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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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Rossetti AO, Claassen J, Gaspard N. Status epilepticus in the ICU. Intensive Care Med 2024; 50:1-16. [PMID: 38117319 DOI: 10.1007/s00134-023-07263-w] [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: 07/14/2023] [Accepted: 10/26/2023] [Indexed: 12/21/2023]
Abstract
Status epilepticus (SE) is a common medical emergency associated with significant morbidity and mortality. Management that follows published guidelines is best suited to improve outcomes, with the most severe cases frequently being managed in the intensive care unit (ICU). Diagnosis of convulsive SE can be made without electroencephalography (EEG), but EEG is required to reliably diagnose nonconvulsive SE. Rapidly narrowing down underlying causes for SE is crucial, as this may guide additional management steps. Causes may range from underlying epilepsy to acute brain injuries such as trauma, cardiac arrest, stroke, and infections. Initial management consists of rapid administration of benzodiazepines and one of the following non-sedating intravenous antiseizure medications (ASM): (fos-)phenytoin, levetiracetam, or valproate; other ASM are increasingly used, such as lacosamide or brivaracetam. SE that continues despite these medications is called refractory, and most commonly treated with continuous infusions of midazolam or propofol. Alternatives include further non-sedating ASM and non-pharmacologic approaches. SE that reemerges after weaning or continues despite management with propofol or midazolam is labeled super-refractory SE. At this step, management may include non-sedating or sedating compounds including ketamine and barbiturates. Continuous video EEG is necessary for the management of refractory and super-refractory SE, as these are almost always nonconvulsive. If possible, management of the underlying cause of seizures is crucial particularly for patients with autoimmune encephalitis. Short-term mortality ranges from 10 to 15% after SE and is primarily related to increasing age, underlying etiology, and medical comorbidities. Refractoriness of treatment is clearly related to outcome with mortality rising from 10% in responsive cases, to 25% in refractory, and nearly 40% in super-refractory SE.
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Affiliation(s)
- Andrea O Rossetti
- Department of Neurology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Nicolas Gaspard
- Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
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Lattanzi S, Giovannini G, Orlandi N, Brigo F, Trinka E, Meletti S. How much refractory is 'refractory status epilepticus'? A retrospective study of treatment strategies and clinical outcomes. J Neurol 2023; 270:6133-6140. [PMID: 37587268 DOI: 10.1007/s00415-023-11929-2] [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] [Received: 06/10/2023] [Revised: 07/29/2023] [Accepted: 08/09/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND AND PURPOSE This study aimed to evaluate whether differences in clinical outcomes exist according to treatments received and seizure activity resolution in patients with refractory status epilepticus (RSE). METHODS Consecutive episodes of non-hypoxic status epilepticus (SE) in patients ≥ 14 years old were included. Episodes of RSE were stratified in: (i) SE persistent despite treatment with first-line therapy with benzodiazepines and one second-line treatment with antiseizure medications (ASMs), but responsive to successive treatments with ASMs (RSE-rASMs); (ii) SE persistent despite treatment with first-line therapy with benzodiazepines and successive treatment with one or more second-line ASMs, but responsive to anesthetic drugs [RSE-rGA (general anesthesia)]. Study endpoints were mortality during hospitalization and worsening of modified Rankin Scale (mRS) at discharge. RESULTS Status epilepticus was responsive in 298 (54.1%), RSE-rASMs in 152 (27.6%), RSE-rGA in 46 (8.3%), and super-refractory (SRSE) in 55 (10.0%) out of 551 included cases. Death during hospitalization occurred in 98 (17.8%) and worsening of mRS at discharge in 287 (52.1%) cases. Multivariable analyses revealed increased odds of in-hospital mortality with RSE-rGA (odds ratio [OR] 3.05, 95% confidence interval [CI] 1.27-7.35) and SRSE (OR 3.83, 95%. CI 1.73-8.47), and increased odds of worsening of mRS with RSE-rASMs (OR 2.06, 95% CI 1.28-3.31), RSE-rGA (OR 4.44, 95% CI 1.97-10.00), and SRSE (OR 13.81, 95% CI 5.34-35.67). CONCLUSIONS In RSE, varying degrees of refractoriness may be defined and suit better the continuum spectrum of disease severity and the heterogeneity of SE burden and prognosis.
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Affiliation(s)
- Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy.
| | | | - Niccolò Orlandi
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Via Giardini, 1355, Ospedale Civile S. Agostino Estense, 41126, Modena, Italy
| | - Francesco Brigo
- Division of Neurology, "Franz Tappeiner" Hospital, Merano, BZ, Italy
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
- Center for Cognitive Neuroscience, Salzburg, Austria
- Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Stefano Meletti
- Neurology Unit, OCB Hospital, AOU Modena, Modena, Italy.
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Via Giardini, 1355, Ospedale Civile S. Agostino Estense, 41126, Modena, Italy.
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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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Alvarez V, Novy J, Beuchat I, Rossetti AO. Letter to the editor regarding "early timing of anesthesia in status epilepticus is associated with complete recovery: A 7-year retrospective two-center study". Epilepsia 2023; 64:2530-2531. [PMID: 37376780 DOI: 10.1111/epi.17705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/26/2023] [Indexed: 06/29/2023]
Affiliation(s)
- Vincent Alvarez
- Department of Neurology, Neurocentre, Hôpital du Valais, Sion, Switzerland
- Department of Clinical Neuroscience, University Hospital of Lausanne (CHUV), and University of Lausanne, Lausanne, Switzerland
| | - Jan Novy
- Department of Clinical Neuroscience, University Hospital of Lausanne (CHUV), and University of Lausanne, Lausanne, Switzerland
| | - Isabelle Beuchat
- Department of Clinical Neuroscience, University Hospital of Lausanne (CHUV), and University of Lausanne, Lausanne, Switzerland
| | - Andrea O Rossetti
- Department of Clinical Neuroscience, University Hospital of Lausanne (CHUV), and University of Lausanne, Lausanne, Switzerland
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