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Girard P, Bacq A, Cloarec P, Lesueur C, Verleye M, Castagné V. Stiripentol efficacy against status epilepticus and associated mortality in mice. Heliyon 2024; 10:e34854. [PMID: 39144999 PMCID: PMC11320214 DOI: 10.1016/j.heliyon.2024.e34854] [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: 01/19/2024] [Revised: 07/01/2024] [Accepted: 07/17/2024] [Indexed: 08/16/2024] Open
Abstract
Stiripentol (STP, Diacomit©) is an antiseizure medication indicated for Dravet syndrome, a rare developmental and epileptic encephalopathy characterized by drug-resistant seizures, including status epilepticus (SE). SE is a life-threatening event that may lead to increased risk of morbidity and mortality. Here, we evaluated the effect of STP on SE and SE-associated mortality using a CBA mouse model induced by systemic administration of methionine sulfoximine (MSO), an irreversible inhibitor of glutamine synthetase. MSO induces convulsions, prolonged seizure (SE) and death, with an increase of blood ammonia level. A single acute intraperitoneal pretreatment with 200-300-400 mg/kg of STP significantly inhibited the number of seizures, SE occurrence and death in MSO-treated animals in a dose-dependent manner. Regarding blood ammonia level, STP significantly reduced by 41 % the hyperammonemia induced by MSO. In conclusion, our results show protective effects of STP to reduce and or suppress the occurrence of SE as well as its associated mortality in mice.
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Affiliation(s)
- P. Girard
- Biocodex - Research and Development Center, Compiègne, France
| | - A. Bacq
- Biocodex - Research and Development Center, Compiègne, France
| | - P. Cloarec
- Biocodex - Research and Development Center, Compiègne, France
| | - C. Lesueur
- Biocodex - Research and Development Center, Compiègne, France
| | - M. Verleye
- Biocodex - Research and Development Center, Compiègne, France
| | - V. Castagné
- Biocodex - Research and Development Center, Compiègne, France
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2
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Damien C, Leitinger M, Kellinghaus C, Strzelczyk A, De Stefano P, Beier CP, Sutter R, Kämppi L, Strbian D, Taubøll E, Rosenow F, Helbok R, Rüegg S, Damian M, Trinka E, Gaspard N. Sustained effort network for treatment of status epilepticus/European academy of neurology registry on adult refractory status epilepticus (SENSE-II/AROUSE). BMC Neurol 2024; 24:19. [PMID: 38178048 PMCID: PMC10765797 DOI: 10.1186/s12883-023-03505-y] [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: 07/14/2023] [Accepted: 12/11/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Status Epilepticus (SE) is a common neurological emergency associated with a high rate of functional decline and mortality. Large randomized trials have addressed the early phases of treatment for convulsive SE. However, evidence regarding third-line anesthetic treatment and the treatment of nonconvulsive status epilepticus (NCSE) is scarce. One trial addressing management of refractory SE with deep general anesthesia was terminated early due to insufficient recruitment. Multicenter prospective registries, including the Sustained Effort Network for treatment of Status Epilepticus (SENSE), have shed some light on these questions, but many answers are still lacking, such as the influence exerted by distinct EEG patterns in NCSE on the outcome. We therefore initiated a new prospective multicenter observational registry to collect clinical and EEG data that combined may further help in clinical decision-making and defining SE. METHODS Sustained effort network for treatment of status epilepticus/European Academy of Neurology Registry on refractory Status Epilepticus (SENSE-II/AROUSE) is a prospective, multicenter registry for patients treated for SE. The primary objectives are to document patient and SE characteristics, treatment modalities, EEG, neuroimaging data, and outcome of consecutive adults admitted for SE treatment in each of the participating centers and to identify factors associated with outcome and refractoriness. To reach sufficient statistical power for multivariate analysis, a cohort size of 3000 patients is targeted. DISCUSSION The data collected for the registry will provide both valuable EEG data and information about specific treatment steps in different patient groups with SE. Eventually, the data will support clinical decision-making and may further guide the planning of clinical trials. Finally, it could help to redefine NCSE and its management. TRIAL REGISTRATION NCT number: NCT05839418.
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Affiliation(s)
- Charlotte Damien
- Department of Neurology, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Markus Leitinger
- Department of Neurology Neurointensive Care and Neurorehabilitation, Centre for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, European Reference Network EpiCARE, Salzburg, Austria
- Neuroscience Institute, Department of Neurology, Centre for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | | | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Pia De Stefano
- EEG & 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
| | - Christoph P Beier
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Raoul Sutter
- Department of Neurology, University Hospital Basel, Basel, Switzerland
- Intensive Care Units, University Hospital Basel, Basel, Switzerland
| | - Leena Kämppi
- Department of Neurology, Epilepsia Helsinki, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Epilepsia Helsinki, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Erik Taubøll
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Felix Rosenow
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Goethe-University and University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Raimund Helbok
- Department of Neurology, Johannes Kepler University Linz, Linz, Austria
| | - Stephan Rüegg
- Department of Neurology, Epilepsia Helsinki, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maxwell Damian
- Department of Critical Care, Essex Cardiothoracic Centre, Basildon, UK
| | - Eugen Trinka
- Department of Neurology Neurointensive Care and Neurorehabilitation, Centre for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, European Reference Network EpiCARE, Salzburg, Austria
- Neuroscience Institute, Department of Neurology, Centre for Cognitive Neuroscience, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute of Neurorehabilitation and Space Neurology, Salzburg, Austria
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University for Health Sciences, Medical Informatics and Technology, Hall en Tyrol, Austria
| | - Nicolas Gaspard
- Department of Neurology, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Brussels, Belgium.
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
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Loser V, Novy J, Beuchat I, Rossetti AO. Acute Valproate-Induced Encephalopathy in Status Epilepticus: A Registry-Based Assessment. CNS Drugs 2023; 37:725-731. [PMID: 37466895 PMCID: PMC10439035 DOI: 10.1007/s40263-023-01024-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Valproate-induced encephalopathy (VIE) affects between 0.1% and 2.5% of patients under long-term epilepsy treatment. Its frequency and characteristics in adults with status epilepticus (SE) is, however, unknown. OBJECTIVE The aim of this study was to characterize the frequency and the clinico-biological characteristics of VIE in adult SE patients. METHODS We reviewed all patients included in our institutional SE registry who were treated for an SE episode between November 2021 and February 2023 and identified 39 patients who received valproate for their SE treatment. Acute VIE was defined by worsening of consciousness having led to the discontinuation of valproate, and improvement of consciousness within 96 hours after discontinuation of valproate during acute hospital treatment. RESULTS Patients had a mean valproate intravenous loading dose of 34.5 mg/kg and a mean maintenance dose of 15.3 mg/kg/d (1078 mg/d). Four out of 29 patients with measured ammonium had hyperammonemia. We identified four (10%) patients fulfilling acute VIE criteria. Median time from administration of valproate to the occurrence of VIE, and to resolution of VIE after cessation of valproate treatment, was 2 days for each. Three of the four VIE patients had no associated hyperammonemia. Patients who developed VIE more frequently had a history of liver disease (p = 0.023), and tended to be younger, but other clinical variables did not differ significantly from patients without VIE, including valproate loading or maintenance doses, SE cause, duration or severity, other concomitant antiseizure medications (none received topiramate, phenobarbital, or primidone). CONCLUSION Pending larger studies, VIE in SE seems relatively frequent and difficult to foresee; clinical alertness to symptoms is mandatory, even without hyperammonemia, and valproate withdrawal should be considered in suspected cases.
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Affiliation(s)
- Valentin Loser
- Department of Clinical Neurosciences, Service of Neurology, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Jan Novy
- Department of Clinical Neurosciences, Service of Neurology, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Isabelle Beuchat
- Department of Clinical Neurosciences, Service of Neurology, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Andrea O. Rossetti
- Department of Clinical Neurosciences, Service of Neurology, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
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Bauer K, Rosenow F, Knake S, Willems LM, Kämppi L, Strzelczyk A. Clinical characteristics and outcomes of patients with recurrent status epilepticus episodes. Neurol Res Pract 2023; 5:34. [PMID: 37438822 DOI: 10.1186/s42466-023-00261-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/27/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Multiple studies have focused on medical and pharmacological treatments and outcome predictors of patients with status epilepticus (SE). However, a sufficient understanding of recurrent episodes of SE is lacking. Therefore, we reviewed recurrent SE episodes to investigate their clinical characteristics and outcomes in patients with relapses. METHODS In this retrospective, multicenter study, we reviewed recurrent SE patient data covering 2011 to 2017 from the university hospitals of Frankfurt and Marburg, Germany. Clinical characteristics and outcome variables were compared among the first and subsequent SE episodes using a standardized form for data collection. RESULTS We identified 120 recurrent SE episodes in 80 patients (10.2% of all 1177 episodes). The mean age at the first SE episode was 62.2 years (median 66.5; SD 19.3; range 21-91), and 42 of these patients were male (52.5%). A mean of 262.4 days passed between the first and the second episode. Tonic-clonic seizure semiology and a cerebrovascular disease etiology were predominant in initial and recurrent episodes. After subsequent episodes, patients showed increased disability as indicated by the modified Rankin Scale (mRS), and 9 out of 80 patients died during the second episode (11.3%). Increases in refractory and super-refractory SE (RSE and SRSE, respectively) were noted during the second episode, and the occurrence of a non-refractory SE (NRSE) during the first SE episode did not necessarily provide a protective marker for subsequent non-refractory episodes. An increase in the use of intravenous-available anti-seizure medication (ASM) was observed in the treatment of SE patients. Patients were discharged from hospital with a mean of 2.8 ± 1.0 ASMs after the second SE episode and 2.1 ± 1.2 ASMs after the first episode. Levetiracetam was the most common ASM used before admission and on discharge for SE patients. CONCLUSIONS This retrospective, multicenter study used the mRS to demonstrate worsened outcomes of patients at consecutive SE episodes. ASM accumulations after subsequent SE episodes were registered over the study period. The study results underline the necessity for improved clinical follow-ups and outpatient care to reduce the health care burden from recurrent SE episodes.
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Affiliation(s)
- Kristina Bauer
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, University Hospital and Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, University Hospital and Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Susanne Knake
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany
| | - Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, University Hospital and Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Leena Kämppi
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, University Hospital and Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany
- Epilepsia Helsinki, European Reference Network EpiCARE, Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main and Department of Neurology, University Hospital and Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany.
- Epilepsy Center Hessen and Department of Neurology, Philipps-University Marburg, Marburg (Lahn), Germany.
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5
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Reindl C, Madžar D, Hamer HM. [Status epilepticus-Detection and treatment in the intensive care unit]. DER NERVENARZT 2023; 94:120-128. [PMID: 36534176 DOI: 10.1007/s00115-022-01418-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/08/2022] [Indexed: 12/24/2022]
Abstract
Status epilepticus is characterized by persistent or repetitive seizures which, without successful treatment, can lead to neuronal damage, neurological deficits and death of the patient.While status epilepticus with motor symptoms can usually be clinically diagnosed, nonconvulsive status epilepticus is often clinically overlooked due to its ambiguous semiology, so that electroencephalography (EEG) recording is necessary. The treatment of status epilepticus is performed in four treatment steps, whereby a difficult to treat status epilepticus is present from the third step at the latest and intensive medical care of the patient is necessary. Timely initiation of treatment and sufficient dosage of anticonvulsive medication are decisive for the success of treatment. There is little evidence for the "late" stages of treatment. Intensive medical measures pose the risk of complications that worsen the prognosis. Especially in nonconvulsive status epilepticus, the use of anesthetics must be weighed against possible complications of mechanical ventilation.
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Affiliation(s)
- Caroline Reindl
- Neurologische Klinik, Epilepsiezentrum, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Deutschland.
| | - Dominik Madžar
- Neurologische Klinik, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Deutschland
| | - Hajo M Hamer
- Neurologische Klinik, Epilepsiezentrum, Universitätsklinikum Erlangen, Schwabachanlage 6, 91054, Erlangen, Deutschland
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6
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Osman GM, Hocker SE. Status Epilepticus in Older Adults: Diagnostic and Treatment Considerations. Drugs Aging 2023; 40:91-103. [PMID: 36745320 DOI: 10.1007/s40266-022-00998-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2022] [Indexed: 02/07/2023]
Abstract
Status epilepticus (SE) is one of the leading life-threatening neurological emergencies in the elderly population, with significant morbidity and mortality. SE presents unique diagnostic and therapeutic challenges in the older population given overlap with other causes of encephalopathy, complicating diagnosis, and the common occurrence of multiple comorbid diseases complicates treatment. First-line therapy involves the use of rescue benzodiazepine in the form of intravenous lorazepam or diazepam, intramuscular or intranasal midazolam and rectal diazepam. Second-line therapies include parenteral levetiracetam, fosphenytoin, valproate and lacosamide, and underlying comorbidities guide the choice of appropriate medication, while third-line therapies may be influenced by the patient's code status as well as the cause and type of SE. The standard of care for convulsive SE is treatment with an intravenous anesthetic, including midazolam, propofol, ketamine and pentobarbital. There is currently limited evidence guiding appropriate therapy in patients failing third-line therapies. Adjunctive strategies may include immunomodulatory treatments, non-pharmacological strategies such as ketogenic diet, neuromodulation therapies and surgery in select cases. Surrogate decision makers should be updated early and often in refractory episodes of SE and informed of the high morbidity and mortality associated with the disease as well as the high probability of subsequent epilepsy among survivors.
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Affiliation(s)
- Gamaleldin M Osman
- Department of Neurology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN, 55905, USA.
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7
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Löscher W, Trinka E. The potential of intravenous topiramate for the treatment of status epilepticus. Epilepsy Behav 2023; 138:109032. [PMID: 36528009 DOI: 10.1016/j.yebeh.2022.109032] [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: 10/06/2022] [Revised: 11/28/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
There is considerable clinical evidence that topiramate (TPM) has a high potential in the treatment of refractory and super-refractory status epilepticus (RSE, SRSE). Because TPM is only approved for oral administration, it is applied as suspension via a nasogastric tube for SE treatment. However, this route of administration is impractical in an emergency setting and leads to variable absorption with unpredictable plasma levels and time to peak concentration. Thus, the development of an intravenous (i.v.) solution for TPM is highly desirable. Here we present data on two parenteral formulations of TPM that are currently being developed. One of these solutions is using sulfobutylether-β-cyclodextrin (SBE-β-CD; Captisol®) as an excipient. A 1% solution of TPM in 10% Captisol® has been reported to be well tolerated in safety studies in healthy volunteers and patients with epilepsy or migraine, but efficacy data are not available. The other solution uses the FDA- and EMA-approved excipient amino sugar meglumine. Meglumine is much more effective to dissolve TPM in water than Captisol®. A 1% solution of TPM can be achieved with 0.5-1% of meglumine. While the use of Captisol®-containing solutions is restricted in children and patients with renal impairment, such restrictions do not apply to meglumine. Recently, first-in-human data were reported for a meglumine-based solution of TPM, indicating safety and efficacy when used as a replacement for oral administration in a woman with epilepsy. Based on the multiple mechanisms of action of TPM that directly target the molecular neuronal alterations that are thought to underlie the loss of efficacy of benzodiazepines and other anti-seizure medications during prolonged SE and its rapid brain penetration after i.v. administration, we suggest that parenteral (i.v.) TPM is ideally suited for the treatment of RSE and SRSE. 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)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology, and Pharmacy, University of Veterinary Medicine Hannover, 30559 Hannover, Germany; Center for Systems Neuroscience, 30559 Hannover, Germany.
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria; Center for Cognitive Neuroscience, Salzburg, Austria
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8
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Wang X, Yang F, Chen B, Jiang W. Non‐convulsive seizures and non‐convulsive status epilepticus in neuro‐intensive care unit. Acta Neurol Scand 2022; 146:752-760. [DOI: 10.1111/ane.13718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 10/07/2022] [Accepted: 10/11/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Xuan Wang
- Department of Neurology, Xijing Hospital Fourth Military Medical University Xi'an China
| | - Fang Yang
- Department of Neurology, Xijing Hospital Fourth Military Medical University Xi'an China
| | - Beibei Chen
- Department of Neurology, Xijing Hospital Fourth Military Medical University Xi'an China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital Fourth Military Medical University Xi'an China
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9
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Willems LM, Rosenow F, Knake S, Beuchat I, Siebenbrodt K, Strüber M, Schieffer B, Karatolios K, Strzelczyk A. Repetitive Electroencephalography as Biomarker for the Prediction of Survival in Patients with Post-Hypoxic Encephalopathy. J Clin Med 2022; 11:6253. [PMID: 36362477 PMCID: PMC9658509 DOI: 10.3390/jcm11216253] [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: 10/08/2022] [Revised: 10/19/2022] [Accepted: 10/20/2022] [Indexed: 09/08/2024] Open
Abstract
Predicting survival in patients with post-hypoxic encephalopathy (HE) after cardiopulmonary resuscitation is a challenging aspect of modern neurocritical care. Here, continuous electroencephalography (cEEG) has been established as the gold standard for neurophysiological outcome prediction. Unfortunately, cEEG is not comprehensively available, especially in rural regions and developing countries. The objective of this monocentric study was to investigate the predictive properties of repetitive EEGs (rEEGs) with respect to 12-month survival based on data for 199 adult patients with HE, using log-rank and multivariate Cox regression analysis (MCRA). A total number of 59 patients (29.6%) received more than one EEG during the first 14 days of acute neurocritical care. These patients were analyzed for the presence of and changes in specific EEG patterns that have been shown to be associated with favorable or poor outcomes in HE. Based on MCRA, an initially normal amplitude with secondary low-voltage EEG remained as the only significant predictor for an unfavorable outcome, whereas all other relevant parameters identified by univariate analysis remained non-significant in the model. In conclusion, rEEG during early neurocritical care may help to assess the prognosis of HE patients if cEEG is not available.
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Affiliation(s)
- Laurent M. Willems
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Goethe-University Frankfurt am Main, 60323 Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt am Main, 60323 Frankfurt am Main, Germany
| | - Felix Rosenow
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Goethe-University Frankfurt am Main, 60323 Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt am Main, 60323 Frankfurt am Main, Germany
| | - Susanne Knake
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt am Main, 60323 Frankfurt am Main, Germany
- Department of Neurology and Epilepsy Center Hessen, Philipps-University Marburg, 35037 Marburg, Germany
| | - Isabelle Beuchat
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Goethe-University Frankfurt am Main, 60323 Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt am Main, 60323 Frankfurt am Main, Germany
- Department of Neurology, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, 1011 Lausanne, Switzerland
| | - Kai Siebenbrodt
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Goethe-University Frankfurt am Main, 60323 Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt am Main, 60323 Frankfurt am Main, Germany
| | - Michael Strüber
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Goethe-University Frankfurt am Main, 60323 Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt am Main, 60323 Frankfurt am Main, Germany
| | - Bernhard Schieffer
- Department of Cardiology, Philipps-University Marburg, 35037 Marburg, Germany
| | | | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, Goethe-University Frankfurt am Main, 60323 Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt am Main, 60323 Frankfurt am Main, Germany
- Department of Neurology, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, 1011 Lausanne, Switzerland
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Abstract
Epilepsy is a common neurological disease in both humans and domestic dogs, making dogs an ideal translational model of epilepsy. In both species, epilepsy is a complex brain disease characterized by an enduring predisposition to generate spontaneous recurrent epileptic seizures. Furthermore, as in humans, status epilepticus is one of the more common neurological emergencies in dogs with epilepsy. In both species, epilepsy is not a single disease but a group of disorders characterized by a broad array of clinical signs, age of onset, and underlying causes. Brain imaging suggests that the limbic system, including the hippocampus and cingulate gyrus, is often affected in canine epilepsy, which could explain the high incidence of comorbid behavioral problems such as anxiety and cognitive alterations. Resistance to antiseizure medications is a significant problem in both canine and human epilepsy, so dogs can be used to study mechanisms of drug resistance and develop novel therapeutic strategies to benefit both species. Importantly, dogs are large enough to accommodate intracranial EEG and responsive neurostimulation devices designed for humans. Studies in epileptic dogs with such devices have reported ictal and interictal events that are remarkably similar to those occurring in human epilepsy. Continuous (24/7) EEG recordings in a select group of epileptic dogs for >1 year have provided a rich dataset of unprecedented length for studying seizure periodicities and developing new methods for seizure forecasting. The data presented in this review substantiate that canine epilepsy is an excellent translational model for several facets of epilepsy research. Furthermore, several techniques of inducing seizures in laboratory dogs are discussed as related to therapeutic advances. Importantly, the development of vagus nerve stimulation as a novel therapy for drug-resistant epilepsy in people was based on a series of studies in dogs with induced seizures. Dogs with naturally occurring or induced seizures provide excellent large-animal models to bridge the translational gap between rodents and humans in the development of novel therapies. Furthermore, because the dog is not only a preclinical species for human medicine but also a potential patient and pet, research on this species serves both veterinary and human medicine.
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Affiliation(s)
- Wolfgang Löscher
- Department of Pharmacology, Toxicology and Pharmacy, University of Veterinary Medicine, Hannover, Germany
- Center for Systems Neuroscience, Hannover, Germany
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11
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Brauchitsch SV, Strzelczyk A, Rosenow F, Neuhaus E, Dubinski D, Steinbach JP, Voss M. High end-of-life incidence of seizures and status epilepticus in patients with primary and secondary brain tumors. J Neurooncol 2022; 160:277-284. [PMID: 36329367 PMCID: PMC9722831 DOI: 10.1007/s11060-022-04133-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Seizures pose a significant burden in patients with primary and secondary brain tumors during the end-of-life period. A wide range of 6 to 56% of clinically observed epileptic seizures at the end of life has been reported. We aimed to analyse the incidence of epileptic seizures at the end of life in brain tumor patients more accurately using not only clinical but also electrophysiological findings. METHODS This retrospective, single center study included brain tumor patients who died during the stay on the ward or within 7 days after discharge between 01/2015 and 08/2020. Clinical observation of seizures derived from the original medical records and EEG findings (within 45 days prior to death) were analyzed to determine the incidence of seizures in that period. RESULTS Of the 68 eligible patients, 50 patients (73.5%) suffered from seizures within 45 days prior to death, of which n = 24 had a status epilepticus. The diagnosis of seizures/ status epilepticus was determined either by the presentation of clinical signs in 45 patients and if not, by the detection of a (possible) non-convulsive status epilepticus in the EEG of five patients. CONCLUSION In the presence of neurologically trained staff and with the frequent use of routine EEG, we were able to identify seizures and to distinguish status epilepticus from encephalopathy/ hypoactive delirium. We detected a higher incidence of seizures and status epilepticus at the end of life in neurooncological patients than previously reported.
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Affiliation(s)
- Sophie von Brauchitsch
- grid.7839.50000 0004 1936 9721Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- grid.7839.50000 0004 1936 9721Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- grid.7839.50000 0004 1936 9721Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Elisabeth Neuhaus
- grid.7839.50000 0004 1936 9721Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721LOEWE Center for Personalized and Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721Institute of Neuroradiology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Daniel Dubinski
- grid.10493.3f0000000121858338Department of Neurosurgery, Faculty of Medicine, University of Rostock, Rostock, Germany
| | - Joachim P. Steinbach
- grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute of Neurooncology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721University Cancer Center Frankfurt (UCT), University Hospital/Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7497.d0000 0004 0492 0584German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin Voss
- grid.7839.50000 0004 1936 9721Dr. Senckenberg Institute of Neurooncology, University Hospital/ Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7839.50000 0004 1936 9721University Cancer Center Frankfurt (UCT), University Hospital/Goethe University Frankfurt, Frankfurt am Main, Germany ,grid.7497.d0000 0004 0492 0584German Cancer Consortium (DKTK), Partner Site Frankfurt/Mainz, and German Cancer Research Center (DKFZ), Heidelberg, Germany
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Vasquez A, Farias-Moeller R, Sánchez-Fernández I, Abend NS, Amengual-Gual M, Anderson A, Arya R, Brenton JN, Carpenter JL, Chapman K, Clark J, Gaillard WD, Glauser T, Goldstein JL, Goodkin HP, Guerriero RM, Lai YC, McDonough TL, Mikati MA, Morgan LA, Novotny EJ, Ostendorf AP, Payne ET, Peariso K, Piantino J, Riviello JJ, Sands TT, Sannagowdara K, Tasker RC, Tchapyjnikov D, Topjian A, Wainwright MS, Wilfong A, Williams K, Loddenkemper T. Super-Refractory Status Epilepticus in Children: A Retrospective Cohort Study. Pediatr Crit Care Med 2021; 22:e613-e625. [PMID: 34120133 DOI: 10.1097/pcc.0000000000002786] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To characterize the pediatric super-refractory status epilepticus population by describing treatment variability in super-refractory status epilepticus patients and comparing relevant clinical characteristics, including outcomes, between super-refractory status epilepticus, and nonsuper-refractory status epilepticus patients. DESIGN Retrospective cohort study with prospectively collected data between June 2011 and January 2019. SETTING Seventeen academic hospitals in the United States. PATIENTS We included patients 1 month to 21 years old presenting with convulsive refractory status epilepticus. We defined super-refractory status epilepticus as continuous or intermittent seizures lasting greater than or equal to 24 hours following initiation of continuous infusion and divided the cohort into super-refractory status epilepticus and nonsuper-refractory status epilepticus groups. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 281 patients (157 males) with a median age of 4.1 years (1.3-9.5 yr), including 31 super-refractory status epilepticus patients. Compared with nonsuper-refractory status epilepticus group, super-refractory status epilepticus patients had delayed initiation of first nonbenzodiazepine-antiseizure medication (149 min [55-491.5 min] vs 62 min [33.3-120.8 min]; p = 0.030) and of continuous infusion (495 min [177.5-1,255 min] vs 150 min [90-318.5 min]; p = 0.003); prolonged seizure duration (120 hr [58-368 hr] vs 3 hr [1.4-5.9 hr]; p < 0.001) and length of ICU stay (17 d [9.5-40 d] vs [1.8-8.8 d]; p < 0.001); more medical complications (18/31 [58.1%] vs 55/250 [22.2%] patients; p < 0.001); lower return to baseline function (7/31 [22.6%] vs 182/250 [73.4%] patients; p < 0.001); and higher mortality (4/31 [12.9%] vs 5/250 [2%]; p = 0.010). Within the super-refractory status epilepticus group, status epilepticus resolution was attained with a single continuous infusion in 15 of 31 patients (48.4%), two in 10 of 31 (32.3%), and three or more in six of 31 (19.4%). Most super-refractory status epilepticus patients (30/31, 96.8%) received midazolam as first choice. About 17 of 31 patients (54.8%) received additional treatments. CONCLUSIONS Super-refractory status epilepticus patients had delayed initiation of nonbenzodiazepine antiseizure medication treatment, higher number of medical complications and mortality, and lower return to neurologic baseline than nonsuper-refractory status epilepticus patients, although these associations were not adjusted for potential confounders. Treatment approaches following the first continuous infusion were heterogeneous, reflecting limited information to guide clinical decision-making in super-refractory status epilepticus.
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Affiliation(s)
- Alejandra Vasquez
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Division of Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Raquel Farias-Moeller
- Department of Neurology, Division of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Iván Sánchez-Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Department of Child Neurology, Hospital Sant Joan de Déu, Universidad de Barcelona, Barcelona, Spain
| | - Nicholas S Abend
- Division of Neurology, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Pediatric Neurology Unit, Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain
| | - Anne Anderson
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Ravindra Arya
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - James N Brenton
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, VA
| | - Jessica L Carpenter
- Center for Neuroscience, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Kevin Chapman
- Departments of Pediatrics and Neurology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Justice Clark
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - William D Gaillard
- Center for Neuroscience, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Tracy Glauser
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Joshua L Goldstein
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Howard P Goodkin
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, VA
| | - Rejean M Guerriero
- Division of Pediatric Neurology, Washington University Medical Center, Washington University School of Medicine, Saint Louis, MO
| | - Yi-Chen Lai
- Section of Pediatric Critical Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Tiffani L McDonough
- Division of Child Neurology, Department of Neurology, Columbia University Medical Center, Columbia University, New York, NY
- Division of Pediatric Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mohamad A Mikati
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, NC
| | - Lindsey A Morgan
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle, WA
| | - Edward J Novotny
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle, WA
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA
| | - Adam P Ostendorf
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University. Columbus, OH
| | - Eric T Payne
- Division of Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, MN
| | - Katrina Peariso
- Division of Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Juan Piantino
- Department of Pediatrics, Division Pediatric Neurology, Neuro-Critical Care Program, Oregon Health and Science University, Portland, OR
| | - James J Riviello
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Tristan T Sands
- Division of Child Neurology, Department of Neurology, Columbia University Medical Center, Columbia University, New York, NY
| | - Kumar Sannagowdara
- Department of Neurology, Division of Pediatric Neurology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Robert C Tasker
- Division of Critical Care, Departments of Neurology, Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Dmitry Tchapyjnikov
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, NC
| | - Alexis Topjian
- Critical Care and Pediatrics, The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mark S Wainwright
- Department of Neurology, Division of Pediatric Neurology, University of Washington, Seattle, WA
| | - Angus Wilfong
- Department of Child Health, University of Arizona College of Medicine and Barrow's Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Korwyn Williams
- Department of Child Health, University of Arizona College of Medicine and Barrow's Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Welling LC, Rabelo NN, Yoshikawa MH, Telles JPM, Teixeira MJ, Figueiredo EG. Efficacy of topiramate as an add-on therapy in patients with refractory status epilepticus: a short systematic review. Rev Bras Ter Intensiva 2021; 33:440-444. [PMID: 35107556 PMCID: PMC8555390 DOI: 10.5935/0103-507x.20210054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 12/19/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To identify current evidence on the use of topiramate for refractory status epilepticus. METHODS We reviewed the literature to investigate the efficacy of topiramate in the treatment of refractory status epilepticus. The search terms used were "status epilepticus", "refractory", "treatment" and "topiramate". No restrictions were used. RESULTS The search yielded 487 articles that reported using topiramate as a treatment for refractory status epilepticus and its outcomes. Case reports, review articles, and animal experiments were excluded. After excluding duplicates and applying inclusion and exclusion criteria, nine studies were included for analyses. Descriptive and qualitative analyses were performed, and the results were as follows: response rates (defined as termination in-hospital until 72 hours after the administration of topiramate) varied from 27% to 100%. The mortality rate varied from 5.9% to 68%. Positive functional long-term outcomes, defined as discharge, back to baseline or rehabilitation, were documented by seven studies, and the rates ranged between 4% and 55%. Most studies reported no or mild adverse effects. CONCLUSION Topiramate was effective in terminating refractory status epilepticus, presented relatively low mortality and was well tolerated. Therefore, topiramate could be a good option as a third-line therapy for refractory status epilepticus, but further studies are necessary.
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Al-Faraj AO, Abdennadher M, Pang TD. Diagnosis and Management of Status Epilepticus. Semin Neurol 2021; 41:483-492. [PMID: 34619776 DOI: 10.1055/s-0041-1733787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Seizures are among the most common neurological presentations to the emergency room. They present on a spectrum of severity from isolated new-onset seizures to acute repetitive seizures and, in severe cases, status epilepticus. The latter is the most serious, as it is associated with high morbidity and mortality. Prompt recognition and treatment of both seizure activity and associated acute systemic complications are essential to improve the overall outcome of these patients. The purpose of this review is to provide the current viewpoint on the diagnostic evaluation and pharmacological management of patients presenting with status epilepticus, and the common associated systemic complications.
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Affiliation(s)
- Abrar O Al-Faraj
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Myriam Abdennadher
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Trudy D Pang
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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EEG patterns and their correlations with short- and long-term mortality in patients with hypoxic encephalopathy. Clin Neurophysiol 2021; 132:2851-2860. [PMID: 34598037 DOI: 10.1016/j.clinph.2021.07.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 06/29/2021] [Accepted: 07/20/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To analyze the association between electroencephalographic (EEG) patterns and overall, short- and long-term mortality in patients with hypoxic encephalopathy (HE). METHODS Retrospective, mono-center analysis of 199 patients using univariate log-rank tests (LR) and multivariate cox regression (MCR). RESULTS Short-term mortality, defined as death within 30-days post-discharge was 54.8%. Long-term mortality rates were 69.8%, 71.9%, and 72.9%, at 12-, 24-, and 36-months post-HE, respectively. LR revealed a significant association between EEG suppression (SUP) and short-term mortality, and identified low voltage EEG (LV), burst suppression (BSP), periodic discharges (PD) and post-hypoxic status epilepticus (PSE) as well as missing (aBA) or non-reactive background activity (nrBA) as predictors for overall, short- and long-term mortality. MCR indicated SUP, LV, BSP, PD, aBA and nrBA as significantly associated with overall and short-term mortality to varying extents. LV and BSP were significant predictors for long-term mortality in short-term survivors. Rhythmic delta activity, stimulus induced rhythmic, periodic or ictal discharges and sharp waves were not significantly associated with a higher mortality. CONCLUSION The presence of several specific EEG patterns can help to predict overall, short- and long-term mortality in HE patients. SIGNIFICANCE The present findings may help to improve the challenging prognosis estimation in HE patients.
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Pharmacotherapy for Nonconvulsive Seizures and Nonconvulsive Status Epilepticus. Drugs 2021; 81:749-770. [PMID: 33830480 DOI: 10.1007/s40265-021-01502-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2021] [Indexed: 12/22/2022]
Abstract
Most seizures in critically ill patients are nonconvulsive. A significant number of neurological and medical conditions can be complicated by nonconvulsive seizures (NCSs) and nonconvulsive status epilepticus (NCSE), with brain infections, hemorrhages, global hypoxia, sepsis, and recent neurosurgery being the most prominent etiologies. Prolonged NCSs and NCSE can lead to adverse neurological outcomes. Early recognition requires a high degree of suspicion and rapid and appropriate duration of continuous electroencephalogram (cEEG) monitoring. Although high quality research evaluating treatment with antiseizure medications and long-term outcome is still lacking, it is probable that expeditious pharmacological management of NCSs and NCSE may prevent refractoriness and further neurological injury. There is limited evidence on pharmacotherapy for NCSs and NCSE, although a few clinical trials encompassing both convulsive and NCSE have demonstrated similar efficacy of different intravenous (IV) antiseizure medications (ASMs), including levetiracetam, valproate, lacosamide and fosphenytoin. The choice of specific ASMs lies on tolerability and safety since critically ill patients frequently have impaired renal and/or hepatic function as well as hematological/hemodynamic lability. Treatment frequently requires more than one ASM and occasionally escalation to IV anesthetic drugs. When multiple ASMs are required, combining different mechanisms of action should be considered. There are several enteral ASMs that could be used when IV ASM options have been exhausted. Refractory NCSE is not uncommon, and its treatment requires a very judicious selection of ASMs aiming at reducing seizure burden along with management of the underlying condition.
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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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Ochoa JG, Dougherty M, Papanastassiou A, Gidal B, Mohamed I, Vossler DG. Treatment of Super-Refractory Status Epilepticus: A Review. Epilepsy Curr 2021; 21:1535759721999670. [PMID: 33719651 PMCID: PMC8652329 DOI: 10.1177/1535759721999670] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Super-refractory status epilepticus (SRSE) presents management challenges due to the absence of randomized controlled trials and a plethora of potential medical therapies. The literature on treatment options for SRSE reports variable success and quality of evidence. This review is a sequel to the 2020 American Epilepsy Society (AES) comprehensive review of the treatment of convulsive refractory status epilepticus (RSE). METHODS We sought to determine the effectiveness of treatment options for SRSE. We performed a structured literature search (MEDLINE, Embase, CENTRAL, CINAHL) for studies on reported treatments of SRSE. We excluded antiseizure medications (ASMs) covered in the 2016 AES guideline on the treatment of established SE and the convulsive RSE comprehensive review of the 2020 AES. Literature was reviewed on the effectiveness of vagus nerve stimulation, ketogenic diet (KD), lidocaine, inhalation anesthetics, brain surgery, therapeutic hypothermia, perampanel, pregabalin (PGB), and topiramate in the treatment of SRSE. Two authors reviewed each therapeutic intervention. We graded the level of the evidence according to the 2017 classification scheme of the American Academy of Neurology. RESULTS For SRSE (level U; 39 class IV studies total), insufficient evidence exists to support that perampanel, PGB, lidocaine, or acute vagus nerve stimulation (VNS) is effective. For children and adults with SRSE, insufficient evidence exists to support that the KD is effective (level U; 5 class IV studies). For adults with SRSE, insufficient evidence exists that brain surgery is effective (level U, 7 class IV studies). For adults with SRSE insufficient, evidence exists that therapeutic hypothermia is effective (level C, 1 class II and 4 class IV studies). For neonates with hypoxic-ischemic encephalopathy, insufficient evidence exists that therapeutic hypothermia reduces seizure burden (level U; 1 class IV study). For adults with SRSE, insufficient evidence exists that inhalation anesthetics are effective (level U, 1 class IV study) and that there is a potential risk of neurotoxicity. CONCLUSION For patients with SRSE insufficient, evidence exists that any of the ASMs reviewed, inhalational anesthetics, ketogenic diet, acute VNS, brain surgery, and therapeutic hypothermia are effective treatments. Data supporting the use of these treatments for SRSE are scarce and limited mainly to small case series and case reports and are confounded by differences in patients' population, and comedications, among other factors.
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Affiliation(s)
| | | | | | | | - Ismail Mohamed
- Department of Pediatrics, University of Alabama, Birmingham, USA
| | - David G. Vossler
- University of Washington, Seattle, WA, USA
- Treatments Committee, American Epilepsy Society, Chicago, IL, USA
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Mantoan Ritter L, Nashef L. New-onset refractory status epilepticus (NORSE). Pract Neurol 2021; 21:practneurol-2020-002534. [PMID: 33674412 DOI: 10.1136/practneurol-2020-002534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2021] [Indexed: 11/04/2022]
Abstract
New-onset refractory status epilepticus and its subcategory febrile infection-related epilepsy syndrome are rare devastating clinical presentations in those without pre-existing relevant history, often in schoolchildren or young adults, without a clear cause on initial investigations. A cause is later identified in up to half of adults, but in many fewer children. Patients often require protracted intensive care and are at significant risk of dying. Functional disability is common and subsequent chronic epilepsy is the norm, but some people do have good outcomes, even after prolonged status epilepticus. Patients need prompt investigations and treatment. Anaesthetic and antiseizure medications are supplemented by other treatment modalities, including the ketogenic diet. Despite limited evidence, it is appropriate to try to modify the presumed underlying pathogenesis with immune modulation early, with a more recent focus on using interleukin inhibitors. Optimising management will require concerted multicentre international efforts.
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Affiliation(s)
- Laura Mantoan Ritter
- Department of Neurology, King's College Hospital, London, UK
- Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
| | - Lina Nashef
- Department of Neurology, King's College Hospital, London, UK
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Lee SK. Diagnosis and Treatment of Status Epilepticus. J Epilepsy Res 2020; 10:45-54. [PMID: 33659195 PMCID: PMC7903042 DOI: 10.14581/jer.20008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/10/2020] [Accepted: 11/24/2020] [Indexed: 12/03/2022] Open
Abstract
The definition of status epilepticus (SE) was revised recently in accordance with the various evidences of neuronal injury and changes in clinical settings. Currently, the most acceptable duration of continuous seizure activity is 5 minutes. In 2015, the International League Against Epilepsy Task Force, which was convened to develop a definition and classification of SE, presented a new classification based on four axes: 1) semiology, 2) etiology, 3) electroencephalogram (EEG) correlates, and 4) age. The essential element of nonconvulsive SE (NCSE) is the presence of neurological abnormalities induced by a prolonged epileptic process. The definition of refractory SE involves either clinical or electrographic seizures that persist after adequate doses of an initial benzodiazepine and acceptable second-line antiseizure drugs. The use of EEG is critical in the diagnosis and treatment of NCSE. However, there are a wide range of EEG abnormalities in NCSE. Both the Neurocritical Care Society and the American Epilepsy Society have suggested a paradigm for treating convulsive SE (CSE). The first-line treatment of CSE with benzodiazepine is well-established. The second-line treatment comprises intravenous (IV) doses of fosphenytoin (phenytoin), valproate, phenobarbital, levetiracetam, or midazolam. Although fosphenytoin (phenytoin) and valproate are commonly used in NCSE, the effectiveness of antiepileptic drugs (AEDs) on NCSE has not been well studied. New AEDs such as IV levetiracetam and lacosamide can also be used to treat NCSE with fewer side effects and drug-drug interactions. For refractory SE, general anesthesia with IV midazolam, propofol, pentobarbital, or thiopental could be applied. Use of ketamine, megadose phenobarbital therapy, and multiple combinations of various AEDs including high doses of oral AEDs can also be considered. New-onset refractory status epilepticus (NORSE) and its subcategory, febrile infection-related epilepsy syndrome, involve autoimmune processes. AEDs alone are poorly effective in the treatment of SE in autoimmune encephalitis. Immunotherapy such as steroids, immunoglobulin, rituximab, or tocilizumab can be effective.
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Affiliation(s)
- Sang Kun Lee
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea
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Łuszczki JJ, Podgórska D, Kozińska J, Jankiewicz M, Plewa Z, Kominek M, Żółkowska D, Florek-Łuszczki M. Polygonogram with isobolographic synergy for three-drug combinations of phenobarbital with second-generation antiepileptic drugs in the tonic-clonic seizure model in mice. Pharmacol Rep 2020; 73:111-121. [PMID: 33025394 PMCID: PMC7862539 DOI: 10.1007/s43440-020-00164-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/05/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023]
Abstract
Background Combination therapy consisting of two or more antiepileptic drugs (AEDs) is usually prescribed for patients with refractory epilepsy. The drug–drug interactions, which may occur among currently available AEDs, are the principal criterion taken by physicians when prescribing the AED combination to the patients. Unfortunately, the number of possible three-drug combinations tremendously increases along with the clinical approval of novel AEDs. Aim To isobolographically characterize three-drug interactions of phenobarbital (PB) with lamotrigine (LTG), oxcarbazepine (OXC), pregabalin (PGB) and topiramate (TPM), the maximal electroshock-induced (MES) seizure model was used in male albino Swiss mice. Materials and method The MES-induced seizures in mice were generated by alternating current delivered via auricular electrodes. To classify interactions for 6 various three-drug combinations of AEDs (i.e., PB + TPM + PGB, PB + OXC + TPM, PB + LTG + TPM, PB + OXC + PGB, PB + LTG + PGB and PB + LTG + OXC), the type I isobolographic analysis was used. Total brain concentrations of PB were measured by fluorescent polarization immunoassay technique. Results The three-drug mixtures of PB + TPM + PGB, PB + OXC + TPM, PB + LTG + TPM, PB + OXC + PGB, PB + LTG + PGB and PB + LTG + OXC protected the male albino Swiss mice from MES-induced seizures. All the observed interactions in this seizure model were supra-additive (synergistic) (p < 0.001), except for the combination of PB + LTG + OXC, which was additive. It was unable to show the impact of the studied second-generation AEDs on total brain content of PB in mice. Conclusions The synergistic interactions among PB and LTG, OXC, PGB and TPM in the mouse MES model are worthy of being transferred to clinical trials, especially for the patients with drug resistant epilepsy, who would benefit these treatment options.
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Affiliation(s)
- Jarogniew J Łuszczki
- Department of Pathophysiology, Medical University, Jaczewskiego 8b, 20-090, Lublin, PL, Poland. .,Isobolographic Analysis Laboratory, Institute of Rural Health, Lublin, Poland.
| | - Dominika Podgórska
- Department of Pathophysiology, Medical University, Jaczewskiego 8b, 20-090, Lublin, PL, Poland
| | - Justyna Kozińska
- Chair and Clinic of Hematooncology and Bone Marrow Transplantation, Medical University, Lublin, Poland
| | - Marek Jankiewicz
- Chair and Clinic of Cardiology, Medical University, Lublin, Poland
| | - Zbigniew Plewa
- Department of General, Oncological and Minimally Invasive Surgery, 1st Military Clinical Hospital, Lublin, Poland
| | - Mateusz Kominek
- Clinic of Orthopedics and Traumatology, Medical University, Lublin, Poland
| | - Dorota Żółkowska
- Department of Neurology, School of Medicine, University of California-Davis, Sacramento, CA, USA
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Willems LM, Bauer S, Jahnke K, Voss M, Rosenow F, Strzelczyk A. Therapeutic Options for Patients with Refractory Status Epilepticus in Palliative Settings or with a Limitation of Life-Sustaining Therapies: A Systematic Review. CNS Drugs 2020; 34:801-826. [PMID: 32705422 PMCID: PMC8316215 DOI: 10.1007/s40263-020-00747-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Refractory status epilepticus (RSE) represents a serious medical condition requiring early and targeted therapy. Given the increasing number of elderly or multimorbid patients with a limitation of life-sustaining therapy (LOT) or within a palliative care setting (PCS), guidelines-oriented therapy escalation options for RSE have to be omitted frequently. OBJECTIVES This systematic review sought to summarize the evidence for fourth-line antiseizure drugs (ASDs) and other minimally or non-invasive therapeutic options beyond guideline recommendations in patients with RSE to elaborate on possible treatment options for patients undergoing LOT or in a PCS. METHODS A systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focusing on fourth-line ASDs or other minimally or non-invasive therapeutic options was performed in February and June 2020 using the MEDLINE, EMBASE and Cochrane databases. The search terminology was constructed using the name of the specific ASD or therapy option and the term 'status epilepticus' with the use of Boolean operators, e.g. "(brivaracetam) AND (status epilepticus)". The respective Medical Subject Headings (MeSH) and Emtree terms were used, if available. RESULTS There is currently no level 1, grade A evidence for the use of ASDs in RSE. The best evidence was found for the use of lacosamide and topiramate (level 3, grade C), followed by brivaracetam, perampanel (each level 4, grade D) and stiripentol, oxcarbazepine and zonisamide (each level 5, grade D). Regarding non-medicinal options, there is little evidence for the use of the ketogenic diet (level 4, grade D) and magnesium sulfate (level 5, grade D) in RSE. The broad use of immunomodulatory or immunosuppressive treatment options in the absence of a presumed autoimmune etiology cannot be recommended; however, if an autoimmune etiology is assumed, steroid pulse, intravenous immunoglobulins and plasma exchange/plasmapheresis should be considered (level 4, grade D). Even if several studies suggested that the use of neurosteroids (level 5, grade D) is beneficial in RSE, the current data situation indicates that there is formal evidence against it. CONCLUSIONS RSE in patients undergoing LOT or in a PCS represents a challenge for modern clinicians and epileptologists. The evidence for the use of ASDs in RSE beyond that in current guidelines is low, but several effective and well-tolerated options are available that should be considered in this patient population. More so than in any other population, advance care planning, advance directives, and medical ethical aspects have to be considered carefully before and during therapy.
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Affiliation(s)
- Laurent M Willems
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany.
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany.
| | - Sebastian Bauer
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Kolja Jahnke
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Martin Voss
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- Dr. Senckenberg Institute of Neuro-Oncology, Goethe University Frankfurt, University Hospital Frankfurt, Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany
- Department of Neurology, Goethe University Frankfurt, Frankfurt am Main, Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University Frankfurt, Frankfurt am Main, Germany
- Department of Neurology, Epilepsy Center Hessen, Philipps University Marburg, Marburg (Lahn), Germany
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Treatment of status epilepticus with zonisamide: A multicenter cohort study of 34 patients and review of literature. Epilepsy Behav 2020; 109:107139. [PMID: 32417381 DOI: 10.1016/j.yebeh.2020.107139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION We present a summary of clinical cases of oral zonisamide (ZNS) used to treat refractory and super-refractory episodes of status epilepticus (SE). METHODS Zonisamide administration in SE was identified in the clinical records of patients treated in Frankfurt and Marburg between 2011 and 2017. RESULTS Zonisamide was administered during a total of 37 SE episodes in 34 patients with a mean age of 58.7 ± 17.8 years, 21 of them were female (61.7%). The median latency from the onset of SE to administration of ZNS was 6.3 days. Patients had already undergone unsuccessful treatment with a median of three other antiseizure drugs (ASDs). The median initial dose of ZNS was 100 mg/d, titrated to a median maintenance dose of 400 mg/d. Patients underwent ZNS treatment for a median period of 7 days. Zonisamide was the final drug administered in 9 of 37 (24.3%) episodes, with a clinical effect attributed to ZNS observed in 6 of 37 (16.2%) episodes. An effect attributed to ZNS was observed in 5 out of 30 episodes of refractory SE (RSE) and in one out of 7 episodes of super-refractory SE (SRSE). Possible negative side effects of ZNS were observed in two patients (one patient each with ataxia and skin rash). The mortality rate in hospitalized patients was 10.4% (n = 4). CONCLUSION The rate of SE resolution attributed to ZNS treatment (16.2%) can be considered relevant, particularly since ZNS treatment tends to be administered only after several other options have been tried, and has a treatment latency of over six days. Zonisamide may therefore be considered as an alternative oral treatment option in RSE and SRSE.
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