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Shi X, Wang Y, Wang X, Kang X, Yang F, Yuan F, Jiang W. Long-term outcomes of adult cryptogenic febrile infection-related epilepsy syndrome (FIRES). Front Neurol 2023; 13:1081388. [PMID: 36686522 PMCID: PMC9848432 DOI: 10.3389/fneur.2022.1081388] [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: 10/27/2022] [Accepted: 12/09/2022] [Indexed: 01/05/2023] Open
Abstract
Background Cryptogenic febrile infection-related epilepsy syndrome (FIRES) is a rare but catastrophic encephalopathic condition. We aimed to investigate the long-term outcome in adult cryptogenic FIRES. Methods This was a retrospective study based on the prospective database in the neuro-intensive care unit of a tertiary hospital in China. Consecutive adult patients with cryptogenic FIRES between July 2007 to December 2021 were included. Long-term outcomes included function independence, the development of drug-resistant epilepsy (DRE), remote recurrent status epilepticus (SE), anti-seizure medications (ASMs), and changes in the brain Magnetic Resonance Imaging (MRI). Results A total of 11 adult patients with cryptogenic FIRES were identified from 270 patients with SE. Four (36%) patients died in the hospital, with three of them withdrawing treatments, and one patient died 12 months after discharge. After the follow-up ranging from 12 to 112 months, 6 (55%) patients were still alive, and all of them achieved functional independence [modified Rankin Scale (mRS) 0-3]. 45% (5/11) patients developed DRE, 18% (2/11) had remote recurrent SE, and 55% (6/11) were on polytherapy with ASMs at the last follow-up. Most of the patients with initial normal or abnormal MRI had abnormalities in the hippocampus at follow-up, and most of the other MRI abnormalities found in the acute stage disappeared over time. Conclusion The outcome of adult cryptogenic FIRES is daunting. More than one-third of patients die in the hospital. Survivors of cryptogenic FIRES may regain functional independence, but they usually develop DRE and receive polytherapy of ASMs for a long time.
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Affiliation(s)
- Xiaojing Shi
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yuanyuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiaogang Kang
- 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
| | - Fang Yuan
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China,Fang Yuan ✉
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China,*Correspondence: Wen Jiang ✉
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Hasan SU, Pervez A, Bhatty S, Shamim S, Naeem A, Naseeb MW. Termination of seizures in the paediatric age group, best benzodiazepine and route of administration: A network meta-analysis. Eur J Neurosci 2022; 56:4234-4245. [PMID: 35674673 DOI: 10.1111/ejn.15732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/03/2022] [Accepted: 06/05/2022] [Indexed: 11/28/2022]
Abstract
This network meta-analysis aims to compare various benzodiazepines and their route of administration using the data published exclusively in randomized controlled trials (RCTs). Two thousand two hundred sixty-three children presenting with an episode of seizure to ER or to a paramedic where they were administered a benzodiazepine as the first-line treatment were included. All the outcomes were measured for their mean with 95% CI and rank probability. The primary outcome was the number of successful seizure cessation. Secondary outcomes were the time interval between drug administration and seizure cessation, the time interval between patient arrival and seizure cessation and the number of episodes of seizure recurrence after drug administration. For the number of successful cessations, intramuscular midazolam showed the highest mean and best rank probability with a value of .881 (.065) and 57.9%, respectively. For the time of cessation, both intravenous lorazepam (IVL) and intravenous diazepam showed a mean of 3.30 (1.30) with IVL having the highest rank probability of 32%. For total time for cessation, intranasal midazolam showed the best mean and rank probability with a value of 4.3 (1.1) and 55%, respectively. Buccal midazolam showed the lowest mean with a value of .106 (.084) for rate of recurrence. Although there was no significant difference between the treatments, but based on the rank probability, IVL shows more promising results for patients who already have an established intravenous line, and for patients presenting in the ER without an intravenous line, the first line of treatment should be INM as it shows the highest rank probability in total time with second-highest successful cessation rate.
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Affiliation(s)
| | - Alina Pervez
- Dow University of Health Sciences, Karachi, Pakistan
| | | | - Shifa Shamim
- Dow University of Health Sciences, Karachi, Pakistan.,Dr Ruth KM Pfau Civil Hospital Karachi, Karachi, Pakistan
| | - Aaima Naeem
- Dow University of Health Sciences, Karachi, Pakistan.,Dr Ruth KM Pfau Civil Hospital Karachi, Karachi, Pakistan
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Status Epilepticus in Patients with Anti-NMDAR Encephalitis Requiring Intensive Care: A Follow-Up Study. Neurocrit Care 2021; 36:192-201. [PMID: 34286465 DOI: 10.1007/s12028-021-01283-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 05/21/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND To date, specialized studies focusing on status epilepticus (SE) in anti-N-methyl D-aspartate receptor (anti-NMDAR) encephalitis are limited, and the association between the occurrence of SE and clinical outcome is controversial. This study aims to investigate the differences between patients with critical anti-NMDAR encephalitis with SE and patients who experienced epileptic seizures without SE and to evaluate the long-term disease outcomes of patients with anti-NMDAR encephalitis with SE who were admitted to the neurological intensive care unit (neuro-ICU). METHODS In this retrospective study based on a prospective registry, patients with anti-NMDAR encephalitis with neuro-ICU admission from 2014 to 2019 were analyzed and divided into two groups based on whether they had SE. Their clinical characteristics during the neuro-ICU stay were assessed and compared. The neurological and seizure outcomes were evaluated every 3 months. RESULTS Of 83 patients with anti-NMDAR encephalitis, 24 required intensive care. In the SE group, 38.5% (5 of 13) of patients developed refractory SE (RSE), and 21.3% (3 of 13) of patients developed super RSE. More patients in the SE group presented with seizures as the initial symptoms (53.8% vs. 9.1%, p = 0.033) and had a strong positive NMDAR antibody titer in the cerebrospinal fluid (76.9% vs. 27.3%, p = 0.043). More patients in the non-SE group had a good neurological outcome (modified Rankin Scale (mRS) score < 2) at 3 months after disease onset (60.0% vs. 15.4%, p = 0.039), but 83.3% of patients with SE had a mRS score < 2 at 9 months after disease onset, which was similar to the rate in the non-SE group. A total of 41.7% of patients with SE had their last seizure within 1 month from disease onset, which was significantly lower than the rate in the non-SE group (90%), but all the patients with SE became seizure free after the acute phase of disease. CONCLUSIONS Patients with critical anti-NMDAR encephalitis who present with SE have a high rate of RSE/super RSE and recover more slowly than patients without SE, but most of them will eventually achieve good long-term neurological outcomes and live seizure free after the acute phase.
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Charalambous M, Volk HA, Van Ham L, Bhatti SFM. First-line management of canine status epilepticus at home and in hospital-opportunities and limitations of the various administration routes of benzodiazepines. BMC Vet Res 2021; 17:103. [PMID: 33663513 PMCID: PMC7934266 DOI: 10.1186/s12917-021-02805-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 02/16/2021] [Indexed: 12/22/2022] Open
Affiliation(s)
- Marios Charalambous
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium.
| | - Holger A Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, 30559, Hannover, Germany
| | - Luc Van Ham
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium
| | - Sofie F M Bhatti
- Small Animal Department, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium
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Sathe AG, Underwood E, Coles LD, Elm JJ, Silbergleit R, Chamberlain JM, Kapur J, Cock HR, Fountain NB, Shinnar S, Lowenstein DH, Rosenthal ES, Conwit RA, Bleck TP, Cloyd JC. Patterns of benzodiazepine underdosing in the Established Status Epilepticus Treatment Trial. Epilepsia 2021; 62:795-806. [PMID: 33567109 DOI: 10.1111/epi.16825] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 12/31/2020] [Accepted: 01/05/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This study was undertaken to describe patterns of benzodiazepine use as first-line treatment of status epilepticus (SE) and test the association of benzodiazepine doses with response to second-line agents in patients enrolled in the Established Status Epilepticus Treatment Trial (ESETT). METHODS Patients refractory to an adequate dose of benzodiazepines for the treatment of SE were enrolled in ESETT. Choice of benzodiazepine, doses given prior to administration of second-line agent, route of administration, setting, and patient weight were characterized. These were compared with guideline-recommended dosing. Logistic regression was used to determine the association of the first dose of benzodiazepine and the cumulative benzodiazepine dose with the response to second-line agent. RESULTS Four hundred sixty patients were administered 1170 doses of benzodiazepines (669 lorazepam, 398 midazolam, 103 diazepam). Lorazepam was most frequently administered intravenously in the emergency department, midazolam intramuscularly or intravenously by the emergency medical services personnel, and diazepam rectally prior to ambulance arrival. The first dose of the first benzodiazepine (N = 460) was lower than guideline recommendations in 76% of midazolam administrations and 81% of lorazepam administrations. Among all administrations, >85% of midazolam and >76% of lorazepam administrations were lower than recommended. Higher first or cumulative benzodiazepine doses were not associated with better outcomes or clinical seizure cessation in response to second-line medications in these benzodiazepine-refractory seizures. SIGNIFICANCE Benzodiazepines as first-line treatment of SE, particularly midazolam and lorazepam, are frequently underdosed throughout the United States. This broad and generalizable cohort confirms prior single site reports that underdosing is both pervasive and difficult to remediate. (ESETT ClinicalTrials.gov identifier: NCT01960075.).
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Affiliation(s)
- Abhishek G Sathe
- Department of Experimental and Clinical Pharmacology, College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ellen Underwood
- Department of Public Health Science, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lisa D Coles
- Department of Experimental and Clinical Pharmacology, College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jordan J Elm
- Department of Public Health Science, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Hospital and Department of Pediatrics and Emergency Medicine, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia, USA
| | - Jaideep Kapur
- Department of Neurology and Department of Neuroscience, Brain Institute, University of Virginia, Charlottesville, Virginia, USA
| | - Hannah R Cock
- Clinical Neurosciences Academic Group, Institute of Molecular and Clinical Sciences, St. George's University of London, London, UK
| | - Nathan B Fountain
- Department of Neurology, Comprehensive Epilepsy Program, University of Virginia, Charlottesville, Virginia, USA
| | - Shlomo Shinnar
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Daniel H Lowenstein
- Department of Neurology, University of California, San Francisco, San Francisco, California, USA
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robin A Conwit
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Thomas P Bleck
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - James C Cloyd
- Department of Experimental and Clinical Pharmacology, College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis, Minnesota, USA
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Sathe AG, Mishra U, Ivaturi V, Brundage RC, Cloyd JC, Elm JJ, Chamberlain JM, Silbergleit R, Kapur J, Lowenstein DH, Shinnar S, Cock HR, Fountain NB, Babcock L, Coles LD. Early Exposure of Fosphenytoin, Levetiracetam, and Valproic Acid After High-Dose Intravenous Administration in Young Children With Benzodiazepine-Refractory Status Epilepticus. J Clin Pharmacol 2021; 61:763-768. [PMID: 33336359 DOI: 10.1002/jcph.1801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Fosphenytoin (FOS) and its active form, phenytoin (PHT), levetiracetam (LEV), and valproic acid (VPA) are commonly used second-line treatments of status epilepticus. However, limited information is available regarding LEV and VPA concentrations following high intravenous doses, particularly in young children. The Established Status Epilepticus Treatment Trial, a blinded, comparative effectiveness study of FOS, LEV, and VPA for benzodiazepine-refractory status epilepticus provided an opportunity to investigate early drug concentrations. Patients aged ≥2 years who continued to seizure despite receiving adequate doses of benzodiazepines were randomly assigned to FOS, LEV, or VPA infused over 10 minutes. A sparse blood-sampling approach was used, with up to 2 samples collected per patient within 2 hours following drug administration. The objective of this work was to report early drug exposure of PHT, LEV, and VPA and plasma protein binding of PHT and VPA. Twenty-seven children with median (interquartile range) age of 4 (2.5-6.5) years were enrolled. The total plasma concentrations ranged from 69 to 151.3 μg/mL for LEV, 11.3 to 26.7 μg/mL for PHT and 126 to 223 μg/mL for VPA. Free fraction ranged from 4% to 19% for PHT and 17% to 51% for VPA. This is the first report in young children of LEV concentrations with convulsive status epilepticus as well as VPA concentrations after a 40 mg/kg dose. Several challenges limited patient enrollment and blood sampling. Additional studies with a larger sample size are required to evaluate the exposure-response relationships in this emergent condition.
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Affiliation(s)
- Abhishek G Sathe
- Center for Orphan Drug Research, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Usha Mishra
- Center for Orphan Drug Research, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Vijay Ivaturi
- Center for Translational Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Richard C Brundage
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - James C Cloyd
- Center for Orphan Drug Research, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jordan J Elm
- Department of Public Health Science, Medical University of South Carolina, Charleston, South Carolina, USA
| | - James M Chamberlain
- Division of Emergency Medicine, Children's National Hospital and the Department of Pediatrics and Emergency Medicine, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia, USA
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jaideep Kapur
- Department of Neurology and Department of Neuroscience, Brain Institute, University of Virginia, Charlottesville, Virginia, USA
| | - Daniel H Lowenstein
- Department of Neurology, University of California, San Francisco, California, USA
| | - Shlomo Shinnar
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Hannah R Cock
- Clinical Neurosciences Academic Group, Institute of Molecular and Clinical Sciences, St George's University of London, London, UK
| | - Nathan B Fountain
- Department of Neurology, Comprehensive Epilepsy Program, Charlottesville, Virginia, USA
| | - Lynn Babcock
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Lisa D Coles
- Center for Orphan Drug Research, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA.,Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
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Gömceli Y, Altındağ E, Baykan B. Different attitudes in the management of different types of status epilepticus: A survey study among neurologists demonstrating evidence gap. NEUROL SCI NEUROPHYS 2021. [DOI: 10.4103/nsn.nsn_70_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Handral A, Veerappa BG, Gowda VK, Shivappa SK, Benakappa N, Benakappa A. Levetiracetam versus Fosphenytoin in Pediatric Convulsive Status Epilepticus: A Randomized Controlled Trial. J Pediatr Neurosci 2020; 15:252-256. [PMID: 33531940 PMCID: PMC7847106 DOI: 10.4103/jpn.jpn_109_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 01/20/2020] [Accepted: 03/29/2020] [Indexed: 11/06/2022] Open
Abstract
Objectives: The aim of this study was to compare the efficacy and safety of intravenous levetiracetam and fosphenytoin in the management of pediatric status epilepticus. Materials and Methods: This is an open-labeled randomized controlled trial, conducted at tertiary care pediatric intensive care unit. Subjects between 1 month and 18 years who presented with status epilepticus were enrolled. If seizures persisted even after two doses of lorazepam, participants were randomized to receive either fosphenytoin 30 mg/kg or levetiracetam 30 mg/kg intravenously and followed up till 48h, for seizure recurrence and adverse drug effects. Outcome measures were cessation of seizures within 10–20 min following the end of the infusion of drugs fosphenytoin and levetiracetam, respectively, and no recurrence of seizures was noted over next 48h. Results: Subjects in both study groups were comparable in baseline characteristics. Seizures stopped in 54 (93.1%) and 53 (91.4%) in fosphenytoin and levetiracetam groups, respectively (P = 1.000). Seizure recurrence was noted in 13 (22.4%) and 10 (17.2%) patients in fosphenytoin and levetiracetam groups, respectively (n = 0.485). In fosphenytoin group, one (1.7%) child had bradycardia, two (3.4%) children required inotropes, and three (5.2%) children required intubation. In levetiracetam group, none had bradyarrhythmia, required inotropes, and intubation was required in one (1.7%) child each. No statistically significant difference was observed in outcome parameters in two groups. Conclusion: Levetiracetam is as efficacious as fosphenytoin in control of pediatric status epilepticus and is associated with lesser side effects.
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Affiliation(s)
- Anusha Handral
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Basavraja G Veerappa
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Vykuntaraju K Gowda
- Department of Pediatric Neurology, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Sanjay K Shivappa
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Naveen Benakappa
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Asha Benakappa
- Department of Pediatrics, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
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Outin H, Gueye P, Alvarez V, Auvin S, Clair B, Convers P, Crespel A, Demeret S, Dupont S, Engels JC, Engrand N, Freund Y, Gelisse P, Girot M, Marcoux MO, Navarro V, Rossetti A, Santoli F, Sonneville R, Szurhaj W, Thomas P, Titomanlio L, Villega F, Lefort H, Peigne V. Recommandations Formalisées d’Experts SRLF/SFMU : Prise en charge des états de mal épileptiques en préhospitalier, en structure d’urgence et en réanimation dans les 48 premières heures (A l’exclusion du nouveau-né et du nourrisson). ANNALES FRANCAISES DE MEDECINE D URGENCE 2020. [DOI: 10.3166/afmu-2020-0232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
La Société de réanimation de langue française et la Société française de médecine d’urgence ont décidé d’élaborer de nouvelles recommandations sur la prise en charge de l’état mal épileptique (EME) avec l’ambition de répondre le plus possible aux nombreuses questions pratiques que soulèvent les EME : diagnostic, enquête étiologique, traitement non spécifique et spécifique. Vingt-cinq experts ont analysé la littérature scientifique et formulé des recommandations selon la méthodologie GRADE. Les experts se sont accordés sur 96 recommandations. Les recommandations avec le niveau de preuve le plus fort ne concernent que l’EME tonico-clonique généralisé (EMTCG) : l’usage des benzodiazépines en première ligne (clonazépam en intraveineux direct ou midazolam en intramusculaire) est recommandé, répété 5 min après la première injection (à l’exception du midazolam) en cas de persistance clinique. En cas de persistance 5 min après cette seconde injection, il est proposé d’administrer la seconde ligne thérapeutique : valproate de sodium, (fos-)phénytoïne, phénobarbital ou lévétiracétam. La persistance avérée de convulsions 30 min après le début de l’administration du traitement de deuxième ligne signe l’EMETCG réfractaire. Il est alors proposé de recourir à un coma thérapeutique au moyen d’un agent anesthésique intraveineux de type midazolam ou propofol. Des recommandations spécifiques à l’enfant et aux autres EME sont aussi énoncées.
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Leng X, Yuan F, Zhao J, Song C, Zhao Z, Zhang Y, Gao Q, Yang F, Jiang W. Long-term seizure outcome in patients with status epilepticus due to acute encephalitis. Seizure 2019; 69:70-75. [DOI: 10.1016/j.seizure.2019.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 04/05/2019] [Accepted: 04/06/2019] [Indexed: 11/15/2022] Open
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Chegondi M, Garland MM, Sendi P, Jayakar AR, Totapally BR. Course and Outcome of Children with Convulsive Status Epilepticus Admitted to a Pediatric Intensive Care Unit. Cureus 2019; 11:e4471. [PMID: 31249749 PMCID: PMC6579347 DOI: 10.7759/cureus.4471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Introduction The objective of this study was to describe the course and the outcomes of children with convulsive status epilepticus and to evaluate the differences between two groups of children with new-onset seizures and known seizure disorders. Methods This is a retrospective, single-center study. Children with convulsive status epilepticus admitted to our tertiary care pediatric intensive care unit were included in the study. Medical records were reviewed to obtain the demographic- and seizure-related variables. Results Among 139 children with status epilepticus, 69.7% (n = 99) had a known seizure disorder. Focal seizures were present in 23.9% of children, and 34.6% required intubation; there was an overall mortality rate of 1.2%. The children with new-onset seizures were younger and received electroencephalography (EEG) and neuroimaging more often compared to children with known seizure disorders (p < 0.05). However, an abnormal EEG was more common among children with known seizure disorders (p < 0.001). Conclusions Sub-therapeutic anti-epileptic drugs levels were common among children with known seizure disorders presenting with status epilepticus. Gender, race, insurance status, type of seizures, intubation requirement, lengths of stay, and mortality were not significantly different between the two groups.
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Affiliation(s)
| | - Mary M Garland
- Surgery, Herbert Wertheim College of Medicine, Miami, USA
| | - Prithvi Sendi
- Pediatrics, Nicklaus Children's Hospital, Miami, USA
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Yuan F, Yang F, Jia R, Li W, Jiang Y, Zhao J, Jiang W. Multimodal Predictions of Super-Refractory Status Epilepticus and Outcome in Status Epilepticus Due to Acute Encephalitis. Front Neurol 2018; 9:832. [PMID: 30349506 PMCID: PMC6186801 DOI: 10.3389/fneur.2018.00832] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 09/18/2018] [Indexed: 01/01/2023] Open
Abstract
Objective: Status epilepticus (SE) is one of the most critical symptoms of encephalitis. Studies on early predictions of progression to super-refractory status epilepticus (SRSE) and poor outcome in SE due to acute encephalitis are scarce. We aimed to investigate the values of neuroimaging and continuous electroencephalogram (EEG) in the multimodal prediction. Methods: Consecutive patients with convulsive SE due to acute encephalitis were included in this study. Demographics, clinical features, neuro-imaging characteristics, medical interventions, and anti-epileptic treatment responses were collected. All the patients had EEG monitoring for at least 24 h. We determined the early predictors of SRSE and prognostic factors of 3-month outcome using multivariate logistic regression analyses. Results: From March 2008 to February 2018, 570 patients with acute encephalitis were admitted to neurological intensive care unit (N-ICU) of Xijing hospital. Among them, a total of 94 patients with SE were included in this study. The percentage of non-SRSE and SRSE were 76.6 and 23.4%. Cortical or hippocampal abnormality on neuroimaging (p = 0.002, OR 20.55, 95% CI 3.16-133.46) and END-IT score (p < 0.001, OR 4.07, 95% CI 1.91-8.67) were independent predictors of the progression to SRSE. At 3 months after N-ICU discharge, 56 (59.6%) patients attained good outcomes, and 38 (40.4%) patients had poor outcomes. The recurrence of clinical or EEG seizures within 2 h after the infusion rate of a single anesthetic drug >50% proposed maximal dose (p = 0.044, OR 4.52, 95% CI 1.04-19.68), tracheal intubation (p = 0.011, OR 4.99, 95% CI 1.37-11.69) and emergency resuscitation (p = 0.040, OR 9.80, 95% 1.11-86.47) predicted poor functional outcome. Interpretation: Initial neuro-imaging findings assist early identification of the progression to SRSE. Continuous EEG monitoring contributes to outcome prediction in SE due to acute encephalitis.
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Affiliation(s)
- Fang Yuan
- 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
| | - Ruihua Jia
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Wen Li
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yongli Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jingjing Zhao
- 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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Brigo F, Lattanzi S. Intravenous phenytoin in convulsive status epilepticus: the devil we (think we) know. FUTURE NEUROLOGY 2018. [DOI: 10.2217/fnl-2018-0011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Francesco Brigo
- Department of Neurosciences, Biomedicine & Movement Sciences, University of Verona, Verona, Italy, Piazzale L.A. Scuro, 10 - 37134 Verona, Italy
- Division of Neurology, Franz Tappeiner Hospital, Merano, Italy
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental & Clinical Medicine, Marche Polytechnic University, Ancona, Italy
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14
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Zaccara G, Giorgi FS, Amantini A, Giannasi G, Campostrini R, Giovannelli F, Paganini M, Nazerian P. Why we prefer levetiracetam over phenytoin for treatment of status epilepticus. Acta Neurol Scand 2018; 137:618-622. [PMID: 29624640 DOI: 10.1111/ane.12928] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2018] [Indexed: 11/30/2022]
Abstract
Over last fifty years, intravenous (iv) phenytoin (PHT) loading dose has been the treatment of choice for patients with benzodiazepine-resistant convulsive status epilepticus and several guidelines recommended this treatment regimen with simultaneous iv diazepam. Clinical studies have never shown a better efficacy of PHT over other antiepileptic drugs. In addition, iv PHT loading dose is a complex and time-consuming procedure which may expose patients to several risks, such as local cutaneous reactions (purple glove syndrome), severe hypotension and cardiac arrhythmias up to ventricular fibrillation and death, and increased risk of severe allergic reactions. A further disadvantage of PHT is that it is a strong enzymatic inducer and it may make ineffective several drugs that need to be used simultaneously with antiepileptic treatment. In patients with a benzodiazepine-resistant status epilepticus, we suggest iv administration of levetiracetam as soon as possible. If levetiracetam would be ineffective, a further antiepileptic drug among those currently available for iv use (valproate, lacosamide, or phenytoin) can be added before starting third line treatment.
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Affiliation(s)
- G. Zaccara
- Unit of Neurology; Department of Medicine; Usl centro Toscana Health Authority; Firenze Italy
| | - F. S. Giorgi
- Neurology Unit; Azienda Ospedialiero Universitaria Pisana; Pisa Italy
| | - A. Amantini
- SOD Neurofisiopatologia; Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso; AOU Careggi; Florence Italy
| | - G. Giannasi
- Emergency Department; Usl centro Toscana Health Authority; Firenze Italy
| | - R. Campostrini
- Unit of Neurology; Department of Medicine; Usl centro Toscana Health Authority; Firenze Italy
| | - F. Giovannelli
- Department of Neuroscience, Psychology, Pharmacology and Child Health (NEUROFARBA); University of Florence; Firenze Italy
| | - M. Paganini
- Neurology Unit; Careggi University Hospital; Florence Italy
| | - P. Nazerian
- Emergency Department; Careggi University Hospital; Firenze Italy
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Baysal-Kirac L, Feddersen B, Einhellig M, Rémi J, Noachtar S. Does semiology of status epilepticus have an impact on treatment response and outcome? Epilepsy Behav 2018; 83:81-86. [PMID: 29660507 DOI: 10.1016/j.yebeh.2018.03.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/16/2018] [Accepted: 03/17/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study investigated whether there is an association between semiology of status epilepticus (SE) and response to treatment and outcome. METHOD Two hundred ninety-eight consecutive adult patients (160 females, 138 males) with SE at the University of Munich Hospital were prospectively enrolled. Mean age was 63.2±17.5 (18-97) years. Patient demographics, SE semiology and electroencephalography (EEG) findings, etiology, duration of SE, treatment, and outcome measures were investigated. Status epilepticus semiology was classified according to a semiological status classification. Patient's short-term outcome was determined by Glasgow Outcome Scale (GOS). RESULTS The most frequent SE type was nonconvulsive SE (NCSE) (39.2%), mostly associated with cerebrovascular etiology (46.6%). A potentially fatal etiology was found in 34.8% of the patients. More than half (60.7%) of the patients had poor short-term outcome (GOS≤3) with an overall mortality of 12.4%. SE was refractory to treatment in 21.5% of the patients. Older age, potentially fatal etiology, systemic infections, NCSE in coma, refractory SE, treatment with anesthetics, long SE duration (>24h), low Glasgow Coma Scale (GCS) (≤8) at onset, and high Status Epilepticus Severity Score (STESS-3) (≥3) were associated with poor short-term outcome and death (p<0.05). Potentially fatal etiology and low GCS were the strongest predictors of poor outcome (Exp [b]: 4.74 and 4.10 respectively, p<0.05). CONCLUSION Status epilepticus semiology has no independent association with outcome, but potentially fatal etiology and low GCS were strong predictive factors for poor short-term outcome of SE.
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Affiliation(s)
- Leyla Baysal-Kirac
- Epilepsy Center, Department of Neurology, University of Munich, Munich, Germany
| | - Berend Feddersen
- Epilepsy Center, Department of Neurology, University of Munich, Munich, Germany
| | - Marion Einhellig
- Epilepsy Center, Department of Neurology, University of Munich, Munich, Germany
| | - Jan Rémi
- Epilepsy Center, Department of Neurology, University of Munich, Munich, Germany
| | - Soheyl Noachtar
- Epilepsy Center, Department of Neurology, University of Munich, Munich, Germany.
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Leo A, Giovannini G, Russo E, Meletti S. The role of AMPA receptors and their antagonists in status epilepticus. Epilepsia 2018; 59:1098-1108. [DOI: 10.1111/epi.14082] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2018] [Indexed: 01/08/2023]
Affiliation(s)
- Antonio Leo
- Department of Science of Health; University Magna Graecia of Catanzaro; Catanzaro Italy
| | - Giada Giovannini
- Department of Biomedical Metabolic and Neural Sciences; University of Modena and Reggio Emilia; Modena Italy
| | - Emilio Russo
- Department of Science of Health; University Magna Graecia of Catanzaro; Catanzaro Italy
| | - Stefano Meletti
- Department of Biomedical Metabolic and Neural Sciences; University of Modena and Reggio Emilia; Modena Italy
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17
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Szklener S, Godek M, Korchut A, Balicka-Adamik L, Rejdak R, Rossetti AO, Rejdak K. Outcome prediction in patients with acute repetitive seizures: Application of the Status Epilepticus Severity Score. Epilepsia 2018; 59:e68-e72. [PMID: 29600811 DOI: 10.1111/epi.14061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2018] [Indexed: 12/01/2022]
Abstract
Acute repetitive seizures (ARS) pose a risk of hospital admission with status epilepticus and a mortality threat, which underscores the need for the early prediction of a clinical course. Unfortunately, little attention has been given to ARS in this context, even though we possess the appropriate predictive tools for the stages of status epilepticus. Therefore, the main aim of this study was to assess the prognostic value of the Status Epilepticus Severity Score (STESS) in the population of patients with ARS. The study included a population of 200 patients. Almost half of the patients had achieved seizure cessations after diazepam administration, whereas 19.5% progressed to status epilepticus despite antiepileptic drug treatment. Mortality reached 10.5% of the total population. The receiver operating characteristic (ROC) curve for prediction of death by the STESS had an area under the curve (AUC) of 0.901, with an optimal cutoff point for discrimination ≥2 (sensitivity 0.95, specificity 0.71, and Youden index 0.66). Hosmer-Lemeshow indicated good calibration of the STESS (chi-square goodness-of-fit test = 3.24; P = .919). The study shows excellent effectiveness of the STESS in the prognosis of the clinical course in patients with ARS. STESS may be a valuable tool for the proper planning of diagnostic and therapeutic activities in this population.
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Affiliation(s)
| | - Magdalena Godek
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | - Agnieszka Korchut
- Department of Neurology, Medical University of Lublin, Lublin, Poland
| | | | - Robert Rejdak
- Medical Research Center, Polish Academy of Sciences, Warsaw, Poland
| | - Andrea O Rossetti
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), Lausanne University, Lausanne, Switzerland
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, Lublin, Poland.,Medical Research Center, Polish Academy of Sciences, Warsaw, Poland
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18
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Long B, April MD. Do Intravenous Benzodiazepines or Benzodiazepines by an Alternative Route (Nonintravenous) Abort Seizures Faster? Ann Emerg Med 2018; 71:419-421. [DOI: 10.1016/j.annemergmed.2017.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Indexed: 10/19/2022]
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Warraich S, Ali A, Nizami A, Bakhiet M. Can endotracheal intubation be the first step in management of nonconvulsive status epilepticus?: A case report. Medicine (Baltimore) 2018; 97:e9950. [PMID: 29443785 PMCID: PMC5839821 DOI: 10.1097/md.0000000000009950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Nonconvulsive status epilepticus (NCSE) is prolonged seizure activity without motor manifestations. Clinically, there are certain examination findings, in addition to elements of history, that help differentiate it from other encephalopathies. When diagnosing NCSE, the physician faces significant difficulties due to inconsistent clinical presentation and somewhat nonspecific electroencephalogram (EEG) criteria. PATIENT CONCERNS To highlight the problems faced when dealing with such a patient, a case of a 29-year-old male who presented with an altered state of consciousness is put forth for the reader. Only after an extensive laboratory and radiological workup had ruled out other causes, an eventual diagnosis was established when clinical features were correlated with suggestive EEG results. DIAGNOSES The diagnosis that was reached was NCSE. INTERVENTIONS The initial therapeutic interventions generally deployed in such a scenario ultimately failed and consequently the patient had to be sedated and intubated, while being kept on antiepileptic medication. OUTCOMES This measure resulted in satisfactory recovery. LESSONS Accordingly, we recommend consideration of NCSE in any unconscious patient whose presentation cannot be explained by other disorders. Furthermore, we suggest moving directly to utilizing anesthetic agents and endotracheal intubation, together with anti-epileptic drugs, in the treatment regimen in order to optimize patient outcomes.
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Affiliation(s)
| | - Abbas Ali
- King Hamad University Hospital, Al Sayh
| | | | - Moiz Bakhiet
- King Hamad University Hospital, Al Sayh
- Department of Molecular Medicine, College of Medicine and Medical Science, Arabian Gulf University, Manama
- Princess Al-Jawhara Center for Molecular Medicine, Genetics and Inherited Disorders, Manama, Kingdom of Bahrain
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20
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Brigo F, Bragazzi NL, Lattanzi S, Nardone R, Trinka E. A critical appraisal of randomized controlled trials on intravenous phenytoin in convulsive status epilepticus. Eur J Neurol 2018; 25:451-463. [PMID: 29288520 DOI: 10.1111/ene.13560] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 12/27/2017] [Indexed: 12/17/2022]
Abstract
Since the 1970s, intravenous (IV) phenytoin (PHT) has traditionally been used as second-stage treatment for convulsive status epilepticus (SE) after failure of benzodiazepines. The aim of this review was to critically assess the evidence supporting the use of IV PHT as treatment of convulsive SE in patients of any age. In particular, we critically appraised the results of randomized controlled trials (RCTs) evaluating IV PHT as treatment of convulsive SE. A systematic search of the literature was carried out to identify RCTs evaluating IV PHT as treatment of convulsive SE in patients of any age. Eight RCTs (544 patients allocated to IV PHT) were included. The included studies differed in almost every single characteristic considered. Six RCTs (472 patients) used IV PHT without demonstrating refractoriness of SE to benzodiazepines. Only two RCTs (72 patients) used IV PHT as second-line treatment for benzodiazepine-resistant convulsive SE. Overall, most evidence from RCTs supports the use of IV PHT immediately after IV diazepam, even if seizures have not recurred. The recommendation derived from RCTs supporting the use of IV PHT as second-line treatment in benzodiazepine-resistant convulsive SE is weak. This is emblematic of the lack of robust evidence from large RCTs to inform clinical practice on how to treat SE after failure of first-line drugs. IV PHT given immediately after first-line benzodiazepines could prolong their short antiepileptic effect and prevent seizure recurrence.
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Affiliation(s)
- F Brigo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona.,Department of Neurology, Franz Tappeiner Hospital, Merano
| | - N L Bragazzi
- School of Public Health, Department of Health Sciences (DISSAL), University of Genoa, Genoa
| | - S Lattanzi
- Neurological Clinic, Marche Polytechnic University, Ancona, Italy
| | - R Nardone
- Department of Neurology, Franz Tappeiner Hospital, Merano.,Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg
| | - E Trinka
- Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg.,Center for Cognitive Neuroscience, Salzburg.,Public Health, Health Services Research and HTA, University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
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Di Bonaventura C, Labate A, Maschio M, Meletti S, Russo E. AMPA receptors and perampanel behind selected epilepsies: current evidence and future perspectives. Expert Opin Pharmacother 2017; 18:1751-1764. [PMID: 29023170 DOI: 10.1080/14656566.2017.1392509] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) receptors are the major mediators of glutamate-mediated excitatory neurotransmission, and are critical for synchronization and spread of epileptic activity. Areas covered: AMPA receptor antagonists have been also developed as antiepileptic drugs and perampanel (PER) is the first highly selective, non-competitive AMPA-type glutamate receptor antagonist that is available on the market. It is approved as adjunctive therapy for the treatment of partial-onset seizures with or without secondary generalization, and for primary generalized tonic-clonic seizures in idiopathic generalized epilepsy, in patients aged ≥ 12 years. This article reviews the role of AMPA receptors in the neuronal hyperexcitability underlying epilepsy, the mechanism of action and clinical experience on the anti-seizure activity of PER. Moreover, the rationale for targeting AMPA receptor in specific epileptic disorders, including brain tumor-related epilepsy, mesial temporal lobe epilepsy with/without hippocampal sclerosis, and status epilepticus is evaluated. Finally, the pharmacological rationale for the development of AMPA receptor antagonists in other neurological disorders beyond epilepsy is considered. Expert opinion: Further research aimed at better understanding the pharmacology and blocking mechanism of PER and other AMPA receptor antagonists will drive future development of therapeutic agents that target epilepsy and other neurological diseases.
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Affiliation(s)
- Carlo Di Bonaventura
- a Department of Neurology and Psychiatry, Neurology Unit , 'Sapienza' University , Rome , Italy
| | - Angelo Labate
- b Institute of Neurology , University Magna Graecia of Catanzaro , Catanzaro , Italy.,c Institute of Molecular Bioimaging and Physiology of the National Research Council , Catanzaro , Italy
| | - Marta Maschio
- d Center for Tumor-related Epilepsy, UOSD Neurology , Regina Elena National Cancer Institute , Rome , Italy
| | - Stefano Meletti
- e Department of Biomedical, Metabolic and Neural Sciences, Center for Neuroscience and Neurotechnology , University of Modena and Reggio Emilia , Modena , Italy
| | - Emilio Russo
- f Department of Science of Health, School of Medicine and Surgery , University 'Magna Graecia' of Catanzaro , Catanzaro , Italy
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Alshehri A, Abulaban A, Bokhari R, Kojan S, Alsalamah M, Ferwana M, Murad MH. Intravenous Versus Nonintravenous Benzodiazepines for the Cessation of Seizures: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Acad Emerg Med 2017; 24:875-883. [PMID: 28342192 DOI: 10.1111/acem.13190] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 02/16/2017] [Accepted: 02/18/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND The acquisition of intravenous (IV) access in the actively convulsing patient is difficult. This often delays the administration of the IV benzodiazepine (BDZ) necessary for seizure cessation. Delays in seizure cessation are associated with increased pharmacoresistance, increased risk of neuronal injury, worse patient outcomes, and increased morbidity. OBJECTIVE The objective was to assess whether the delay imposed by IV access acquisition is justified by improved outcomes. We compared IV versus non-IV BDZ efficacy in the real world with regard to failure rates (primary outcome), interval to seizure control, and observed complications (secondary outcomes). METHODS A systematic review was performed using Medline, Embase, and the Cochrane Library. All studies published or in press from the inception of the respective database to July 2016 were included. Only randomized and quasi-randomized controlled trials directly comparing IV to non-IV (buccal, rectal, intranasal, or intramuscular) BDZ were included. RESULTS Our search strategy retrieved 2,604 citations for review. A total of 11 studies were finally included in qualitative synthesis and 10 in quantitative analysis. Only one was of high quality. For treatment failure, non-IV BDZ was superior to IV BDZ (odd ratio [OR] = 0.72; 95% confidence interval [CI] = 0.56-0.92). However, no significant difference was found between the two treatments in the pediatric subgroup (OR = 1.16; 95% CI = 0.74-1.81). Non-IV BDZ was administered faster than IV BDZ and therefore controlled seizures faster (mean difference = 3.41 minutes; 95% CI = 1.69-5.13 minutes) despite a longer interval between drug administration and seizure cessation (mean difference = 0.74 minutes; 95% CI = 0.52-0.95 minutes). Respiratory complications requiring intervention were similar between non-IV BDZ and IV BDZ, regardless of administration route (risk difference = 0.00; 95% CI = -0.02 to 0.01). CONCLUSION Non-IV BDZ, compared to IV BDZ, terminate seizures faster and have a superior efficacy and side effect profile. Higher-quality studies and further evaluation in different age groups are warranted.
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Affiliation(s)
- Abdussalam Alshehri
- Department of Emergency Medicine; King Saud Medical City; Riyadh Saudi Arabia
| | - Ahmad Abulaban
- Department of Neurology; King Abdulaziz Medical City; Riyadh Saudi Arabia
| | - Rakan Bokhari
- Division of Neurosurgery; King Abdulaziz University; Jeddah Saudi Arabia
| | - Suleiman Kojan
- Department of Neurology; King Abdulaziz Medical City; Riyadh Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences; Riyadh Saudi Arabia
| | - Majid Alsalamah
- Department of Emergency Medicine; King Abdulaziz Medical City; Riyadh Saudi Arabia
- College of Public Health and Health Informatics; King Abdulaziz Medical City; Riyadh Saudi Arabia
| | - Mazen Ferwana
- Department of Family Medicine and Primary Health Care; King Abdulaziz Medical City; Riyadh Saudi Arabia
- King Saud bin Abdulaziz University for Health Sciences; Riyadh Saudi Arabia
| | - Mohammad Hassan Murad
- Department of Internal Medicine; Knowledge and Evaluation Research Unit; Mayo Clinic; Rochester MN
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Wu T, Ido K, Osada Y, Kotani S, Tamaoka A, Hanada T. The neuroprotective effect of perampanel in lithium-pilocarpine rat seizure model. Epilepsy Res 2017. [PMID: 28624183 DOI: 10.1016/j.eplepsyres.2017.06.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Status epilepticus (SE) causes irreversible neurodegeneration if not terminated quickly. Perampanel (PER), a potent AMPA receptor antagonist, has previously been shown to terminate seizures in the lithium-pilocarpine SE model. In the present study, we assessed whether PER would also prevent neuronal damage in this model. METHODS SE was induced in rats using lithium chloride and pilocarpine. Initiation of SE was defined as continuous seizures that exhibited as rearing accompanied by bilateral forelimb clonus (Racine score 4). Either PER (0.6, 2, or 6mg/kg) or diazepam (DZP, 10mg/kg) was administered intravenously 30min after SE initiation. Histopathological samples from treated and seizure-naive rats were taken one week after treatment and then stained with an anti-neuronal nuclei (NeuN) antibody. The sections were analyzed by using a pixel-counting algorithm to quantify the amount of staining in the CA1 subregion of the hippocampus, piriform cortex (Pir), and mediodorsal thalamic nucleus (MD). RESULTS DZP administration did not suppress seizures or the degeneration of neurons in the examined areas. Seizures were terminated in 100% of rats treated with 6mg/kg PER (n=8) and in 47% (7/15) of rats treated with 2mg/kg PER, and neurons in the analyzed areas of these animals were preserved to the level seen in naive rats. In the eight animals in which 2mg/kg PER did not terminate the seizures, neuronal loss was partially attenuated in CA1 and Pir, and neurons were fully preserved in MD. Treatment with 0.6mg/kg PER did not terminate the seizures or significantly preserve neurons. The anti-seizure effect of PER correlated well with the degree of neuroprotection in each analyzed area. CONCLUSIONS PER exhibited a strong neuroprotective effect in a drug-refractory SE model, and this effect was correlated with its attenuation of seizure.
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Affiliation(s)
- Ting Wu
- Neurology, Tsukuba Research Department, Discovery, Medicine Creation, Neurology Business Group, Eisai Co., Ltd., Japan; Clinical Sciences, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Japan.
| | - Katsutoshi Ido
- Neurology, Tsukuba Research Department, Discovery, Medicine Creation, Neurology Business Group, Eisai Co., Ltd., Japan
| | - Yoshihide Osada
- Neurology, Tsukuba Research Department, Discovery, Medicine Creation, Neurology Business Group, Eisai Co., Ltd., Japan
| | - Sadaharu Kotani
- Neurology, Tsukuba Research Department, Discovery, Medicine Creation, Neurology Business Group, Eisai Co., Ltd., Japan
| | - Akira Tamaoka
- Institute of Clinical Medicine, Department of Neurology, University of Tsukuba, Japan
| | - Takahisa Hanada
- Neurology, Tsukuba Research Department, Discovery, Medicine Creation, Neurology Business Group, Eisai Co., Ltd., Japan
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25
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Dulin JD, Noreika DM, Coyne PJ. Management of refractory status epilepticus in an actively dying patient. J Pain Palliat Care Pharmacother 2014; 28:243-50. [PMID: 25166773 DOI: 10.3109/15360288.2014.941129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
No consensus guidelines exist for the treatment of refractory myoclonic status epilepticus or refractory myoclonus in the palliative care setting. Evidence-based guidelines for the general medical population are often neither practical nor applicable at the end of life. Many challenges, including medication availability, route of administration, monitoring, and work-up are all unique to the palliative care setting. Two patients with refractory myoclonus versus refractory myoclonic status epilepticus are described here, illustrating the challenges involved in treatment as well the need for further research for therapy in the palliative care setting.
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Hanada T, Ido K, Kosasa T. Effect of perampanel, a novel AMPA antagonist, on benzodiazepine-resistant status epilepticus in a lithium-pilocarpine rat model. Pharmacol Res Perspect 2014; 2:e00063. [PMID: 25505607 PMCID: PMC4186423 DOI: 10.1002/prp2.63] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 06/17/2014] [Accepted: 06/24/2014] [Indexed: 12/15/2022] Open
Abstract
This study assessed the efficacy of diazepam, and the alpha-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA) receptor antagonists perampanel and GYKI52466 in a lithium-pilocarpine status epilepticus (SE) model. SE was induced in rats using lithium chloride, scopolamine methyl bromide, and pilocarpine. Diazepam 10, 20, or 40 mg kg−1, or perampanel 1, 2.5, 5, or 8 mg kg−1 were administered intravenously at 10 or 30 min after seizure onset, and GYKI52466 50 mg kg−1, or combinations of diazepam 2.5–5 mg kg−1 and perampanel 0.5–1 mg kg−1, were administered intravenously at 30 min after seizure onset. Diazepam 20 mg kg−1 terminated seizures (based on electroencephalography and assessment of behavioral seizures) in 2/6 rats at 10 min and 0/6 rats at 30 min (ED50: 10 min, 30 mg kg−1; 30 min, not determined). Perampanel 8 mg kg−1 terminated seizures in 6/6 rats at both 10 and 30 min (ED50: 10 min 1.7 mg kg−1; 30 min, 5.1 mg kg−1). GYKI52466 50 mg kg−1 terminated seizures in 2/4 rats at 30 min. Co-administration of diazepam 5 mg kg−1 and perampanel 1 mg kg−1 terminated seizures in 9/9 rats at 30 min. In conclusion, perampanel and GYKI52466 provided efficacy in a lithium-pilocarpine SE model at 30 min after seizure onset, when SE was refractory to diazepam, supporting the therapeutic potential of AMPA receptor antagonists for refractory SE. The perampanel dose required to terminate seizures was reduced by combination with diazepam, suggesting synergy.
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Affiliation(s)
- Takahisa Hanada
- Global Biopharmacology, Neuroscience & General Medicine Product Creation System, Eisai Co., Ltd Tsukuba, Ibaraki, Japan ; Center for Tsukuba Advanced Research Alliance, Graduate School of Life and Environmental Sciences, University of Tsukuba Tsukuba, Ibaraki, Japan
| | - Katsutoshi Ido
- Global Biopharmacology, Neuroscience & General Medicine Product Creation System, Eisai Co., Ltd Tsukuba, Ibaraki, Japan
| | - Takashi Kosasa
- Global Biopharmacology, Neuroscience & General Medicine Product Creation System, Eisai Co., Ltd Tsukuba, Ibaraki, Japan
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Yasiry Z, Shorvon SD. The relative effectiveness of five antiepileptic drugs in treatment of benzodiazepine-resistant convulsive status epilepticus: a meta-analysis of published studies. Seizure 2013; 23:167-74. [PMID: 24433665 DOI: 10.1016/j.seizure.2013.12.007] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 12/14/2013] [Accepted: 12/16/2013] [Indexed: 01/29/2023] Open
Abstract
PURPOSE Systematic evaluation of published evidence-base of the efficacy of five antiepileptic drugs - lacosamide, levetiracetam, valproate, phenytoin and phenobarbital - in convulsive benzodiazepine-resistant status epilepticus. METHODS Data sources included electronic databases, personal communication, and back tracing of references in pertinent studies. These were prospective and retrospective human studies presenting original data for participants with convulsive benzodiazepine-resistant status epilepticus. Interventions were intravenous lacosamide, levetiracetam, phenobarbital, phenytoin and valproate. Outcome measured is clinically detectable cessation of seizure activity. Level-of-evidence was assessed according to Oxford Centre of Evidence-Based Medicine and The Cochrane Collaboration's Tool for Assessment of Risk. Twenty seven studies (798 cases of convulsive status epilepticus) were identified and 22 included in a meta-analysis. Random-effects analysis of dichotomous outcome of a single group estimate (proportion), with inverse variance weighting, was implemented. Several sources of clinical and methodological heterogeneity were identified. RESULTS Efficacy of levetiracetam was 68.5% (95% CI: 56.2-78.7%), phenobarbital 73.6% (95% CI: 58.3-84.8%), phenytoin 50.2% (95% CI: 34.2-66.1%) and valproate 75.7% (95% CI: 63.7-84.8%). Lacosamide studies were excluded from the meta-analysis due to insufficient data. CONCLUSION Valproate, levetiracetam and phenobarbital can all be used as first line therapy in benzodiazepine-resistant status epilepticus. The evidence does not support the first-line use of phenytoin. There is not enough evidence to support the routine use of lacosamide. Randomized controlled trials are urgently needed.
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Affiliation(s)
- Zeid Yasiry
- Department of Medicine, University of Babylon/College of Medicine, Babil, Iraq.
| | - Simon D Shorvon
- Department of Clinical and Experimental Epilepsy, UCL Institute of Neurology, London, UK
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Sánchez Fernández I, Abend NS, Agadi S, An S, Arya R, Carpenter JL, Chapman KE, Gaillard WD, Glauser TA, Goldstein DB, Goldstein JL, Goodkin HP, Hahn CD, Heinzen EL, Mikati MA, Peariso K, Pestian JP, Ream M, Riviello JJ, Tasker RC, Williams K, Loddenkemper T. Gaps and opportunities in refractory status epilepticus research in children: a multi-center approach by the Pediatric Status Epilepticus Research Group (pSERG). Seizure 2013; 23:87-97. [PMID: 24183923 PMCID: PMC6387832 DOI: 10.1016/j.seizure.2013.10.004] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 10/07/2013] [Accepted: 10/09/2013] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Status epilepticus (SE) is a life-threatening condition that can be refractory to initial treatment. Randomized controlled studies to guide treatment choices, especially beyond first-line drugs, are not available. This report summarizes the evidence that guides the management of refractory convulsive SE (RCSE) in children, defines gaps in our clinical knowledge and describes the development and works of the 'pediatric Status Epilepticus Research Group' (pSERG). METHODS A literature review was performed to evaluate current gaps in the pediatric SE and RCSE literature. In person and online meetings helped to develop and expand the pSERG network. RESULTS The care of pediatric RCSE is largely based on extrapolations of limited evidence derived from adult literature and supplemented with case reports and case series in children. No comparative effectiveness trials have been performed in the pediatric population. Gaps in knowledge include risk factors for SE, biomarkers of SE and RCSE, second- and third-line treatment options, and long-term outcome. CONCLUSION The care of children with RCSE is based on limited evidence. In order to address these knowledge gaps, the multicenter pSERG was established to facilitate prospective collection, analysis, and sharing of de-identified data and biological specimens from children with RCSE. These data will allow identification of treatment strategies associated with better outcomes and delineate evidence-based interventions to improve the care of children with SE.
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Affiliation(s)
- Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States; Department of Child Neurology, Hospital Sant Joan de Déu, University of Barcelona, Spain
| | - Nicholas S Abend
- Division of Neurology, The Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Satish Agadi
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Sookee An
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Ravindra Arya
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
| | - Jessica L Carpenter
- Department of Epilepsy, Neurophysiology, and Critical Care Neurology, The Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Kevin E Chapman
- Department of Pediatrics and Neurology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States
| | - William D Gaillard
- Department of Epilepsy, Neurophysiology, and Critical Care Neurology, The Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Tracy A Glauser
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
| | - David B Goldstein
- Center for Human Genome Variation, Duke University Medical Center, Duke University, Durham, NC, United States
| | - Joshua L Goldstein
- Division of Neurology, Department of Pediatrics, Ann & Robert Lurie's Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Howard P Goodkin
- Department of Neurology and Department of Pediatrics, The University of Virginia Health System, Charlottesville, VA, United States
| | - Cecil D Hahn
- Division of Neurology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Erin L Heinzen
- Center for Human Genome Variation, Duke University Medical Center, Duke University, Durham, NC, United States
| | - Mohamad A Mikati
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, NC, United States
| | - Katrina Peariso
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
| | - John P Pestian
- Comprehensive Epilepsy Center, Division of Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
| | - Margie Ream
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, NC, United States
| | - James J Riviello
- Division of Pediatric Neurology, Department of Neurology, New York University Langone Medical Center, New York University School of Medicine, New York, NY, United States
| | - Robert C Tasker
- Department of Neurology, Department of Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Korwyn Williams
- Division of Pediatric Neurology, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States.
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Mayette M, Gonda J, Hsu JL, Mihm FG. Propofol infusion syndrome resuscitation with extracorporeal life support: a case report and review of the literature. Ann Intensive Care 2013; 3:32. [PMID: 24059786 PMCID: PMC3850887 DOI: 10.1186/2110-5820-3-32] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 09/03/2013] [Indexed: 02/03/2023] Open
Abstract
We report a case of propofol infusion syndrome (PRIS) in a young female treated for status epilepticus. In this case, PRIS rapidly evolved to full cardiovascular collapse despite aggressive supportive care in the intensive care unit, as well as prompt discontinuation of the offending agent. She progressed to refractory cardiac arrest requiring emergent initiation of venoarterial extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR). She regained a perfusing rhythm after prolonged (>8 hours) asystole, was weaned off ECMO and eventually all life support, and was discharged to home. We also present a review of the available literature on the use of ECMO for PRIS.
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Affiliation(s)
- Michael Mayette
- Divisions of Pulmonary and Critical Care Medicine, Critical Care Medicine and Anesthesia, Stanford University School of Medicine, Stanford, CA 94305, USA.
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30
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Douglas VC, Josephson SA. A proposed roadmap for inpatient neurology quality indicators. Neurohospitalist 2013; 1:8-15. [PMID: 23983832 DOI: 10.1177/1941875210380676] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND/PURPOSE In recent years, there has been increasing pressure to measure and report quality in health care. However, there has been little focus on quality measurement in the field of neurology for conditions other than stroke and transient ischemic attack. As the number of evidence-based treatments for neurological conditions grows, so will the demand to measure the quality of care delivered. The purpose of this study was to review essential components of hospital performance measures for neurological disease and propose potential quality indicators for commonly encountered inpatient neurological diagnoses. METHODS We determined the most common inpatient neurological diagnoses at a major tertiary care medical center by reviewing the billing database. We then searched PubMed and the National Guidelines Clearinghouse to identify treatment guidelines for these conditions. Guideline recommendations with class I/level A evidence were evaluated as possible quality indicators. RESULTS We found 94 guidelines for 14 inpatient neurological conditions other than stroke and transient ischemic attack. Of these, 36 guidelines contained at least 1 recommendation with class I evidence. Based on these, potential quality indicators for intracerebral hemorrhage, subarachnoid hemorrhage, pneumococcal meningitis, coma following cardiac arrest, encephalitis, Guillain-Barre syndrome, multiple sclerosis, and benign paroxysmal positional vertigo are proposed. CONCLUSIONS There are several inpatient neurological conditions with treatments or diagnostic test routines supported by high levels of evidence that could be used in the future as quality indicators.
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Affiliation(s)
- Vanja C Douglas
- University of California, San Francisco, Department of Neurology
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Tawfiq RA, Nassar NN, El-Eraky WI, El-Denshary ES. Enhanced efficacy and reduced side effects of diazepam by kava combination. J Adv Res 2013; 5:587-94. [PMID: 25685527 PMCID: PMC4294317 DOI: 10.1016/j.jare.2013.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 07/18/2013] [Accepted: 08/15/2013] [Indexed: 11/29/2022] Open
Abstract
The long term use of antiepileptic drugs possesses many unwanted effects; thus, new safe combinations are urgently mandated. Hence, the present study aimed to investigate the anticonvulsant effect of kava alone or in combination with a synthetic anticonvulsant drug, diazepam (DZ). To this end, female Wistar rats were divided into two subsets, each comprising 6 groups as follows: group (i) received 1% Tween 80 p.o. and served as control, while groups (ii) and (iii) received kava at two dose levels (100 and 200 mg/kg, p.o.). The remaining three groups received (iv) DZ alone (10 mg/kg p.o.) or kava in combination with DZ (v) (5 mg/kg, p.o.) or (vi) (10 mg/kg, p.o.). Results of the present study revealed that kava increased the maximal electroshock seizure threshold (MEST) and enhanced the anticonvulsant effect of diazepam following both acute and chronic treatment. Moreover, neither kava nor its combination with DZ impaired motor co-ordination either acutely or chronically. Furthermore, kava ameliorated both the reduction in locomotor activity as well as changes in liver function tests induced by chronic administration of DZ. Moreover, no elevation was shown in the creatinine concentration vs. control group following chronic administration of kava or DZ either alone or in combination with kava. In conclusion, the present study suggests the possibility of combining a low dose DZ with kava to reduce harmful effects and might be recommended for clinical use in patients chronically treated with this synthetic anticonvulsant drug.
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Key Words
- AED, antiepileptic drug
- ALP, alkaline phosphatase
- ALT, alanine transaminase
- AST, aspartate transaminase
- Anticonvulsant
- BDZ, benzodiazepine
- DZ, diazepam
- Diazepam
- ECT, electroconvulsive treatment
- FDA, Food and Drug Administration
- GABA, γ-aminobutyric acid
- GABAA, γ-aminobutyric acid type A
- Kava
- Locomotor activity
- MEST
- MEST, maximal electroshock threshold
- OTC, over the counter
- WHO, World Health Organization
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Affiliation(s)
- Rasha A Tawfiq
- Egyptian Patent Office, Academy of Scientific Research and Technology, 101 Kasr El-Eini St., Cairo, Egypt
| | - Noha N Nassar
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Cairo University, Kasr El-Eini St., Cairo, Egypt
| | - Wafaa I El-Eraky
- Department of Pharmacology, National Research Center, El-Tahrir St., Giza, Egypt
| | - Ezzeldein S El-Denshary
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Cairo University, Kasr El-Eini St., Cairo, Egypt
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Tiamkao S, Sawanyawisuth K, Chancharoen A. The efficacy of intravenous sodium valproate and phenytoin as the first-line treatment in status epilepticus: a comparison study. BMC Neurol 2013; 13:98. [PMID: 23889906 PMCID: PMC3727978 DOI: 10.1186/1471-2377-13-98] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 07/26/2013] [Indexed: 11/15/2022] Open
Abstract
Background Status epilepticus (SE) is a serious neurological condition and requires prompt treatment. Sodium valproate has been used to treat SE successfully but its role as the first-line antiepileptic drug (AED) is still controversial. This study evaluated the efficacy of intravenous sodium valproate to determine if it is non-inferior to intravenous phenytoin in SE treatment. Methods Patients diagnosed as SE during 2003–2010 who were of an age of more than 15 years and received either intravenous sodium valproate or intravenous phenytoin as the first-line treatment were enrolled. Clinical characteristics and outcomes of SE were recorded and analyzed. The differences of outcomes between sodium valproate and phenytoin group were determined by descriptive statistics. Results During the study period, there were 37 and 17 SE patients who received intravenous phenytoin and intravenous sodium valproate as the first-line treatment, respectively. All patients received diazepam 10 mg intravenously as a rescue medication before starting the antiepileptic agents if uncontrolled except one patient in the sodium valproate group. There were no significant differences between the phenytoin and sodium valproate groups in all outcome variables including numbers of patients with clinically-controlled seizures, non-dependent patients, time to seizure control, and duration of hospitalization, and death. No serious cardiovasculars event such as hypotension occurred in either group. Conclusion Intravenous sodium valproate is non-inferior to intravenous phenytoin as the first-line treatment in SE with no significant cardiovascular compromises.
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Affiliation(s)
- Somsak Tiamkao
- Integrated Epilepsy Research Group, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
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RSE prediction by EEG patterns in adult GCSE patients. Epilepsy Res 2013; 105:174-82. [DOI: 10.1016/j.eplepsyres.2013.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 01/24/2013] [Accepted: 02/16/2013] [Indexed: 11/22/2022]
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Dorandeu F, Dhote F, Barbier L, Baccus B, Testylier G. Treatment of status epilepticus with ketamine, are we there yet? CNS Neurosci Ther 2013; 19:411-27. [PMID: 23601960 PMCID: PMC6493567 DOI: 10.1111/cns.12096] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 02/23/2013] [Accepted: 02/23/2013] [Indexed: 12/24/2022] Open
Abstract
Status epilepticus (SE), a neurological emergency both in adults and in children, could lead to brain damage and even death if untreated. Generalized convulsive SE (GCSE) is the most common and severe form, an example of which is that induced by organophosphorus nerve agents. First- and second-line pharmacotherapies are relatively consensual, but if seizures are still not controlled, there is currently no definitive data to guide the optimal choice of therapy. The medical community seems largely reluctant to use ketamine, a noncompetitive antagonist of the N-methyl-d-aspartate glutamate receptor. However, a review of the literature clearly shows that ketamine possesses, in preclinical studies, antiepileptic properties and provides neuroprotection. Clinical evidences are scarcer and more difficult to analyze, owing to a use in situations of polytherapy. In absence of existing or planned randomized clinical trials, the medical community should make up its mind from well-conducted preclinical studies performed on appropriate models. Although potentially active, ketamine has no real place for the treatment of isolated seizures, better accepted drugs being used. Its best usage should be during GCSE, but not waiting for SE to become totally refractory. Concerns about possible developmental neurotoxicity might limit its pediatric use for refractory SE.
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Affiliation(s)
- Frederic Dorandeu
- Département de Toxicologie et risques chimiques, Institut de Recherche Biomédicale des Armées - Centre de Recherches du Service de Santé des Armées (IRBA-CRSSA), La Tronche Cedex, France.
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Bolt J, Gorman SK. Precision, Bias, and Clinical Utility of the Sheiner-Tozer Equation to Guide Phenytoin Dosing in Critically Ill Adults. J Clin Pharmacol 2013; 53:451-5. [DOI: 10.1002/jcph.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 07/15/2012] [Indexed: 11/10/2022]
Affiliation(s)
- Jennifer Bolt
- Pharmacy Services; Interior Health Authority; #200-1835 Gordon Dr.; Kelowna, BC V1Y3H5
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Ferguson M, Bianchi MT, Sutter R, Rosenthal ES, Cash SS, Kaplan PW, Westover MB. Calculating the risk benefit equation for aggressive treatment of non-convulsive status epilepticus. Neurocrit Care 2013; 18:216-27. [PMID: 23065689 PMCID: PMC3767472 DOI: 10.1007/s12028-012-9785-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To address the question: does non-convulsive status epilepticus warrant the same aggressive treatment as convulsive status epilepticus? METHODS We used a decision model to evaluate the risks and benefits of treating non-convulsive status epilepticus with intravenous anesthetics and ICU-level aggressive care. We investigated how the decision to use aggressive versus non-aggressive management for non-convulsive status epilepticus impacts expected patient outcome for four etiologies: absence epilepsy, discontinued antiepileptic drugs, intraparenchymal hemorrhage, and hypoxic ischemic encephalopathy. Each etiology was defined by distinct values for five key parameters: baseline mortality rate of the inciting etiology; efficacy of non-aggressive treatment in gaining control of seizures; the relative contribution of seizures to overall mortality; the degree of excess disability expected in the case of delayed seizure control; and the mortality risk of aggressive treatment. RESULTS Non-aggressive treatment was favored for etiologies with low morbidity and mortality such as absence epilepsy and discontinued antiepileptic drugs. The risk of aggressive treatment was only warranted in etiologies where there was significant risk of seizure-induced neurologic damage. In the case of post-anoxic status epilepticus, expected outcomes were poor regardless of the treatment chosen. The favored strategy in each case was determined by strong interactions of all five model parameters. CONCLUSIONS Determination of the optimal management approach to non-convulsive status epilepticus is complex and is ultimately determined by the inciting etiology.
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Affiliation(s)
- Matthew Ferguson
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA
| | - Matt T. Bianchi
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA
| | - Raoul Sutter
- Division of Neurosciences Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Neurology, Johns Hopkins Bayview Medical, Center, Baltimore, MD, USA
| | - Eric S. Rosenthal
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA
| | - Sydney S. Cash
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA
| | - Peter W. Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical, Center, Baltimore, MD, USA
| | - M. Brandon Westover
- Department of Neurology, Massachusetts general Hospital, Boston, MA, USA; Wang 7 Neurology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Dorandeu F, Barbier L, Dhote F, Testylier G, Carpentier P. Ketamine combinations for the field treatment of soman-induced self-sustaining status epilepticus. Review of current data and perspectives. Chem Biol Interact 2013; 203:154-9. [DOI: 10.1016/j.cbi.2012.09.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 09/25/2012] [Accepted: 09/26/2012] [Indexed: 12/21/2022]
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Abstract
PURPOSE OF REVIEW To review recent clinical data and summarize actual recommendations for the management of electrographic seizures and status epilepticus in neuro-ICU patients. RECENT FINDINGS Electrographic, 'nonconvulsive', seizures are frequent in neuro-ICU patients including traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage and hypoxic-ischemic encephalopathy. Continuous electroencephalography monitoring is thus of great potential utility. The impact of electrographic seizures on outcome however is not entirely established and it is also unclear what type of electroencephalography paroxysms require treatment and when and how exactly to treat them. Evidence from randomized studies is lacking and will not be available in the near future. Given robust animal and human evidence showing the potential negative impact of seizures on secondary cerebral damage and outcome, treatment of seizures appears reasonable, particularly if related to status epilepticus. On the contrary, over-aggressive antiepileptic therapy entails risks. The management of seizures should therefore be guided individually, based on the underlying cause, the severity of illness and patient comorbidities. SUMMARY We provide a pragmatic approach for the management of electrographic seizures in neuro-ICU patients. International consensus guidelines on continuous electroencephalography monitoring and seizure therapy are needed and would represent the rationale for a future multicenter randomized trial.
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Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ, Shutter L, Sperling MR, Treiman DM, Vespa PM. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17:3-23. [PMID: 22528274 DOI: 10.1007/s12028-012-9695-z] [Citation(s) in RCA: 998] [Impact Index Per Article: 83.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Status epilepticus (SE) treatment strategies vary substantially from one institution to another due to the lack of data to support one treatment over another. To provide guidance for the acute treatment of SE in critically ill patients, the Neurocritical Care Society organized a writing committee to evaluate the literature and develop an evidence-based and expert consensus practice guideline. Literature searches were conducted using PubMed and studies meeting the criteria established by the writing committee were evaluated. Recommendations were developed based on the literature using standardized assessment methods from the American Heart Association and Grading of Recommendations Assessment, Development, and Evaluation systems, as well as expert opinion when sufficient data were lacking.
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Affiliation(s)
- Gretchen M Brophy
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University, Medical College of Virginia Campus, 410 N. 12th Street, P.O. Box 980533, Richmond, VA 23298-0533, USA.
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Pouliot W, Bialer M, Hen N, Shekh-Ahmad T, Kaufmann D, Yagen B, Ricks K, Roach B, Nelson C, Dudek FE. A comparative electrographic analysis of the effect of sec-butyl-propylacetamide on pharmacoresistant status epilepticus. Neuroscience 2012; 231:145-56. [PMID: 23159312 DOI: 10.1016/j.neuroscience.2012.11.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2012] [Accepted: 11/03/2012] [Indexed: 01/10/2023]
Abstract
Better treatment of status epilepticus (SE), which typically becomes refractory after about 30 min, will require new pharmacotherapies. The effect of sec-butyl-propylacetamide (SPD), an amide derivative of valproic acid (VPA), on electrographic status epilepticus (ESE) was compared quantitatively to other standard-of-care compounds. Cortical electroencephalograms (EEGs) were recorded from rats during ESE induced with lithium-pilocarpine. Using a previously-published algorithm, the effects of SPD on ESE were compared quantitatively to other relevant compounds. To confirm benzodiazepine resistance, diazepam (DZP) was shown to suppress ESE when administered 15 min after the first motor seizure, but not after 30 min (100mg/kg). VPA (300 mg/kg) also lacked efficacy at 30 min. SPD (130 mg/kg) strongly suppressed ESE at 30 min, less after 45 min, and not at 60 min. At a higher dose (180 mg/kg), SPD profoundly suppressed ESE at 60 min, similar to propofol (100mg/kg) and pentobarbital (30 mg/kg). After 4-6h of SPD-induced suppression, EEG activity often overshot control levels at 7-12h. Valnoctamide (VCD, 180 mg/kg), an SPD homolog, was also efficacious at 30 min. SPD blocks pilocarpine-induced electrographic seizures when administered at 1h after the first motor seizure. SPD has a faster onset and greater efficacy than DZP and VPA, and is similar to propofol and pentobarbital. SPD and structurally similar compounds may be useful for the treatment of refractory ESE. Further development and use of automated analyses of ESE may facilitate drug discovery for refractory SE.
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Affiliation(s)
- W Pouliot
- Department of Physiology, University of Utah School of Medicine, Salt Lake City, UT, USA
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A consensus-based approach to patient safety in epilepsy monitoring units: recommendations for preferred practices. Epilepsy Behav 2012; 25:449-56. [PMID: 22999858 DOI: 10.1016/j.yebeh.2012.07.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 07/14/2012] [Indexed: 11/21/2022]
Abstract
Patients in an epilepsy monitoring unit (EMU) with video-EEG telemetry have a risk for seizure emergencies, injuries and adverse events, which emphasizes the need for strategies to prevent avoidable harm. An expert consensus process was used to establish recommendations for patient safety in EMUs. Workgroups analyzed literature and expert opinion regarding seizure observation, seizure provocation, acute seizures, and activity/environment. A Delphi methodology was used to establish consensus for items submitted by these workgroups. Fifty-three items reached consensus and were organized into 30 recommendations. High levels of agreement were noted for items pertaining to orientation, training, communication, seizure precautions, individualized plans, and patient/family education. It was agreed that seizure observation should include direct observation or use of closed-circuit camera. The use of continuous observation was strongest in patients with invasive electrodes, at high risk for injury, or undergoing AED withdrawal. This process provides a first step in establishing EMU safety practices.
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Seif-Eddeine H, Treiman DM. Problems and controversies in status epilepticus: a review and recommendations. Expert Rev Neurother 2012; 11:1747-58. [PMID: 22091598 DOI: 10.1586/ern.11.160] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Status epilepticus (SE) is a neurologic emergency that require immediate vigorous treatment in order to prevent serious morbidity or even death. Several investigators have suggested that the underlying etiology is the primary determinant of outcome. We believe that this may be true in aggressively treated SE, but not when the treatment is less than optimal. In this article, we will discuss the factors that have been implicated in affecting SE outcomes, and argue, on the basis of both human and experimental animal data, that aggressive treatment is necessary and appropriate for all presentations of SE in order to maximize the probability of a successful outcome even when the etiology suggests a poor prognosis.
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Affiliation(s)
- Hussam Seif-Eddeine
- Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ 85013, USA
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Abstract
Cocaine, a natural alkaloid derived from the coca plant, is one of the most commonly abused illicit drugs. Cocaine is commonly abused by inhalation, nasal insufflation, and intravenous injection, resulting in many adverse effects that ensue from local anesthetic, vasoconstrictive, sympathomimetic, psychoactive, and prothrombotic mechanisms. Cocaine can affect all body systems and the clinical presentation may primarily result from organ toxicity. Among the most severe complications are seizures, hemorrhagic and ischemic strokes, myocardial infarction, aortic dissection, rhabdomyolysis, mesenteric ischemia, acute renal injury and multiple organ failure.
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Affiliation(s)
- Janice L Zimmerman
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
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Eagleson JS, Platt SR, Strong DLE, Kent M, Freeman AC, Nghiem PP, Zheng B, White CA. Bioavailability of a novel midazolam gel after intranasal administration in dogs. Am J Vet Res 2012; 73:539-45. [PMID: 22452501 DOI: 10.2460/ajvr.73.4.539] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare the pharmacokinetics of a novel bioadhesive gel formulation of midazolam after intranasal (IN) administration with that of midazolam solution after IN, IV, and rectal administration to dogs. ANIMALS 10 (5 males and 5 females) healthy adult Beagles. PROCEDURES Dogs were assigned to 4 treatment groups for a crossover study design. Initially, midazolam solution (5 mg/mL) was administered (0.2 mg/kg) IV to group 1, rectally to group 2, and IN to group 3; a 0.4% hydroxypropyl methylcellulose midazolam gel formulation (50 mg/mL) was administered (0.2 mg/kg, IN) to group 4. Each dog received all 4 treatments; there was a 7-day washout period between subsequent treatments. Blood samples were collected before and after midazolam administration. Plasma concentration of midazolam was determined by use of high-performance liquid chromatography. RESULTS The peak plasma concentration after IN administration of the gel formulation was significantly higher than that after IN and rectal administration of the solution. Mean ± SD time to peak concentration was 11.70 ± 2.63 minutes (gel IN), 17.50 ± 2.64 minutes (solution IN), and 39 ± 14.49 minutes (solution rectally). Mean bioavailability of midazolam was 70.4% (gel IN), 52.0% (solution IN), and 49.0% (solution rectally). Bioavailability after IN administration of the gel formulation was significantly higher than that after IN and rectal administration of the solution. CONCLUSIONS AND CLINICAL RELEVANCE IN administration of midazolam gel was superior to both IN and rectal administration of midazolam solution with respect to peak plasma concentration and bioavailability.
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Affiliation(s)
- Joseph S Eagleson
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA 30602, USA.
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Abstract
This article reviews the evidence regarding the use of phenytoin in adult and paediatric patients experiencing seizures in the ED in Australasia, including relevant pharmacokinetics, dosage, therapeutic drug monitoring and methods of administration. It summarizes current evidence regarding the use of phenytoin in a number of seizure types commonly seen in ED. A search of Medline, Embase and Cochrane was performed using appropriate keyword and MeSH headings. A loading dose of phenytoin should be given to phenytoin naïve patients for the emergency treatment of seizures; parenteral administration results in therapeutic concentration sooner than oral administration but is associated with more frequent and significant adverse effects. Diluting phenytoin is safe but there is limited evidence regarding adverse effects of diluted phenytoin; a filter is probably not needed. Free phenytoin concentrations correlate best with antiseizure efficacy. Phenytoin is used in the treatment of status epilepticus although evidence here is limited; it may also be given to prevent early post-traumatic seizures. It should not be given to treat or prevent eclamptic or alcohol-related seizures. There is insufficient evidence regarding its use in preventing febrile convulsions, treating or preventing seizures due to space occupying lesions or intracerebral haemorrhage and thrombosis. In conclusion, phenytoin is appropriate for treatment of some seizures seen in the ED; it is associated with significant adverse effects; trials are ongoing regarding the use of other anticonvulsants in the treatment of status epilepticus.
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Affiliation(s)
- Katharine Gallop
- Gold Coast Hospital, Southport Campus-Emergency Medicine, Southport, Queensland, Australia.
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Shorvon S, Ferlisi M. The outcome of therapies in refractory and super-refractory convulsive status epilepticus and recommendations for therapy. Brain 2012; 135:2314-28. [DOI: 10.1093/brain/aws091] [Citation(s) in RCA: 255] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Mastrangelo M, Celato A. Diagnostic work-up and therapeutic options in management of pediatric status epilepticus. World J Pediatr 2012; 8:109-15. [PMID: 22573420 DOI: 10.1007/s12519-012-0348-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 02/06/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Status epilepticus (SE) is a life-threatening neurologic disorder comprising prolonged and unremitting crisis, and two or more series of seizures without complete intercritical recovery. DATA SOURCES We reviewed the literature through a Pubmed/Medline research using key words including status epilepticus, antiepileptic drugs and children, in order to revise and compare international/national protocols and to examine pediatric guidelines in SE management. RESULTS Neurologic impairment and SE etiology seem to be the most independent risks for mortality. A deep semiologic evaluation is essential to addressing diagnostic work-up. Ematochemical parameters, plasma levels of antiepileptic drugs and clinically oriented toxic/metabolic screening should be mandatory for investigating both causes and effects of SE. Electroencephalography is clearly helpful to characterize focal from generalized SE and to distinguish epileptic events from pseudoseizures, and it is deal to find nonconvulsive SE. Neuroimaging techniques could detect epileptogenic lesions (such as cortical malformations, tumors, demyelinating disorders or strokes) but are common in practice to find negative or controversial results. Pharmacologic management can be essentially arranged in three stages: benzodiazepines for early SE (lasting less than 30 minutes), phenytoin/fosphenytoin, phenobarbital, valproate, levetiracetam or lacosamide for established SE (30-90 minutes), and anesthetics for refractory SE (more than 90 minutes). CONCLUSIONS Status epilepticus is the most common neurologic emergency in childhood. A systematic diagnostic work-up and a three steps based therapeutic approach is required at this age.
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Affiliation(s)
- Mario Mastrangelo
- Department of Pediatrics, Child Neurology and Psychiatry, La Sapienza-University of Rome, Rome, Italy.
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Affiliation(s)
- Felix Rosenow
- Department of Neurology, Philipps-University Marburg, Marburg, Germany.
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Abstract
Current standard treatment of established status epilepticus after failure of benzodiazepines is intravenous phenytoin/fosphenytoin, phenobarbital, or valproate. Since 2006 two new antiseizure drugs have become available as intravenous formulation: levetiracetam (2006) and lacosamide (2008). Both drugs have been taken up very rapidly by the clinicians to treat acute seizures and status epilepticus, despite lack of evidence from randomized controlled trials. The favorable pharmacokinetic profile and the good tolerability, especially the lack of sedating effects of both drugs make them promising potential alternatives to the standard antiseizure drugs. Future randomized controlled trials are needed to inform clinicians better about the best choice of treatment in established status epilepticus. The experimental evidence as well as the current clinical experience with levetiracetam and lacosamide are summarized in this review.
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Affiliation(s)
- Eugen Trinka
- Department of Neurology, Paracelsus Medical University, Ignaz Harrer Strasse 79, Salzburg, Austria.
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Prasad K, Kaul S, Padma MV, Gorthi SP, Khurana D, Bakshi A. Stroke management. Ann Indian Acad Neurol 2011; 14:S82-96. [PMID: 21847335 PMCID: PMC3152174 DOI: 10.4103/0972-2327.83084] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Indexed: 01/13/2023] Open
Affiliation(s)
- Kameshwar Prasad
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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