epilepticus [SE] onset, more presumably fatal etiologies, longer duration of SE and intensive care, more infections, and arterial hypotension) as compared with patients without, the primary endpoints did not differ between these groups in univariable analyses. Multivariable analyses revealed decreased odds for death with dose escalation (odds ratio 0.09, 95% CI 0.01-0.86), independent of initial GCS score, presumably fatal etiology, SE severity score, SE duration, and nonconvulsive SE with coma, with similar functional outcome among survivors compared with patients without dose escalation. DISCUSSION Our study reveals that anesthetic dose escalation in adult patients with RSE is associated with decreased odds for death without increasing the proportion of surviving patients with worse neurofunctional state than before RSE. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that anesthetic dose escalation decreases the odds of death in patients with RSE.
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Affiliation(s)
- Urs Fisch
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Anja L Jünger
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sira M Baumann
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Saskia Semmlack
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Gian Marco De Marchis
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan J Rüegg
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sabina Hunziker
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Marsch
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Raoul Sutter
- From the Department of Neurology (U.F., G.M.D.M., S.J.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Department of Clinical Research and Medical Faculty of the University of Basel (G.M.D.M., S.J.R., S.H., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
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9
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Orav K, Bosque Varela P, Prüwasser T, Machegger L, Leitinger M, Trinka E, Kuchukhidze G. Post-hypoxic status epilepticus - A distinct subtype of status epilepticus with poor prognosis. Epileptic Disord 2023; 25:823-832. [PMID: 37776308 PMCID: PMC10947449 DOI: 10.1002/epd2.20164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/31/2023] [Accepted: 09/23/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVE To evaluate the clinical outcome of patients with possible and definitive post-hypoxic status epilepticus (SE) and to describe the SE types in patients with definitive post-hypoxic SE. METHODS Patients with definitive or possible SE resulting from hypoxic brain injury after cardiac arrest (CA) were prospectively recruited. Intermittent EEG was used for the diagnosis of SE according to clinical practice. Two raters blinded to outcome analyzed EEGs retrospectively for possible and definitive SE patterns and background features (frequency, continuity, reactivity, and voltage). Definitive SE was classified according to semiology (ILAE). Mortality and Cerebral Performance Categories (CPC) score were evaluated 1 month after CA. RESULTS We included 64 patients of whom 92% died. Among the survivors, only one patient had a good neurological outcome (CPC 1). No patient survived with a burst suppression pattern, low voltage, or electro-cerebral silence in any EEG. Possible or definitive SE was diagnosed in a median of 47 h (IQR 39-72 h) after CA. EEG criteria for definitive electrographic SE were fulfilled in 39% of patients; in 38% - for electroclinical SE and in 23% - for ictal-interictal continuum (IIC). The outcome did not differ significantly between the three groups. The only patient with good functional outcome belonged to the IIC group. Comatose non-convulsive SE (NCSE) without subtle motor phenomenon occurred in 20% of patients with definitive electrographic SE and outcome was similar to other types of SE. SIGNIFICANCE Possible or definitive SE due to hypoxic brain injury is associated with poor prognosis. The outcome of patients with electrographic SE, electroclinical SE, and IIC did not differ significantly. Outcome was similar in patients with definitive electrographic SE with and without prominent motor features.
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Affiliation(s)
- Kateriine Orav
- Department of Neurology, Member of the European Reference Network EpiCARE, Centre for Cognitive Neuroscience, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
- Department of NeurologyNorth Estonia Medical CentreTallinnEstonia
| | - Pilar Bosque Varela
- Department of Neurology, Member of the European Reference Network EpiCARE, Centre for Cognitive Neuroscience, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
| | - Tanja Prüwasser
- Department of Neurology, Member of the European Reference Network EpiCARE, Centre for Cognitive Neuroscience, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
- Department of MathematicsParis‐Lodron UniversitySalzburgAustria
| | - Lukas Machegger
- Department of Neuroradiology, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
| | - Markus Leitinger
- Department of Neurology, Member of the European Reference Network EpiCARE, Centre for Cognitive Neuroscience, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
| | - Eugen Trinka
- Department of Neurology, Member of the European Reference Network EpiCARE, Centre for Cognitive Neuroscience, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
- Neuroscience InstituteChristian Doppler University HospitalSalzburgAustria
- Karl Landsteiner Institute for Neurorehabilitation and Space NeurologySalzburgAustria
| | - Giorgi Kuchukhidze
- Department of Neurology, Member of the European Reference Network EpiCARE, Centre for Cognitive Neuroscience, Christian Doppler University HospitalParacelsus Medical University of SalzburgSalzburgAustria
- Neuroscience InstituteChristian Doppler University HospitalSalzburgAustria
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Braun KRM, Pham LL, Wall GC, Welty TE. Suboptimal Dosing of Benzodiazepines and Levetiracetam in a Cohort of Status Epilepticus Patients and Outcomes Associated with Inadequate Dosing. J Pharm Pract 2023; 36:1068-1071. [PMID: 35403498 DOI: 10.1177/08971900221088804] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Status epilepticus (SE) is a neurologic emergency that can result in serious morbidity and mortality. Recent studies have suggested underdosing of both benzodiazepines (BZDs) and antiseizure medications (ASM) which may result in poorer outcomes. Objectives: This study aims to determine the dose of BZDs and levetiracetam given in our emergency department for episodes of SE and determine the outcomes associated with this dosing. Methods: We conducted a retrospective cohort study of all adult patients with SE admitted to our hospital from 2017 to 2020. We collected demographic data, type of SE, dose of BZD and levetiracetam, and outcomes which included mortality and a calculated Glasgow outcome scale (GOS). We compared outcomes of patients with SE who received adequate dosing (according to practice guidelines) to those who did not. Results: 111 adult patients were included of whom 91% were seen initially in our emergency department. 75% had convulsive SE on presentation. Approximately 55% and 68% of patients did not receive an appropriate dose of BZD or levetiracetam, respectively. Inadequate dosing of BZD was associated with worse clinical outcomes based on GOS (43.6% favorable outcome vs 62.5% with adequate dosing P = .046 (95% CI, 1.01-4.60)) and inadequate dosing of both drugs was also associated with a worse GOS outcome (HR, 2.91 (95% CI, 1.05-9.67, P = .02). No difference was found in length of stay or mortality alone. Conclusion: Our study found inadequate dosing of drugs to treat SE in adults was common in our institution and was associated with worse outcomes.
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Affiliation(s)
- Kristina R M Braun
- Internal Medicine Residency, Iowa Methodist Medical Center, Des Moines, IA USA
| | - L Lisa Pham
- Internal Medicine Residency, Iowa Methodist Medical Center, Des Moines, IA USA
| | - Geoffrey C Wall
- Internal Medicine Residency, Iowa Methodist Medical Center, Des Moines, IA USA
- Drake University College of Pharmacy and Health Sciences, Des Moines, IA USA
| | - Timothy E Welty
- Drake University College of Pharmacy and Health Sciences, Des Moines, IA USA
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11
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De Stefano P, Baumann SM, Grzonka P, Sarbu OE, De Marchis GM, Hunziker S, Rüegg S, Kleinschmidt A, Quintard H, Marsch S, Seeck M, Sutter R. Early timing of anesthesia in status epilepticus is associated with complete recovery: A 7-year retrospective two-center study. Epilepsia 2023; 64:1493-1506. [PMID: 37032415 DOI: 10.1111/epi.17614] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/07/2023] [Accepted: 04/07/2023] [Indexed: 04/11/2023]
Abstract
OBJECTIVE This study was undertaken to investigate the efficacy, tolerability, and outcome of different timing of anesthesia in adult patients with status epilepticus (SE). METHODS Patients with anesthesia for SE from 2015 to 2021 at two Swiss academic medical centers were categorized as anesthetized as recommended third-line treatment, earlier (as first- or second-line treatment), and delayed (later as third-line treatment). Associations between timing of anesthesia and in-hospital outcomes were estimated by logistic regression. RESULTS Of 762 patients, 246 received anesthesia; 21% were anesthetized as recommended, 55% earlier, and 24% delayed. Propofol was preferably used for earlier (86% vs. 55.5% for recommended/delayed anesthesia) and midazolam for later anesthesia (17.2% vs. 15.9% for earlier anesthesia). Earlier anesthesia was statistically significantly associated with fewer infections (17% vs. 32.7%), shorter median SE duration (.5 vs. 1.5 days), and more returns to premorbid neurologic function (52.9% vs. 35.5%). Multivariable analyses revealed decreasing odds for return to premorbid function with every additional nonanesthetic antiseizure medication given prior to anesthesia (odds ratio [OR] = .71, 95% confidence interval [CI] = .53-.94) independent of confounders. Subgroup analyses revealed decreased odds for return to premorbid function with increasing delay of anesthesia independent of the Status Epilepticus Severity Score (STESS; STESS = 1-2: OR = .45, 95% CI = .27-.74; STESS > 2: OR = .53, 95% CI = .34-.85), especially in patients without potentially fatal etiology (OR = .5, 95% CI = .35-.73) and in patients experiencing motor symptoms (OR = .67, 95% CI = .48-.93). SIGNIFICANCE In this SE cohort, anesthetics were administered as recommended third-line therapy in only every fifth patient and earlier in every second. Increasing delay of anesthesia was associated with decreased odds for return to premorbid function, especially in patients with motor symptoms and no potentially fatal etiology.
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Affiliation(s)
- Pia De Stefano
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Sira M Baumann
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Pascale Grzonka
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| | - Oana E Sarbu
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Medical faculty of the University of Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical faculty of the University of Basel, Basel, Switzerland
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Basel, Switzerland
| | - Stephan Rüegg
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Medical faculty of the University of Basel, Basel, Switzerland
| | - Andreas Kleinschmidt
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Medical faculty of the University of Geneva, Geneva, Switzerland
| | - Hervé Quintard
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland
- Medical faculty of the University of Geneva, Geneva, Switzerland
| | - Stephan Marsch
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Medical faculty of the University of Basel, Basel, Switzerland
| | - Margitta Seeck
- EEG and Epilepsy Unit, Department of Clinical Neurosciences, University Hospital of Geneva, Geneva, Switzerland
- Medical faculty of the University of Geneva, Geneva, Switzerland
| | - Raoul Sutter
- Clinic for Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Medical faculty of the University of Basel, Basel, Switzerland
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12
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Fisch U, Jünger AL, Baumann SM, Semmlack S, De Marchis GM, Hunziker S, Rüegg S, Marsch S, Sutter R. Association Between Induced Burst Suppression and Clinical Outcomes in Patients With Refractory Status Epilepticus: A 9-Year Cohort Study. Neurology 2023; 100:e1955-e1966. [PMID: 36889924 PMCID: PMC10186226 DOI: 10.1212/wnl.0000000000207129] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/17/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND AND OBJECTIVES To investigate the frequency of induced EEG burst suppression pattern during continuous IV anesthesia (IVAD) and associated outcomes in adult patients treated for refractory status epilepticus (RSE). METHODS Patients with RSE treated with anesthetics at a Swiss academic care center from 2011 to 2019 were included. Clinical data and semiquantitative EEG analyses were assessed. Burst suppression was categorized as incomplete burst suppression (with ≥20% and <50% suppression proportion) or complete burst suppression (with ≥50% suppression proportion). The frequency of induced burst suppression and association of burst suppression with outcomes (persistent seizure termination, in-hospital survival, and return to premorbid neurologic function) were the endpoints. RESULTS We identified 147 patients with RSE treated with IVAD. Among 102 patients without cerebral anoxia, incomplete burst suppression was achieved in 14 (14%) with a median of 23 hours (interquartile range [IQR] 1-29) and complete burst suppression was achieved in 21 (21%) with a median of 51 hours (IQR 16-104). Age, Charlson comorbidity index, RSE with motor symptoms, the Status Epilepticus Severity Score and arterial hypotension requiring vasopressors were identified as potential confounders in univariable comparisons between patients with and without any burst suppression. Multivariable analyses revealed no associations between any burst suppression and the predefined endpoints. However, among 45 patients with cerebral anoxia, induced burst suppression was associated with persistent seizure termination (72% without vs 29% with burst suppression, p = 0.004) and survival (50% vs 14% p = 0.005). DISCUSSION In adult patients with RSE treated with IVAD, burst suppression with ≥50% suppression proportion was achieved in every fifth patient and not associated with persistent seizure termination, in-hospital survival, or return to premorbid neurologic function.
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Affiliation(s)
- Urs Fisch
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Anja L Jünger
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sira M Baumann
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Saskia Semmlack
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Gian Marco De Marchis
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sabina Hunziker
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Rüegg
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Marsch
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Raoul Sutter
- From the Department of Neurology (U.F., G.M.D.M., S.R., R.S.), and Clinic for Intensive Care Medicine (A.L.J., S.M.B., S.S., S.H., S.M., R.S.), University Hospital Basel; Medical Faculty of the University of Basel (G.M.D.M., S.H., S.R., S.M., R.S.); and Medical Communication and Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland.
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13
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Wagner AS, Baumann SM, Semmlack S, Frei AI, Rüegg S, Hunziker S, Marsch S, Sutter R. Comparing Patients With Isolated Seizures and Status Epilepticus in Intensive Care Units: An Observational Cohort Study. Neurology 2023; 100:e1763-e1775. [PMID: 36878696 PMCID: PMC10136011 DOI: 10.1212/wnl.0000000000206838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 12/06/2022] [Indexed: 03/08/2023] Open
Abstract
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.
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Affiliation(s)
- Anna S Wagner
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sira M Baumann
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Saskia Semmlack
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Anja I Frei
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Rüegg
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Sabina Hunziker
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Stephan Marsch
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland
| | - Raoul Sutter
- From the Department of Neurology (A.S.W., S.M.B., S.R., R.S.), Department of Anesthesiology (S.S.), and Department of Intensive Care (A.I.F., S.M., R.S.), University Hospital Basel; Medical Faculty (S.R., S.H., S.M., R.S.), University of Basel; and Department of Psychosomatic Medicine (S.H.), University Hospital Basel, Switzerland.
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14
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Hsiao SC, Lai WH, Chen IL, Shih FY. Clinical impact of carbapenems in critically ill patients with valproic acid therapy: A propensity-matched analysis. Front Neurol 2023; 14:1069742. [PMID: 37034060 PMCID: PMC10074422 DOI: 10.3389/fneur.2023.1069742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 01/30/2023] [Indexed: 03/12/2023] Open
Abstract
BackgroundValproic acid (VPA) is one of the most widely used broad-spectrum antiepileptic drugs, and carbapenems (CBPs) remain the drug of choice for severe infection caused by multidrug-resistant bacteria in critically ill patients. The interaction between VPA and CBPs can lead to a rapid depletion of serum VPA level. This may then cause status epilepticus (SE), which is associated with significant mortality. However, the prognostic impact of drug interactions in critically ill patients remains an under-investigated issue.ObjectiveThe aim of this study was to compare the prognosis of critically ill patients treated with VPA and concomitant CBPs or other broad-spectrum antibiotics.MethodsAdult patients admitted to a medical center intensive care unit between January 2007 and December 2017 who concomitantly received VPA and antibiotics were enrolled. The risk of reduced VPA serum concentration, seizures and SE, mortality rate, length of hospital stay (LOS), and healthcare expenditure after concomitant administration were analyzed after propensity score matching.ResultsA total of 1,277 patients were included in the study, of whom 264 (20.7%) concomitantly received VPA and CBPs. After matching, the patients who received CBPs were associated with lower VPA serum concentration (15.8 vs. 60.8 mg/L; p < 0.0001), a higher risk of seizures (51.2 vs. 32.4%; adjusted odds ratio [aOR], 2.19; 95% CI, 1.48–3.24; p < 0.0001), higher risk of SE (13.6 vs. 4.7%; aOR, 3.20; 95% CI, 1.51–6.74; p = 0.0014), higher in-hospital mortality rate (33.8 vs. 24.9%; aOR, 1.57; 95% CI, 1.03–2.20; p = 0.036), longer LOS after concomitant therapy (41 vs. 30 days; p < 0.001), and increased healthcare expenditure (US$20,970 vs. US$12,848; p < 0.0001) than those who received other broad-spectrum antibiotics.ConclusionThe administration of CBPs in epileptic patients under VPA therapy was associated with lower VAP serum concentration, a higher risk of seizures and SE, mortality, longer LOS, and significant utilization of healthcare resources. Healthcare professionals should pay attention to the concomitant use of VPA and CBPs when treating patients with epilepsy. Further studies are warranted to investigate the reason for the poor outcomes and whether avoiding the co-administration of VPA and CBP can improve the outcomes of epileptic patients.
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Affiliation(s)
- Shu-Chen Hsiao
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wei-Hung Lai
- Department of Trauma Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - I-Ling Chen
- Department of Pharmacy, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
- I-Ling Chen
| | - Fu-Yuan Shih
- Department of Neurosurgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- *Correspondence: Fu-Yuan Shih
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15
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Benaiteau M, Valton L, Gardy L, Denuelle M, Debs R, Wucher V, Rulquin F, Barbeau EJ, Bonneville F, Pariente J, Curot J. Specific profiles of new-onset vs. non-inaugural status epilepticus: From diagnosis to 1-year outcome. Front Neurol 2023; 14:1101370. [PMID: 36860570 PMCID: PMC9969963 DOI: 10.3389/fneur.2023.1101370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
While new-onset status epilepticus (NOSE) is a harbinger of chronic epilepsy, prospective medical data are sparse in terms of specifying whether the evolution of status epilepticus (SE) and seizure expression in NOSE resembles what occurs in patients who have already been diagnosed with epilepsy [non-inaugural SE (NISE)] in all aspects apart from its inaugural nature. The aim of this study was to compare the clinical, MRI, and EEG features that could distinguish NOSE from NISE. We conducted a prospective monocentric study in which all patients ≥18 years admitted for SE over a 6-month period were included. A total of 109 patients (63 NISE and 46 NOSE cases) were included. Despite similar modified Rankin scores before SE, several aspects of the clinical history distinguished NOSE from NISE patients. NOSE patients were older and frequently had neurological comorbidity and preexisting cognitive decline, but they had a similar prevalence of alcohol consumption to NISE patients. NOSE and NISE evolve in the same proportions as refractory SE (62.5% NOSE, 61% NISE) and share common features such as the same incidence (33% NOSE, 42% NISE, and p = 0.53) and volumes of peri-ictal abnormalities on MRI. However, in NOSE patients, we observed greater non-convulsive semiology (21.7% NOSE, 6% NISE, and p = 0.02), more periodic lateral discharges on EEG (p = 0.004), later diagnosis, and higher severity according to the STESS and EMSE scales (p < 0.0001). Mortality occurred in 32.6% of NOSE patients and 21% of NISE patients at 1 year (p = 0.19), but with different causes of death occurring at different time points: more early deaths directly linked to SE at 1 month occurred in the NOSE group, while there were more remote deaths linked to causal brain lesions in the NISE group at final follow-up. In survivors, 43.6% of the NOSE cases developed into epilepsy. Despite acute causal brain lesions, the novelty related to its inaugural nature is still too often associated with a delay in diagnosing SE and a poorer outcome, which justifies the need to more clearly specify the various types of SE to constantly raise awareness among clinicians. These results highlight the relevance of including novelty-related criteria, clinical history, and temporality of occurrence in the nosology of SE.
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Affiliation(s)
- Marie Benaiteau
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, University Hospital of Lyon HCL, Lyon, France,Neurology Department, Toulouse University Hospital, Toulouse, France,*Correspondence: Marie Benaiteau ✉
| | - Luc Valton
- Neurology Department, Toulouse University Hospital, Toulouse, France,Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France,Luc Valton ✉
| | - Ludovic Gardy
- Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France
| | - Marie Denuelle
- Neurology Department, Toulouse University Hospital, Toulouse, France,Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France
| | - Rachel Debs
- Neurology Department, Toulouse University Hospital, Toulouse, France
| | - Valentin Wucher
- French Reference Center on Paraneoplastic Neurological Syndromes and Autoimmune Encephalitis, University Hospital of Lyon HCL, Lyon, France,Synaptopathies and Autoantibodies (SynatAc) Team, NeuroMyoGene-MeLis Institute, INSERM U1314/CNRS UMR 5284, University of Lyon, Lyon, France
| | - Florence Rulquin
- Neurology Department, Toulouse University Hospital, Toulouse, France
| | - Emmanuel J. Barbeau
- Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France,Faculty of Health, University of Toulouse-Paul Sabatier, Toulouse, France
| | - Fabrice Bonneville
- Faculty of Health, University of Toulouse-Paul Sabatier, Toulouse, France,INSERM, U1214, Toulouse Neuro Imaging Center (ToNIC), Toulouse, France,Neuroradiology Department, Toulouse University Hospital, Toulouse, France
| | - Jérémie Pariente
- Neurology Department, Toulouse University Hospital, Toulouse, France,Faculty of Health, University of Toulouse-Paul Sabatier, Toulouse, France,INSERM, U1214, Toulouse Neuro Imaging Center (ToNIC), Toulouse, France
| | - Jonathan Curot
- Neurology Department, Toulouse University Hospital, Toulouse, France,Brain and Cognition Research Center (CerCo), French National Scientific Research Center, UMR5549, Toulouse, France,Faculty of Health, University of Toulouse-Paul Sabatier, Toulouse, France,Jonathan Curot ✉
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16
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Cetnarowski A, Cunningham B, Mullen C, Fowler M. Evaluation of intravenous lorazepam dosing strategies and the incidence of refractory status epilepticus. Epilepsy Res 2023; 190:107067. [PMID: 36610189 DOI: 10.1016/j.eplepsyres.2022.107067] [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: 04/12/2022] [Revised: 11/29/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Status epilepticus (SE) is a neurological emergency associated with high mortality if not identified and treated promptly. For the emergent treatment of SE, the recommended intravenous (IV) lorazepam dose is 0.1 mg/kg/dose, up to a maximum of 4 mg. It has been shown that lorazepam is commonly under dosed in SE, but there is conflicting data on whether this has a negative impact on patient outcomes. This study assessed any dose less than 4 mg to help identify the effects of under dosing lorazepam in SE. METHODS This was a retrospective cohort study of patients admitted to a quaternary health system between October 1, 2017 and September 30, 2019 that experienced SE and were initially treated with IV lorazepam. Patients were divided into two cohorts, less than 4 mg or 4 mg, based on the initial one-time dose of lorazepam received. The primary outcome was the proportion of patients that progressed to refractory status epilepticus (RSE) that received an initial IV lorazepam dose of 4 mg compared to less than 4 mg for the treatment of SE. Secondary outcomes evaluated include length of stay, mortality, time in SE, number of seizures, cumulative lorazepam dose prior to urgent therapy, number of lorazepam doses prior to urgent therapy, time to urgent therapy, appropriately dosed urgent therapy, and number of antiepileptic drugs given in SE. RESULTS One hundred twenty patients were included in this study (107 patients received less than 4 mg and 13 patients received 4 mg). All patients included in the study were greater than 40 kg. The primary outcome of progression to RSE was observed in a significantly greater proportion of patients in the less than 4 mg group compared to the 4 mg group (93 [87%] vs. 8 [62%], p = 0.03). There was no difference in hospital or intensive care unit length of stay. However, there was an increased rate of in-hospital mortality in patients who received 4 mg compared to less than 4 mg (5 [39%] vs. 12[11%], p = 0.02). DISCUSSION The majority of patients in the study received less than the recommended dose of IV lorazepam for SE. Patients who received less than 4 mg experienced an increased progression to RSE, which supports current guideline recommended dosing. While there was an increased rate of mortality in patients who received 4 mg compared to less than 4 mg, time in SE was prolonged in the patient population and severity of illness was only available for a limited number of patients included.
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Affiliation(s)
- Alicia Cetnarowski
- Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH 44307, USA.
| | | | - Chanda Mullen
- Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH 44307, USA.
| | - Melissa Fowler
- Cleveland Clinic Akron General, 1 Akron General Ave, Akron, OH 44307, USA.
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17
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Sutter R, Jünger AL, Baumann SM, Grzonka P, De Stefano P, Fisch U. Balancing the risks and benefits of anesthetics in status epilepticus. Epilepsy Behav 2023; 138:109027. [PMID: 36496337 DOI: 10.1016/j.yebeh.2022.109027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/23/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE According to international guidelines, status epilepticus refractory to first- and second-line antiseizure medication should be treated with anesthetics. Therefore, continuously delivered intravenous midazolam, propofol, or barbiturates are recommended as third-line therapy. While electroencephalographically (EEG)-controlled titration of anesthetics to seizure termination or to the emergence of an EEG burst-suppression pattern makes sense, evidence of the efficacy and tolerability of such third-line treatment is limited and concerns regarding the risks of anesthesia remain. The lack of treatment alternatives and persistent international discord reflecting contradictory results from some studies leave clinicians on their own when deciding to escalate treatment. In this conference-accompanying narrative review, we highlight the challenges of EEG-monitored third-line treatment and discuss recent studies that examined earlier administration of anesthetics. RESULTS Based on the literature, maintaining continuous burst suppression is difficult despite the constant administration of anesthetics, and the evidence for burst suppression as an adequate surrogate target is limited by methodological shortcomings as acknowledged by international guidelines. In our Swiss cohort including 102 patients with refractory status epilepticus, burst suppression as defined by the American Clinical Neurophysiology Society's Critical Care EEG Terminology 2021 was established in only 21%. Besides case reports suggesting that rapid but short-termed anesthesia can be sufficient to permanently stop seizures, a study including 205 patients revealed that anesthesia as second-line treatment was associated with a shorter median duration of status epilepticus (0.5 versus 12.5 days, p < 0.001), median ICU (2 versus 5.5 days, p < 0.001) and hospital stay (8 versus 17 days, p < 0.001) with equal rates of complications when compared to anesthesia as third-line treatment. CONCLUSIONS Recent investigations have led to important findings and new insights regarding the use of anesthetics in refractory status epilepticus. However, numerous methodological limitations and remaining questions need to be considered when it comes to the translation into clinical practice, and, in consequence, call for prospective randomized studies. This paper was presented at the 8th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in September 2022.
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Affiliation(s)
- Raoul Sutter
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland; Department of Neurology, University Hospital Basel, Basel, Switzerland; Medical Faculty of the University of Basel, Basel, Switzerland.
| | - Anja L Jünger
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland; Center for Interdisciplinary Brain Sciences Research, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Sira M Baumann
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
| | - Pascale Grzonka
- Intensive Care Medicine, Department of Acute Medical Care, University Hospital Basel, Basel, Switzerland
| | - Pia De Stefano
- Neuro-Intensive Care Unit, Department of Intensive Care, University Hospital of Geneva, Geneva, Switzerland; EEG and Epilepsy Unit, Department of Clinical Neurosciences and Faculty of Medicine of Geneva, University Hospital of Geneva, Geneva, Switzerland
| | - Urs Fisch
- Department of Neurology, University Hospital Basel, Basel, Switzerland
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18
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Iswarajati N, Kumara IF, Triono A. Status epilepticus in pediatric patients severity score (STEPPS) as an outcome predictor in children. PAEDIATRICA INDONESIANA 2022. [DOI: 10.14238/pi62.6.2022.396-403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Status epilepticus (SE) is a neurological emergency, with short-term mortality ranging from 0.9 to 3.6% in children. The disease burden of SE includes morbidity, treatment costs, and mortality. Various scoring tools for predicting outcomes in adult SE cases have been widely studied, but there are few tools for predicting outcomes in children with SE.
Objective To evaluate the usefulness of status epilepticus in pediatric patients severity score (STEPSS), a clinical score for predicting functional outcome and mortality in pediatric patients with status epilepticus, as well as to identify characteristics of SE patients.
Methods This retrospective cohort study included 88 pediatric patients with status epilepticus aged >1 month to ?18 years by consecutive sampling, who were treated at Dr. Sardjito Hospital, Yogyakarta. All subjects underwent assessment by STEPPS score, which were compared to functional outcome assessed by Pediatric Overall Performance Capacity (POPC) score and mortality.
Results STEPPS > 3 was significantly correlated with poor functional outcome (OR 2.85; 95%CI 1.04 to 7.87; P=0.043), but was not significantly correlated with mortality outcome in children with SE (P=0.411).
Conclusion STEPPS score with cut-off >3 can be used as a predictor of poor functional outcome in pediatric patients with SE aged >1 month to ?18 years, but cannot be used as a predictor of mortality.
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19
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Vaitkevicius H, Ramsay RE, Swisher CB, Husain AM, Aimetti A, Gasior M. Intravenous ganaxolone for the treatment of refractory status epilepticus: Results from an open-label, dose-finding, phase 2 trial. Epilepsia 2022; 63:2381-2391. [PMID: 35748707 PMCID: PMC9796093 DOI: 10.1111/epi.17343] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Patients with refractory status epilepticus (RSE) have failed treatment with benzodiazepines and ≥1 second-line intravenous (IV) antiseizure medication (ASM). Guidelines recommend IV anesthesia when second-line ASMs have failed, but potential harms can outweigh the benefits. Novel treatments are needed to stop and durably control RSE without escalation to IV anesthetics. Ganaxolone is an investigational neuroactive steroid in development for RSE treatment. This study's objective was to determine the appropriate dosing for IV ganaxolone in RSE and obtain a preliminary assessment of efficacy and safety. METHODS This was an open-label, phase 2 trial conducted from February 19, 2018 to September 18, 2019, at three sites in the United States. Patients were aged ≥12 years, had convulsive or nonconvulsive SE, and failed to respond to ≥1 second-line IV ASM. Twenty-one patients were screened; 17 were enrolled. Patients received IV ganaxolone added to standard-of-care ASMs. Ganaxolone infusion was initiated as an IV bolus (over 3 min) with continuous infusion of decreasing infusion rates for 48-96 h followed by an 18-h taper. There were three ganaxolone dosing cohorts: low, 500 mg/day; medium, 650 mg/day; and high, 713 mg/day. The primary end point was the number of patients not requiring escalation to IV anesthetic treatment within 24 h of ganaxolone initiation. RESULTS Most of the 17 enrolled patients (65%) had nonconvulsive SE, and had failed a median of three prior ASMs, including first-line benzodiazepine and second-line IV ASM therapy. Median time to SE cessation following ganaxolone initiation was 5 min. No patient required escalation to third-line IV anesthetics during the 24-h period following ganaxolone initiation. Two treatment-related serious adverse events (sedation) were reported. Of the three deaths, none was considered related to ganaxolone; all occurred 9-22 days after completing ganaxolone. SIGNIFICANCE IV ganaxolone achieved rapid and durable seizure control in patients with RSE, and showed acceptable safety and tolerability.
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Affiliation(s)
- Henrikas Vaitkevicius
- Department of NeurologyBrigham and Women's HospitalBostonMassachusettsUSA,Marinus PharmaceuticalsRadnorPennsylvaniaUSA
| | - R. Eugene Ramsay
- International Center for EpilepsySt. Bernard HospitalNew OrleansLouisianaUSA
| | | | - Aatif M. Husain
- Department of NeurologyDuke UniversityDurhamNorth CarolinaUSA,Neurodiagnostic CenterVeterans Affairs Medical CenterDurhamNorth CarolinaUSA
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20
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Sharma S, Nunes M, Alkhachroum A. Adult Critical Care Electroencephalography Monitoring for Seizures: A Narrative Review. Front Neurol 2022; 13:951286. [PMID: 35911927 PMCID: PMC9334872 DOI: 10.3389/fneur.2022.951286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022] Open
Abstract
Electroencephalography (EEG) is an important and relatively inexpensive tool that allows intensivists to monitor cerebral activity of critically ill patients in real time. Seizure detection in patients with and without acute brain injury is the primary reason to obtain an EEG in the Intensive Care Unit (ICU). In response to the increased demand of EEG, advances in quantitative EEG (qEEG) created an approach to review large amounts of data instantly. Finally, rapid response EEG is now available to reduce the time to detect electrographic seizures in limited-resource settings. This review article provides a concise overview of the technical aspects of EEG monitoring for seizures, clinical indications for EEG, the various available modalities of EEG, common and challenging EEG patterns, and barriers to EEG monitoring in the ICU.
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Affiliation(s)
- Sonali Sharma
- Department of Neurology, University of Miami, Miami, FL, United States
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, United States
| | - Michelle Nunes
- Department of Neurology, University of Miami, Miami, FL, United States
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, United States
| | - Ayham Alkhachroum
- Department of Neurology, University of Miami, Miami, FL, United States
- Department of Neurology, Jackson Memorial Hospital, Miami, FL, United States
- *Correspondence: Ayham Alkhachroum
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21
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Brigo F, Turcato G, Lattanzi S, Orlandi N, Turchi G, Zaboli A, Giovannini G, Meletti S. Out-of-hospital versus in-hospital status epilepticus: the role of etiology and comorbidities. Eur J Neurol 2022; 29:2885-2894. [PMID: 35730536 PMCID: PMC9545890 DOI: 10.1111/ene.15472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 06/02/2022] [Indexed: 11/28/2022]
Abstract
Background and purpose Our objectives were to identify differences in clinical characteristics between patients with out‐of‐hospital and in‐hospital status epilepticus (SE) onset, and to evaluate the influence of SE onset setting on 30‐day mortality and SE cessation. Methods We included consecutive patients with SE admitted from 2013–2021 at Modena Academic Hospital. A propensity score was obtained with clinical variables unevenly distributed between the two groups. Results Seven hundred eleven patients were included; 55.8% (397/711) with out‐of‐hospital and 44.2% (314/711) with in‐hospital onset. Patients with in‐hospital SE onset were older and had a higher frequency of comorbidities, acute and/or potentially fatal etiologies, impaired consciousness before treatment, and nonconvulsive or myoclonic SE. No difference was found in SE cessation between the groups. Patients with in‐hospital SE had higher 30‐day mortality (127/314, 62.9% vs. 75/397, 37.1%; p < 0.001). In‐hospital onset was an independent risk factor for 30‐day mortality (adjusted odds ratio = 1.720; 95% confidence interval = 1.107–2.674; p = 0.016). In the propensity group (n = 244), no difference was found in 30‐day mortality and SE cessation between out‐of‐hospital and in‐hospital SE onset groups (36/122, 29.5% vs. 34/122, 27.9%; p = 0.888; and 47/122, 38.5% vs. 39/122; 32%; p = 0.347, respectively). Conclusions In‐hospital SE is associated with higher 30‐day mortality without difference in SE cessation. The two groups differ considerably for age, acute and possibly fatal etiologies, comorbidities, and SE semiology. The patient location at SE onset is an important prognostic predictor. However, the increased mortality is probably unrelated to the setting of SE onset and reflects intrinsic prognostic predictors.
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Affiliation(s)
- Francesco Brigo
- Department of Neurology, Hospital of Merano-Meran (SABES-ASDAA), Italy
| | - Gianni Turcato
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Niccolò Orlandi
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, Italy.,Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio-Emilia, Italy
| | - Giulia Turchi
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, Italy
| | - Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Giada Giovannini
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, Italy.,Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio-Emilia, Italy.,PhD program in Clinical and Experimental Medicine, University of Modena and Reggio-Emilia, Modena, Italy
| | - Stefano Meletti
- Neurology Department, Azienda Ospedaliera-Universitaria di Modena, Italy.,Department of Biomedical, Metabolic, and Neural Sciences, University of Modena and Reggio-Emilia, Italy
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22
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First-Response ABCDE Management of Status Epilepticus: A Prospective High-Fidelity Simulation Study. J Clin Med 2022; 11:jcm11020435. [PMID: 35054129 PMCID: PMC8780943 DOI: 10.3390/jcm11020435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 02/01/2023] Open
Abstract
Respiratory infections following status epilepticus (SE) are frequent, and associated with higher mortality, prolonged ICU stay, and higher rates of refractory SE. Lack of airway protection may contribute to respiratory infectious complications. This study investigates the order and frequency of physicians treating a simulated SE following a systematic Airways-Breathing-Circulation-Disability-Exposure (ABCDE) approach, identifies risk factors for non-adherence, and analyzes the compliance of an ABCDE guided approach to SE with current guidelines. We conducted a prospective single-blinded high-fidelity trial at a Swiss academic simulator training center. Physicians of different affiliations were confronted with a simulated SE. Physicians (n = 74) recognized SE and performed a median of four of the five ABCDE checks (interquartile range 3–4). Thereof, 5% performed a complete assessment. Airways were checked within the recommended timeframe in 46%, breathing in 66%, circulation in 92%, and disability in 96%. Head-to-toe (exposure) examination was performed in 15%. Airways were protected in a timely manner in 14%, oxygen supplied in 69%, and antiseizure drugs (ASDs) administered in 99%. Participants’ neurologic affiliation was associated with performance of fewer checks (regression coefficient −0.49; p = 0.015). We conclude that adherence to the ABCDE approach in a simulated SE was infrequent, but, if followed, resulted in adherence to treatment steps and more frequent protection of airways.
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23
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Vassallo P, Novy J, Zubler F, Schindler K, Alvarez V, Rüegg S, Rossetti AO. EEG spindles integrity in critical care adults. Analysis of a randomized trial. Acta Neurol Scand 2021; 144:655-662. [PMID: 34309006 PMCID: PMC9290497 DOI: 10.1111/ane.13510] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 07/15/2021] [Accepted: 07/18/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Occurrence of EEG spindles has been recently associated with favorable outcome in ICU patients. Available data mostly rely on relatively small patients' samples, particular etiologies, and limited variables ascertainment. We aimed to expand previous findings on a larger dataset, to identify clinical and EEG patterns correlated with spindle occurrence, and explore its prognostic implications. METHODS Retrospective observational study of prospectively collected data from a randomized trial (CERTA, NCT03129438) assessing the relationship of continuous (cEEG) versus repeated routine EEG (rEEG) with outcome in adults with acute consciousness impairment. Spindles were prospectively assessed visually as 12-16Hz activity on fronto-central midline regions, at any time during EEG interventions. Uni- and multivariable analyses explored correlations between spindles occurrence, clinical and EEG variables, and outcome (modified Rankin Scale, mRS; mortality) at 6 months. RESULTS Among the analyzed 364 patients, spindles were independently associated with EEG background reactivity (OR 13.2, 95% CI: 3.11-56.26), and cEEG recording (OR 4.35, 95% CI: 2.5 - 7.69). In the cEEG subgroup (n=182), 33.5% had spindles. They had better FOUR scores (p=0.004), fewer seizures or status epilepticus (p=0.02), and lower mRS (p=0.02). Mortality was reduced (p=0.002), and independently inversely associated with spindle occurrence (OR 0.50, CI 95% 0.25-0.99) and increased EEG background continuity (OR 0.16, 95% CI: 0.07 - 0.41). CONCLUSIONS Besides confirming that spindle activity occurs in up to one third of acutely ill patients and is associated with better outcome, this study shows that cEEG has a higher yield than rEEG in identifying them. Furthermore, it unravels associations with several clinical and EEG features in this clinical setting.
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Affiliation(s)
- Paola Vassallo
- Department of Clinical NeuroscienceLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Jan Novy
- Department of Clinical NeuroscienceLausanne University Hospital and University of LausanneLausanneSwitzerland
| | - Frédéric Zubler
- Sleep – Wake – Epilepsy ‐ CenterDepartment of NeurologyInselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Kaspar Schindler
- Sleep – Wake – Epilepsy ‐ CenterDepartment of NeurologyInselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Vincent Alvarez
- Department of Clinical NeuroscienceLausanne University Hospital and University of LausanneLausanneSwitzerland
- Department of NeurologyHôpital du ValaisSionSwitzerland
| | - Stephan Rüegg
- Department of NeurologyUniversity Hospital Basel and University of BaselBaselSwitzerland
| | - Andrea O. Rossetti
- Department of Clinical NeuroscienceLausanne University Hospital and University of LausanneLausanneSwitzerland
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Peedicail J, Mehdiratta N, Zhu S, Nedjadrasul P, Ng MC. Quantitative burst suppression on serial intermittent EEG in refractory status epilepticus. Clin Neurophysiol Pract 2021; 6:275-280. [PMID: 34825115 PMCID: PMC8604990 DOI: 10.1016/j.cnp.2021.10.003] [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: 04/03/2021] [Revised: 10/03/2021] [Accepted: 10/23/2021] [Indexed: 11/24/2022] Open
Abstract
Quantitative burst suppression ratios (QBSR) represent depth of EEG suppression. Deeper QBSR on serial intermittent EEG did not affect survival in RSE. Non-suppressive continuous EEG effects on RSE mortality merits further research.
Objectives In refractory status epilepticus (RSE), the optimal degree of suppression (EEG burst suppression or merely suppressing seizures) remains unknown. Many centers lacking continuous EEG must default to serial intermittent recordings where uncertainty from lack of data may prompt more aggressive suppression. In this study, we sought to determine whether the quantitative burst suppression ratio (QBSR) from serial intermittent EEG recording is associated with RSE patient outcome. Methods We screened the EEG database to identify non-anoxic adult RSE patients for EEG and chart review. QBSR was calculated per 10-second EEG epoch as the percentage of time during which EEG amplitude was <3 µV. Patients who survived 1–3 months after discharge from ICU and hospital comprised the favorable group. Further to initial unadjusted univariate analysis of all pooled QBSR, we conducted multivariate analyses to account for individual patient confounders (“per-capita analysis”), uneven number of EEG recordings (“per-session analysis”), and uneven number of epochs (“per-epoch analysis”). We analyzed gender, anesthetic number, and adjusted status epilepticus severity score (aSTESS) as confounders. Results In 135,765 QBSR values over 160 EEG recordings (median 2.17 h every ≥24 h) from 17 patients on Propofol, Midazolam, and/or Ketamine, QBSR was deeper in the favorable group (p < 0.001) on initial unadjusted analysis. However, on adjusted multivariate analysis, there was consistently no association between QBSR and outcome. Higher aSTESS consistently associated with unfavorable outcome on per-capita (p = 0.033), per-session (p = 0.048) and per-epoch (p < 0.001) analyses. Greater maximal number of non-barbiturate anesthetic associated with favorable outcome on per-epoch analysis (p < 0.001). Conclusions There was no association between depth of EEG suppression using non-barbiturate anesthetic and RSE patient outcome based on QBSR from serial intermittent EEG. A per-epoch association between non-barbiturate anesthetic and favorable outcome suggests an effect from non-suppressive time-varying EEG content. Significance Targeting and following deeper burst suppression through non-barbiturate anesthetics on serial intermittent EEG monitoring of RSE is of limited utility.
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Affiliation(s)
- Joseph Peedicail
- Section of Neurology, University of Manitoba, Winnipeg, MB, Canada
| | - Neil Mehdiratta
- Section of Neurology, University of Manitoba, Winnipeg, MB, Canada
| | - Shenghua Zhu
- Department of Radiology, University of Ottawa, Ottawa, ON, Canada
| | | | - Marcus C Ng
- Section of Neurology, University of Manitoba, Winnipeg, MB, Canada
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Zorlu MM, Chuang DT, Buyukozkan M, Aydemir S, Zarnegar R. Prognostic Significance of Cyclic Seizures in Status Epilepticus. J Clin Neurophysiol 2021; 38:516-524. [PMID: 32398513 DOI: 10.1097/wnp.0000000000000714] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Status epilepticus (SE) is a commonly encountered neurologic condition associated with high mortality rates. Cyclic seizures (CS) are a common form of SE, but its prognostic significance has not been well established. In this retrospective study, the mortality of cyclic versus noncyclic forms (NCSs) of SE are compared. METHODS A total of 271 patients were identified as having seizures or SE on EEG reports, of which 65 patients were confirmed as having SE. Based on EEG characteristics, the patients were then classified as cyclic or noncyclic patterns. Cyclic seizures were defined as recurrent seizures occurring at nearly regular and uniform intervals. Noncyclic form included all other patterns of SE. Pertinent clinical data were collected and reviewed for each case. RESULTS Of the 65 patients with SE, 25 patients had CS and 40 patients had NCS. Patients with CS showed a lower rate of in-hospital mortality although not statistically significant (P = 0.19). When looking at patients younger than 75 years, the CS group had significantly lower in-hospital mortality rate (P = 0.007). CONCLUSIONS The findings of this study suggest that CS may have a more favorable outcome compared with NCS in patients younger than 75 years. This study is also the first to report the rate of CS among all cases of confirmed SE (38%). Future studies with a larger sample size are needed to further evaluate the difference in outcome between CS and NCS.
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Affiliation(s)
- Musab M Zorlu
- Department of Neurology, Weill Cornell Medical College, New York, New York, U.S.A
- Department of Neurology, New York Presbyterian Queens, Flushing, New York, U.S.A
- Department of Neurology, University of Connecticut Health Center, Farmington, Connecticut, U.S.A .; and
| | - David T Chuang
- Department of Neurology, Weill Cornell Medical College, New York, New York, U.S.A
- Department of Neurology, New York Presbyterian Queens, Flushing, New York, U.S.A
| | - Mustafa Buyukozkan
- Department of Physiology and Biophysics, Weill Cornell Medical College, New York, New York, U.S.A
| | - Seyhmus Aydemir
- Department of Neurology, Weill Cornell Medical College, New York, New York, U.S.A
- Department of Neurology, New York Presbyterian Queens, Flushing, New York, U.S.A
| | - Reza Zarnegar
- Department of Neurology, New York Presbyterian Queens, Flushing, New York, U.S.A
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Dericioglu N, Ayvacioglu Cagan C, Sokmen O, Arsava EM, Topcuoglu MA. Frequency and Types of Complications Encountered in Patients With Nonconvulsive Status Epilepticus in the Neurological ICU: Impact on Outcome. Clin EEG Neurosci 2021; 54:265-272. [PMID: 34714180 DOI: 10.1177/15500594211046722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives. The frequency and types of complications in patients with nonconvulsive status epilepticus (NCSE) who are followed up in the intensive care unit (ICU), and the impact of these complications on outcome are not well-known. We investigated the complications and their effects on prognosis in NCSE patients. Methods. After reviewing the video-EEG monitoring (VEEGM) reports of all the consecutive patients who were followed up in our ICU between 2009 and 2019, we identified two groups of patients: 1-patients with NCSE (study group) and 2-patients who underwent VEEGM for possible NCSE but did not have ictal recordings (no-NCSE group). Electronic health records were reviewed to identify demographic and clinical data, duration of ICU care, medical and surgical complications, pharmacologic treatment, and outcome. These parameters were compared statistically between the groups. We also investigated the parameters affecting prognosis at discharge. Results. Thirty-two patients with NCSE comprised the study group. Infection developed in 84%. More than half were intubated, had tracheostomy or percutaneous endoscopic gastrostomy application. Refractory NCSE was associated with significantly more frequent complications and worse outcome. There was a higher tendency of infections in the study group (P = .059). Higher organ failure scores and prolonged stay in ICU predicted worse outcome (P < .05). Conclusion. The frequency of complications in patients with NCSE who are cared for in the ICU is considerable. Most of the complications are similar to the other patients in ICU, except for the higher frequency of infections. Increased physician awareness about modifiable parameters and timely interventions might help improve prognosis.
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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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Stetefeld HR, Schaal A, Scheibe F, Nichtweiß J, Lehmann F, Müller M, Gerner ST, Huttner HB, Luger S, Fuhrer H, Bösel J, Schönenberger S, Dimitriadis K, Neumann B, Fuchs K, Fink GR, Malter MP. Isoflurane in (Super-) Refractory Status Epilepticus: A Multicenter Evaluation. Neurocrit Care 2021; 35:631-639. [PMID: 34286464 PMCID: PMC8692280 DOI: 10.1007/s12028-021-01250-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 04/07/2021] [Indexed: 11/26/2022]
Abstract
Background We aimed to determine the association between seizure termination and side effects of isoflurane for the treatment of refractory status epilepticus (RSE) and super-refractory status epilepticus (SRSE) in neurointensive care units (neuro-ICUs). Methods This was a multicenter retrospective study of patients with RSE/SRSE treated with isoflurane for status epilepticus termination admitted to the neuro-ICUs of nine German university centers during 2011–2018. Results We identified 45 patients who received isoflurane for the treatment of RSE/SRSE. During isoflurane treatment, electroencephalograms showed no epileptiform discharges in 33 of 41 (80%) patients, and burst suppression pattern was achieved in 29 of 41 patients (71%). RSE/SRSE was finally terminated after treatment with isoflurane in 23 of 45 patients (51%) for the entire group and in 13 of 45 patients (29%) without additional therapy. Lengths of stay in the hospital and in the neuro-ICU were significantly extended in cases of ongoing status epilepticus under isoflurane treatment (p = 0.01 for length of stay in the hospital, p = 0.049 for length in the neuro-ICU). During isoflurane treatment, side effects were reported in 40 of 45 patients (89%) and mainly included hypotension (n = 40, 89%) and/or infection (n = 20, 44%). Whether side effects occurred did not affect the outcome at discharge. Of 22 patients with follow-up magnetic resonance imaging, 2 patients (9%) showed progressive magnetic resonance imaging alterations that were considered to be potentially associated with RSE/SRSE itself or with isoflurane therapy. Conclusions Isoflurane was associated with a good effect in stopping RSE/SRSE. Nevertheless, establishing remission remained difficult. Side effects were common but without effect on the outcome at discharge. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01250-z.
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Affiliation(s)
- Henning R Stetefeld
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Alexander Schaal
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Franziska Scheibe
- Department of Neurology, Universitätsmedizin Berlin Campus Charité Mitte, Berlin, Germany
- NeuroCure Clinical Research Center, Universitätsmedizin Berlin Campus Charité Mitte, Berlin, Germany
| | - Julia Nichtweiß
- Department of Neurology, Universitätsmedizin Berlin Campus Charité Mitte, Berlin, Germany
| | - Felix Lehmann
- Department of Anesthesiology and Intensive Care, University Hospital Bonn, Bonn, Germany
| | - Marcus Müller
- Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Sebastian Luger
- Center of Neurology and Neurosurgery, Department of Neurology, Goethe-University Hospital Frankfurt, Frankfurt, Germany
| | - Hannah Fuhrer
- Department of Neurology, University of Freiburg, Freiburg, Germany
| | - Julian Bösel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Kassel, Kassel, Germany
| | | | | | - Bernhard Neumann
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Kornelius Fuchs
- Department of Neurology, University Medical Center Regensburg, Regensburg, Germany
| | - Gereon R Fink
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany
- Cognitive Neuroscience, Institute of Neuroscience and Medicine, Research Center Jülich, Jülich, Germany
| | - Michael P Malter
- Department of Neurology, Faculty of Medicine, University Hospital Cologne, University of Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
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Ascoli M, Ferlazzo E, Gasparini S, Mastroianni G, Citraro R, Roberti R, Russo E. Epidemiology and Outcomes of Status Epilepticus. Int J Gen Med 2021; 14:2965-2973. [PMID: 34234526 PMCID: PMC8254099 DOI: 10.2147/ijgm.s295855] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 06/15/2021] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Michele Ascoli
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Regional Epilepsy Centre, Great Metropolitan Hospital, Reggio, Calabria, Italy
| | - Edoardo Ferlazzo
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Regional Epilepsy Centre, Great Metropolitan Hospital, Reggio, Calabria, Italy
| | - Sara Gasparini
- Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy.,Regional Epilepsy Centre, Great Metropolitan Hospital, Reggio, Calabria, Italy
| | | | - Rita Citraro
- Science of Health Department, Magna Græcia University, Catanzaro, Italy
| | - Roberta Roberti
- Science of Health Department, Magna Græcia University, Catanzaro, Italy
| | - Emilio Russo
- Science of Health Department, Magna Græcia University, Catanzaro, Italy
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De Stefano P, Baumann SM, Semmlack S, Rüegg S, Marsch S, Seeck M, Sutter R. Safety and Efficacy of Coma Induction Following First-Line Treatment in Status Epilepticus: A 2-Center Study. Neurology 2021; 97:e564-e576. [PMID: 34045273 DOI: 10.1212/wnl.0000000000012292] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 05/05/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explore the safety and efficacy of artificial coma induction to treat status epilepticus (SE) immediately after first-line antiseizure treatment instead of following the recommended approach of first using second-line drugs. METHODS Clinical and electrophysiologic data of all adult patients treated for SE from 2017 to 2018 in the Swiss academic medical care centers from Basel and Geneva were retrospectively assessed. Primary outcomes were return to premorbid neurologic function and in-hospital death. Secondary outcomes were the emergence of complications during SE, duration of SE, and intensive care unit (ICU) and hospital stays. RESULTS Of 230 patients, 205 received treatment escalation after first-line medication. Of those, 27.3% were directly treated with artificial coma and 72.7% with second-line nonanesthetic antiseizure drugs. Of the latter, 16.6% were subsequently put on artificial coma after failure of second-line treatment. Multivariable analyses revealed increasing odds for coma induction after first-line treatment with younger age, the presence of convulsions, and an increased SE severity as quantified by the Status Epilepticus Severity Score (STESS). While outcomes and complications did not differ compared to patients with treatment escalation according to the guidelines, coma induction after first-line treatment was associated with shorter SE duration and ICU and hospital stays. CONCLUSIONS Early induction of artificial coma is performed in more than every fourth patient and especially in younger patients presenting with convulsions and more severe SE. Our data demonstrate that this aggressive treatment escalation was not associated with an increase in complications but with shorter duration of SE and ICU and hospital stays. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that early induction of artificial coma after unsuccessful first-line treatment for SE is associated with shorter duration of SE and ICU and hospital stays compared to the use of a second-line nonanesthetic antiseizure drug instead of or before anesthetics, without an associated increase in complications.
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Affiliation(s)
- Pia De Stefano
- From the EEG and Epilepsy Unit (P.D.S., M.S.), Department of Clinical Neurosciences and Faculty of Medicine of Geneva, University Hospital of Geneva; Medical Faculty (S.M.B., S.M., R.S.) and Department of Clinical Research (R.S.), University of Basel; and Department of Intensive Care (S.S., S.R., S.M., R.S.) and Division of Neurophysiology (S.R., R.S.), Department of Neurology, University Hospital Basel, Switzerland.
| | - Sira Maria Baumann
- From the EEG and Epilepsy Unit (P.D.S., M.S.), Department of Clinical Neurosciences and Faculty of Medicine of Geneva, University Hospital of Geneva; Medical Faculty (S.M.B., S.M., R.S.) and Department of Clinical Research (R.S.), University of Basel; and Department of Intensive Care (S.S., S.R., S.M., R.S.) and Division of Neurophysiology (S.R., R.S.), Department of Neurology, University Hospital Basel, Switzerland
| | - Saskia Semmlack
- From the EEG and Epilepsy Unit (P.D.S., M.S.), Department of Clinical Neurosciences and Faculty of Medicine of Geneva, University Hospital of Geneva; Medical Faculty (S.M.B., S.M., R.S.) and Department of Clinical Research (R.S.), University of Basel; and Department of Intensive Care (S.S., S.R., S.M., R.S.) and Division of Neurophysiology (S.R., R.S.), Department of Neurology, University Hospital Basel, Switzerland
| | - Stephan Rüegg
- From the EEG and Epilepsy Unit (P.D.S., M.S.), Department of Clinical Neurosciences and Faculty of Medicine of Geneva, University Hospital of Geneva; Medical Faculty (S.M.B., S.M., R.S.) and Department of Clinical Research (R.S.), University of Basel; and Department of Intensive Care (S.S., S.R., S.M., R.S.) and Division of Neurophysiology (S.R., R.S.), Department of Neurology, University Hospital Basel, Switzerland
| | - Stephan Marsch
- From the EEG and Epilepsy Unit (P.D.S., M.S.), Department of Clinical Neurosciences and Faculty of Medicine of Geneva, University Hospital of Geneva; Medical Faculty (S.M.B., S.M., R.S.) and Department of Clinical Research (R.S.), University of Basel; and Department of Intensive Care (S.S., S.R., S.M., R.S.) and Division of Neurophysiology (S.R., R.S.), Department of Neurology, University Hospital Basel, Switzerland
| | - Margitta Seeck
- From the EEG and Epilepsy Unit (P.D.S., M.S.), Department of Clinical Neurosciences and Faculty of Medicine of Geneva, University Hospital of Geneva; Medical Faculty (S.M.B., S.M., R.S.) and Department of Clinical Research (R.S.), University of Basel; and Department of Intensive Care (S.S., S.R., S.M., R.S.) and Division of Neurophysiology (S.R., R.S.), Department of Neurology, University Hospital Basel, Switzerland
| | - Raoul Sutter
- From the EEG and Epilepsy Unit (P.D.S., M.S.), Department of Clinical Neurosciences and Faculty of Medicine of Geneva, University Hospital of Geneva; Medical Faculty (S.M.B., S.M., R.S.) and Department of Clinical Research (R.S.), University of Basel; and Department of Intensive Care (S.S., S.R., S.M., R.S.) and Division of Neurophysiology (S.R., R.S.), Department of Neurology, University Hospital Basel, Switzerland
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[S2k guidelines: status epilepticus in adulthood : Guidelines of the German Society for Neurology]. DER NERVENARZT 2021; 92:1002-1030. [PMID: 33751150 PMCID: PMC8484257 DOI: 10.1007/s00115-020-01036-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 01/16/2023]
Abstract
This S2k guideline on diagnosis and treatment of status epilepticus (SE) in adults is based on the last published version from 2021. New definitions and evidence were included in the guideline and the clinical pathway. A seizures lasting longer than 5 minutes (or ≥ 2 seizures over more than 5 mins without intermittend recovery to the preictal neurological state. Initial diagnosis should include a cCT or, if possible, an MRI. The EEG is highly relevant for diagnosis and treatment-monitoring of non-convulsive SE and for the exclusion or diagnosis of psychogenic non-epileptic seizures. As the increasing evidence supports the relevance of inflammatory comorbidities (e.g. pneumonia) related clinical chemistry should be obtained and repeated over the course of a SE treatment, and antibiotic therapy initiated if indicated.Treatment is applied on four levels: 1. Initial SE: An adequate dose of benzodiazepine is given i.v., i.m., or i.n.; 2. Benzodiazepine-refractory SE: I.v. drugs of 1st choice are levetiracetam or valproate; 3. Refractory SE (RSE) or 4. Super-refractory SE (SRSE): I.v. propofol or midazolam alone or in combination or thiopental in anaesthetic doses are given. In focal non-convulsive RSE the induction of a therapeutic coma depends on the circumstances and is not mandatory. In SRSE the ketogenic diet should be given. I.v. ketamine or inhalative isoflorane can be considered. In selected cased electroconvulsive therapy or, if a resectable epileptogenic zone can be defined epilepsy surgery can be applied. I.v. allopregnanolone or systemic hypothermia should not be used.
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Diagnostic yield of cerebrospinal fluid analysis in status epilepticus: an 8-year cohort study. J Neurol 2021; 268:3325-3336. [PMID: 33666722 PMCID: PMC8357741 DOI: 10.1007/s00415-021-10447-3] [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: 01/10/2021] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 01/07/2023]
Abstract
Background We investigate the frequency and diagnostic yield of cerebrospinal fluid (CSF) analysis in adult patients with status epilepticus (SE) and its impact on the outcome.
Methods From 2011 to 2018, adult patients treated at the University Hospital Basel were included. Primary outcomes were defined as the frequency of lumbar puncture and results from chemical, cellular, and microbiologic CSF analyses. Secondary outcomes were differences between patients receiving and not receiving lumbar puncture in the context of SE. Results In 18% of 408 patients, a lumbar puncture was performed. Of those, infectious pathogens were identified in 21% with 15% detected ± 24 h around SE diagnosis. 74% of CSF analyses revealed abnormal chemical or cellular components without infectious pathogens. Screening for autoimmune diseases was only performed in 22%. In 8%, no or late (i.e., > 24 after SE diagnosis) lumbar puncture was performed despite persistent unknown SE etiology in all, transformation into refractory SE in 78%, and no recovery to premorbid neurologic function in 66%. Withholding lumbar puncture was associated with no return to premorbid neurologic function during hospital stay independent of potential confounders. Not receiving a lumbar puncture was associated with presumed known etiology and signs of systemic infectious complications. Conclusions Withholding lumbar puncture in SE patients is associated with increased odds for no return to premorbid neurologic function, and CSF analyses in SE detect infectious pathogens frequently. These results and pathologic chemical and cellular CSF findings in the absence of infections call for rigorous screening to confirm or exclude infectious or autoimmune encephalitis in this context which should not be withheld.
Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10447-3.
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Kim D, Kim JM, Cho YW, Yang KI, Kim DW, Lee ST, No YJ, Seo JG, Byun JI, Kang KW, Kim KT. Antiepileptic Drug Therapy for Status Epilepticus. J Clin Neurol 2021; 17:11-19. [PMID: 33480193 PMCID: PMC7840311 DOI: 10.3988/jcn.2021.17.1.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 12/31/2022] Open
Abstract
Status epilepticus (SE) is one of the most serious neurologic emergencies. SE is a condition that encompasses a broad range of semiologic subtypes and heterogeneous etiologies. The treatment of SE primarily involves the management of the underlying etiology and the use of antiepileptic drug therapy to rapidly terminate seizure activities. The Drug Committee of the Korean Epilepsy Society performed a review of existing guidelines and literature with the aim of providing practical recommendations for antiepileptic drug therapy. This article is one of a series of review articles by the Drug Committee and it summarizes staged antiepileptic drug therapy for SE. While evidence of good quality supports the use of benzodiazepines as the first-line treatment of SE, such evidence informing the administration of second- or third-line treatments is lacking; hence, the recommendations presented herein concerning the treatment of established and refractory SE are based on case series and expert opinions. The choice of antiepileptic drugs in each stage should consider the characteristics and circumstances of each patient, as well as their estimated benefit and risk to them. In tandem with the antiepileptic drug therapy, careful searching for and treatment of the underlying etiology are required.
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Affiliation(s)
- Daeyoung Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae Moon Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea.
| | - Yong Won Cho
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea.
| | - Kwang Ik Yang
- Department of Neurology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Dong Wook Kim
- Department of Neurology, Konkuk University School of Medicine, Seoul, Korea
| | - Soon Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Young Joo No
- Department of Neurology, Samsung Noble County, Yongin, Korea
| | - Jong Geun Seo
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jung Ick Byun
- Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Keun Tae Kim
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
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Levetiracetam versus Phenytoin for the Pharmacotherapy of Benzodiazepine-Refractory Status Epilepticus: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. CNS Drugs 2020; 34:1205-1215. [PMID: 33111213 DOI: 10.1007/s40263-020-00770-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Recent studies have shown conflicting results regarding the effectiveness of levetiracetam for treating benzodiazepine-refractory status epilepticus (SE) compared with phenytoin. Therefore, a meta-analysis was carried out to assess the value of levetiracetam versus phenytoin in the pharmacotherapy of benzodiazepine-refractory SE. OBJECTIVE The aim of this systematic review and meta-analysis was to compare the efficacy and safety of levetiracetam and phenytoin in the treatment of benzodiazepine-refractory SE. METHODS The MEDLINE, EMBASE, CENTRAL and ClinicalTrials.gov databases were searched for randomized controlled trials (RCTs) that had been conducted to evaluate levetiracetam versus phenytoin for benzodiazepine-refractory SE, to April 2020. The data were assessed using Review Manager 5.3 software. The risk ratio (RR) was analyzed using dichotomous outcomes, and calculated using a random-effect model. RESULTS We pooled 1850 patients from 12 RCTs. Patients in the levetiracetam group had a significantly higher rate of clinical seizure cessation than in the phenytoin group (75.2% vs. 67.8%; RR 1.14, 95% confidence interval [CI] 1.05-1.25, p = 0.003). Moreover, less adverse events were observed in the levetiracetam group than in the phenytoin group (17.8% vs. 21.4%; RR 0.82, 95% CI 0.70-0.97, p = 0.02). In subgroup analysis, clinical seizure cessation was achieved more frequently with a higher dose of levetiracetam (> 30 mg/kg) [RR 1.15, 95% CI 1.00-1.32, p = 0.05]. Furthermore, in the subgroup of children, levetiracetam showed a higher rate of clinical seizure cessation than phenytoin (RR 1.13, 95% CI 1.02-1.25, p = 0.02). CONCLUSION Pharmacotherapy for BZD-refractory SE by LEV is superior to PHT in efficacy and safety outcomes.
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Caronna E, Vilaseca A, Maria Gràcia Gozalo R, Sanchez Corral A, Santafé M, Sueiras M, Guzmán L, Quintana M, Toledo‐Argany M, Santamarina E. Long-term prognosis related to deep sedation in refractory status Epilepticus. Acta Neurol Scand 2020; 142:555-562. [PMID: 32614067 DOI: 10.1111/ane.13302] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 06/10/2020] [Accepted: 06/19/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate long-term prognosis in patients with refractory status epilepticus according to the level of sedation reached during drug-induced coma. MATERIALS AND METHODS Longitudinal study of patients with status epilepticus who received anesthetics to induce therapeutic coma. Demographic data, clinical, and electroencephalographic characteristics were collected, as well as variables related to sedation. We considered as deep sedation the EEG burst-suppression patterns (suppression ratio > 50%). A GOSE (Glasgow Outcome Scale Extended) score of 7 or 8 was considered as good prognosis. A comparative study was carried out to identify predictors of good or poor prognosis at discharge, at 1 and 2 years of follow-up. RESULTS We included 61 patients: 63.9% were men; mean age 53.5 ± 16.8 years (range 16-86 years), 39.3% reached deep sedation; 62.3% had > 48 h induced coma. The median hospital stay was 21 days, while 10 days in the intensive care unit (ICU). In the multiple regression analysis, an ICU length of stay ≥ 7 days was associated with poor prognosis at discharge and at long-term (P < .05), while deep sedation was associated only with poor long-term prognosis (1 and 2 years, P < .05). The Kaplan-Meier curve showed higher survival in the group that did not undergo deep sedation (P < .05). CONCLUSIONS In refractory status epilepticus, deep sedation is associated with poor prognosis at long-term.
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Affiliation(s)
- Edoardo Caronna
- Epilepsy Unit Neurology Department Hospital Universitari Vall d’Hebron Barcelona Spain
| | - Andreu Vilaseca
- Epilepsy Unit Neurology Department Hospital Universitari Vall d’Hebron Barcelona Spain
| | | | | | - Manel Santafé
- Intensive Care Unit Hospital Universitari Vall d’Hebron Barcelona Spain
| | - María Sueiras
- Neurophysiology Department Hospital Universitari Vall d’Hebron Barcelona Spain
| | - Lorena Guzmán
- Neurophysiology Department Hospital Universitari Vall d’Hebron Barcelona Spain
| | - Manuel Quintana
- Epilepsy Unit Neurology Department Hospital Universitari Vall d’Hebron Barcelona Spain
| | - Manuel Toledo‐Argany
- Epilepsy Unit Neurology Department Hospital Universitari Vall d’Hebron Barcelona Spain
| | - Estevo Santamarina
- Epilepsy Unit Neurology Department Hospital Universitari Vall d’Hebron Barcelona Spain
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Frequency and Implications of Complications in the ICU After Status Epilepticus: No Calm After the Storm. Crit Care Med 2020; 48:1779-1789. [PMID: 33205920 DOI: 10.1097/ccm.0000000000004642] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To investigate the frequency, types, and implications of complications during intensive care in patients after status epilepticus has been successfully terminated. DESIGN Retrospective study. SETTING ICUs at a Swiss tertiary academic medical care center. PATIENTS Data were collected from the digital patient records of all adult patients with status epilepticus from 2012 to 2018. INTERVENTIONS None. METHODS Primary outcomes were defined as frequency of complications following status epilepticus termination and return to premorbid functional baseline. Univariable analyses regarding the relative risks of complications occurring after status epilepticus termination for no return to premorbid neurologic function were estimated by Poisson regression with robust error variance. RESULTS Of 311 patients with status epilepticus, 224 patients (72%) were treated on the ICU for more than 24 hours following status epilepticus termination. Ninety-six percent of patients remained in a prolonged state of altered consciousness for a median of 2 days (interquartile range, 1-3 d) and 80% had complications during their ICU treatment. Fifty-five percent had new-onset delirium with a median duration of 2 days (interquartile range, 1-3 d). Forty-two percent had mechanical ventilation for a median of 4 days (interquartile range, 2-11 d) and 21% had nosocomial infections diagnosed after status epilepticus. Multivariable analyses revealed that mechanical ventilation for more than 24 hours after status epilepticus, and arterial hypotension requiring vasopressors were independently associated with increased risk of no return to premorbid function (RRfor each additional day = 1.01; 95% CI, 1.02-1.03 and RRfor each additional day = 1.03; 95% CI, 1.01-1.05) and death (RRfor each additional day = 1.11; 95% CI, 1.04-1.19 and RRfor each additional day = 1.15; 95% CI, 1.03-1.28). Delirium was independently associated with a decreased relative risk of death (RRfor each additional day = 0.55; 95% CI, 0.37-0.80), but prolonged ICU- and hospital stays. CONCLUSIONS Complications after status epilepticus termination are frequent and associated with no return to premorbid function, death, and prolonged ICU- and hospital stays. These results call for heightened awareness and further studies mainly regarding prediction and preventive strategies in this context.
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Fisch U, Baumann SM, Semmlack S, Marsch S, Rüegg S, Sutter R. Accuracy of Calculated Free Valproate Levels in Adult Patients With Status Epilepticus. Neurology 2020; 96:e102-e110. [PMID: 33055270 DOI: 10.1212/wnl.0000000000011000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/20/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test the accuracy of an equation in adult patients with status epilepticus that calculates the free concentration of serum valproic acid (fVPA) from the total concentration of serum valproic acid (tVPA) and serum albumin. METHODS All adult patients with status epilepticus who were treated at a Swiss academic medical center between 2005 and 2018 with concurrent measurements of tVPA, fVPA, and serum albumin were included. fVPA was categorized as subtherapeutic, therapeutic (5-10 mg/L), or supratherapeutic. Agreement was defined as the proportion of measured and calculated fVPA falling within the same category. RESULTS Of 676 patients with status epilepticus, 104 had 506 measurements, with a median of 3 (interquartile range [IQR] 1.5-6.5) per patient. The median tVPA was 43.5 mg/L (27.4-63.6), with measured fVPA 9.1 mg/L (4.5-14.7) and calculated fVPA 10.1 mg/L (7.0-13.0), respectively. The median deviation of calculated from measured fVPA was -0.8 mg/L (-3.2 to 2.5) with 336 measurements >1 mg/L. While the association between measured and calculated fVPA was linear (regression coefficient 1.1, 95% confidence interval 0.9-1.2, p < 0.0001), the agreement on effective drug levels did not match in 39.8% of measurements regardless of serum albumin levels, with calculated fVPA overestimating measured fVPA in 30.4%. tVPA and serum albumin independently influenced the accuracy of the calculated fVPA in the multivariable model. CONCLUSIONS Calculated fVPA is inaccurate when using the proposed equation in adult patients with status epilepticus, calling for drug monitoring based on measured fVPA in this context.
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Affiliation(s)
- Urs Fisch
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland.
| | - Sira M Baumann
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
| | - Saskia Semmlack
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
| | - Stephan Marsch
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
| | - Stephan Rüegg
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
| | - Raoul Sutter
- From the Department of Neurology (U.F., S.R.) and Clinic for Intensive Care Medicine (S.M.B., S.S., S.M., R.S.), University Hospital Basel; and Medical Faculty of the University of Basel (S.M., S.R., R.S.), Switzerland
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Jiang Y, Yang Y, Feng F, Zhang Y, Wang XH, Ni FL, Hou Q, Zhang LP. Improving the ability to predict hospital mortality among adults by combining two status epilepticus outcome scoring tools. Epilepsy Behav 2020; 110:107149. [PMID: 32480304 DOI: 10.1016/j.yebeh.2020.107149] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/26/2020] [Accepted: 04/26/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The goal of this study was to compare the predictive ability of the Status Epilepticus Severity Score (STESS), the Encephalitis-nonconvulsive status epilepticus (NCSE)-Diazepam resistance-Image abnormalities-Tracheal intubation (END-IT), and the combination of these two scoring tools to predict mortality among inhospital patients with status epilepticus (SE). METHODS A retrospective analysis was conducted of adult patients with SE who were admitted to the neurology department, the emergency department, and the intensive care unit from January 2013 to December 2017. The patients were divided into two groups: survivors and nonsurvivors. The STESS data were obtained when the patient arrived at the hospital, and the END-IT data were collected 24 h after patients were initially treated in the hospital. The ability of the scoring tools to predict death in patients with SE, alone or in combination, was evaluated. RESULTS A total of 123 patients with SE were included in the study, of which 22 died, for a mortality rate of 17.9%. The STESS and END-IT scores of nonsurvivors were both significantly higher than those of survivors (median STESS 4 vs. 2, p = 0.003; median END-IT 3 vs. 1, p < 0.001). The area under the receiver operating characteristic curve (AUC) was 0.698 for the STESS and 0.852 for the END-IT, and the cutoff values were 4 and 3, respectively. The AUC of the END-IT with the optimal cutoff value was larger than that of the STESS (p = 0.024). The sensitivity and specificity of combining the STESS and END-IT by the serial method (STESS ≥ 4∩END-IT ≥ 3) were 0.50 and 0.95, respectively, and the specificity was significantly higher than the STESS or END-IT (both p's < 0.001). The sensitivity and specificity of combining the STESS and END-IT by the parallel method (STESS ≥ 4⋃END-IT ≥ 3) were 0.91 and 0.53, respectively, and the sensitivity was higher than the STESS was (p = 0.016). CONCLUSION Our results indicated that the combined score of the STESS and END-IT systems was a better predictor of survival of patients with SE than the scores of either the STESS system or the END-IT system alone and that combining the scores may be considered to be a new method for early identification of patients for both good and bad outcomes.
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Affiliation(s)
- Yan Jiang
- Department of Neurology, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yi Yang
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fei Feng
- Department of Gerontology, Hangzhou First People's Hospital, Hangzhou, China
| | - Ying Zhang
- Clinical Evaluation Analysis Center, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiao-Hang Wang
- Department of Neurology, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China
| | - Fei-Lin Ni
- Department of Neurology, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China
| | - Qun Hou
- Department of Neurology, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China
| | - Li-Ping Zhang
- Department of Neurology, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China.
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A feasibility study of electrocorticography during routine craniotomy to predict tumor-related epilepsy. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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The Unease When Using Anesthetics for Treatment-Refractory Status Epilepticus: Still Far Too Many Questions. J Clin Neurophysiol 2020; 37:399-405. [DOI: 10.1097/wnp.0000000000000606] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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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: 14] [Impact Index Per Article: 3.5] [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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Kafle DR, Avinash AJ, Shrestha A. Predictors of outcome in refractory generalized convulsive status epilepticus. Epilepsia Open 2020; 5:248-254. [PMID: 32524050 PMCID: PMC7278539 DOI: 10.1002/epi4.12394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/18/2020] [Accepted: 03/26/2020] [Indexed: 12/03/2022] Open
Abstract
Objective Refractory status epilepticus is a serious condition in which seizure continues despite use of two antiepileptic medications. Retrospective studies have shown that 29%‐43% of SE patients progress into RSE despite treatment. Mortality following RSE is high. We aimed to evaluate the predictors of outcome in patients with RSE at a tertiary care center. Methods Sixty‐eight consecutive patients with RSE who presented to our hospital between February 2018 and January 2020 were evaluated for outcome. Result In our study 28(41.2%), patients who failed to respond to first‐ and second‐line antiepileptic drug responded to the third‐line antiepileptic drug thus avoiding mechanical ventilation and intravenous anesthesia. Low GCS at admission (P < .001), need for mechanical ventilation and intravenous anesthesia (P = .018), and long duration of RSE before recovery (P = .035) were strongly associated with worse outcome. Duration of RSE before starting treatment (P = .147), previous history of seizure (P = .717), and age of the patient (P = .319) did not influence the outcome. Significance In our study, we prospectively evaluated patients with RSE and followed them for one month after discharge from the hospital. Unlike some of the previous studies, we identified an interesting finding whereby a significant proportion of the patients responded to the third‐line antiepileptic drug and thus avoiding the complications related to mechanical ventilation.
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Rüegg S, Sutter R. All in the numbers? Computational prediction of optimal anaesthetic weaning in status epilepticus. Brain 2020; 143:1048-1050. [PMID: 32318730 DOI: 10.1093/brain/awaa073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
This scientific commentary refers to ‘Electrographic predictors of successful weaning from anaesthetics in refractory status epilepticus’, by Rubin etal. (doi:10.1093/brain/awaa069).
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Affiliation(s)
- Stephan Rüegg
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Raoul Sutter
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
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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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New-onset super refractory status epilepticus: A case-series. Seizure 2020; 75:174-184. [DOI: 10.1016/j.seizure.2019.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 01/29/2023] Open
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Tatro HA, Hamilton LA, Peters C, Rowe AS. Identification of Risk Factors for Refractory Status Epilepticus. Ann Pharmacother 2020; 54:14-21. [DOI: 10.1177/1060028019867155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: The objective of this study is to identify risk factors for the development of refractory status epilepticus (RSE). Methods: This was an IRB-approved, retrospective case control study that included patients admitted with status epilepticus between August 1, 2014, and July 31, 2017. Cases were defined as those with RSE, and controls were those who did not develop RSE. A bivariate analysis was conducted comparing those with RSE and those without RSE. A stepwise logistic regression model was constructed predicting for progression to RSE. Risk factors for progression to RSE were extrapolated from this model. Results: A total of 184 patients met inclusion criteria for the study (99 controls and 49 cases). After adjusting for covariates in the logistic regression, patients with convulsive seizures had a lower odds of developing RSE (odds ratio [OR] = 0.375; 95% CI = 0.148 to 0.951; P = 0.0388). Treatment with benzodiazepines plus levetiracetam had a higher odds of developing RSE (OR = 3.804; 95% CI = 1.523 to 9.499; P = 0.0042). Conclusion and Relevance: This study found that patients with convulsive seizures had a lower odds of developing RSE. In addition, patients treated with benzodiazepines and levetiracetam had a higher odds of developing RSE. This information can be used to potentially identify patients at higher risk of developing RSE, so that treatment can be modified to reduce morbidity and mortality. These results may warrant further investigation into the effectiveness of levetiracetam as a first-line agent for the treatment of SE.
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Affiliation(s)
- Hayley A. Tatro
- University of Tennessee Medical Center, Knoxville, TN, USA
- University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA
| | - Leslie A. Hamilton
- University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA
| | - Cassey Peters
- University of Tennessee Medical Center, Knoxville, TN, USA
| | - A. Shaun Rowe
- University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA
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Sirikarn P, Pattanittum P, Tiamkao S. One- to 10-year Status Epilepticus Mortality (SEM) score after 30 days of hospital discharge: development and validation using competing risks analysis. BMC Neurol 2019; 19:307. [PMID: 31787084 PMCID: PMC6886213 DOI: 10.1186/s12883-019-1540-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 11/25/2019] [Indexed: 11/18/2022] Open
Abstract
Background Status epilepticus (SE) is an emergency neurological disorder that affects quality of life and is associated with high mortality risk. Three scores have been developed to predict the risk of in-hospital death, but these scores are poor discrimination of mortality after discharge. This study aimed to develop and validate a simple risk score for long-term mortality in SE patients. Methods This retrospective cohort study was conducted using SE patient data collected from Thailand’s Universal Coverage Scheme database between the fiscal years of 2005 and 2015 and followed-up to 2016. Patients who died in hospital or within 30 days after discharge were excluded. Data were divided at random into either a derivation or validation set. A proportional hazards model for the sub-distribution of competing risks was fitted with backward stepwise method. The coefficients from the model were used to develop a point-based scoring system. The discrimination ability of the model was evaluated using a time-dependent receiver operating characteristic (ROC) curve. Results A total of 20,792 SE patients (with ages ranging from the first day of life to 99 years at first admission) were randomly separated into two groups: 13,910 in the development group and 6882 in the validation group. A sub-distribution hazard model was used to determine nine predictors to be included in the final model, which was, in turn, used to develop the scoring system: age (0–19 points), male (two points), brain tumor (12 points), stroke (three points), cancer (11 points), diabetes (three points), chronic kidney disease (five points), pneumonia (five points), and urinary tract infection (four points). The possible total score ranged from zero to 64 and the cumulative incidence function was used to determine the probability of mortality associated with each total score within the first 10 years after the first admission. The area under the ROC curve (AUC) of the first to last time point ranged from 0.760 to 0.738. Conclusion A nine-factor risk score for predicting 10-year mortality in SE patients was developed. Further studies should focus on external validity and including a range seizure types and duration of seizure as the predictors.
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Affiliation(s)
- Prapassara Sirikarn
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand.,Integrated Epilepsy Research Group, Khon Kaen University, Khon Kaen, Thailand
| | - Porjai Pattanittum
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
| | - Somsak Tiamkao
- Integrated Epilepsy Research Group, Khon Kaen University, Khon Kaen, Thailand. .,Division of Neurology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
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Sirikarn P, Pattanittum P, Sawanyawisuth K, Tiamkao S. Causes of death in patients with status epilepticus. Epilepsy Behav 2019; 101:106372. [PMID: 31300380 DOI: 10.1016/j.yebeh.2019.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 06/11/2019] [Indexed: 11/26/2022]
Abstract
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".
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Affiliation(s)
- Prapassara Sirikarn
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand; Integrated Epilepsy Research Group, Khon Kaen University, Khon Kaen, Thailand.
| | - Porjai Pattanittum
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand.
| | - Kittisak Sawanyawisuth
- Division of Neurology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; Sleep Apnea Research Group, Research Center in Back, Neck and Other Joint Pain and Human Performance, Research and Training Center for Enhancing Quality of Life of Working Age People, and Research and Diagnostic Center for Emerging Infectious Diseases (RCEID), Khon Kaen University, Khon Kaen, Thailand.
| | - Somsak Tiamkao
- Division of Neurology, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand; Integrated Epilepsy Research Group, Khon Kaen University, Khon Kaen, Thailand.
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Legriel S. Hypothermia as a treatment in status epilepticus: A narrative review. Epilepsy Behav 2019; 101:106298. [PMID: 31133509 DOI: 10.1016/j.yebeh.2019.04.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/26/2019] [Accepted: 04/27/2019] [Indexed: 12/19/2022]
Abstract
Status epilepticus (SE) is associated with high mortality and morbidity rates, notably in its refractory and super-refractory forms. This narrative review discusses recent data on the potential benefits of targeted temperature management. In studies of patients with cerebral injury due to various factors, therapeutic hypothermia had variable effects on survival and functional outcomes. Sources of this variability may include the underlying etiology, whether hypothermia was used for prophylaxis or treatment, the degree and duration of hypothermia, and the hypothermia application modalities. Data from animal studies strongly suggest benefits from therapeutic hypothermia in SE. In humans, beneficial effects have been described in anecdotal case reports and small case series, but the level of evidence is low. A randomized controlled trial found no evidence that moderate hypothermia (32-34 °C) was neuroprotective in critically ill patients with convulsive SE. Nevertheless, some promising effects were noted, suggesting that therapeutic hypothermia might have a role as an adjuvant to anticonvulsant drug therapy in patients with refractory or super-refractory SE. This article is part of a Special Issue entitled "Status Epilepticus". This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Affiliation(s)
- Stéphane Legriel
- Medico-Surgical Intensive Care Department, Centre Hospitalier de Versailles, 177 rue de Versailles, 78150 Le Chesnay Cedex, France; Paris Descartes University, Sorbonne Paris Cité-Medical School, Paris, France; INSERM U970, Paris Cardiovascular Research Center, Paris, France; IctalGroup, France.
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Silveira DC, Sagi A, Romero R. Are seizures predictors of mortality in critically ill patients in the intensive care unit (ICU)? Seizure 2019; 73:14-16. [PMID: 31689583 DOI: 10.1016/j.seizure.2019.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/08/2019] [Accepted: 10/10/2019] [Indexed: 11/24/2022] Open
Abstract
PURPOSE This study aimed to determine if seizures in critically ill patients are predictive of in-hospital mortality. METHODS Patients above the age of 55 who underwent continuous electroencephalogram (cEEG) monitoring between 2015 and 2018 at the Hackensack Meridian Health and JFK Neuroscience Institute were included in the present study. Patients were subdivided into those with and without seizures. Age, sex, seizure types, CNS disorders, and other associated comorbidities were collected by chart review. After descriptive analysis, we used multiple logistic regression analyses to evaluate if seizures and mortality were associated. P-values less than 0.05 were considered statistically significant. RESULTS One hundred and one critically ill patients (62.4% female) were included in this study. Sixty-six (65.3%) were between 55 and 75 years of age, while 35 (34.7%) were above 75 years of age. Most patients (n = 31, 83.8%) had focal-onset seizures, and 10 had nonconvulsive status epilepticus (NCSE). Twelve (11.9%) patients with seizures did not survive. However, seizures were not independently associated with mortality in either unadjusted (OR 1.13, CI 0.47-2.72, p = 0.773) or adjusted (OR 1.20, CI 0.35-4.05, p = 0.760) regression models. Secondary predictors of mortality included mechanical ventilation (OR 5.36, CI 1.69-16.96, p = 0.001) and acute ischemic stroke (OR 2.77, CI 1.08-7.09, p = 0.034). CONCLUSION Seizures did not predict in-hospital mortality in critically ill patients. Larger prospective studies are needed to confirm our current findings.
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Affiliation(s)
- Diosely C Silveira
- Hackensack Meridian Health and JFK Neuroscience Institute, 65 James Street, Edison NJ 08820, United States.
| | | | - Raquel Romero
- Hackensack Meridian Health and JFK Neuroscience Institute, 65 James Street, Edison NJ 08820, United States
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