Causes of status epilepticus

Mammalian models of status epilepticus - Their value and limitations

Status epilepticus (SE) is a medical and neurologic emergency that may lead to permanent brain damage, morbidity, or death. Animal models of SE are particularly important to study the pathophysiology of SE and mechanisms of SE resistance to antiseizure medications with the aim to develop new, more effective treatments. In addition to rodents (rats or mice), larger mammalian species such as dogs, pigs, and nonhuman primates are used. This short review describes and discusses the value and limitations of the most frequently used mammalian models of SE. Issues that are discussed include (1) differences between chemical and electrical SE models; (2) the role of genetic background and environment on SE in rodents; (3) the use of rodent models (a) to study the pathophysiology of SE and mechanisms of SE resistance; (b) to study developmental aspects of SE; (c) to study the efficacy of new treatments, including drug combinations, for refractory SE; (d) to study the long-term consequences of SE and identify biomarkers; (e) to develop treatments that prevent or modify epilepsy; (e) to study the pharmacology of spontaneous seizures; (4) the limitations of animal models of induced SE; and (5) the advantages (and limitations) of naturally (spontaneously) occurring SE in epileptic dogs and nonhuman primates. Overall, mammalian models of SE have significantly increased our understanding of the pathophysiology and drug resistance of SE and identified potential targets for new, more effective treatments. This paper was presented at the 9th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures held in April 2024.

Regional determinants for outcome and cost of status epilepticus

OBJECTIVE

Status epilepticus (SE) requires informed management. Since regional differences exist in practice and outcome, we aimed to characterize the epidemiology of SE and identify the factors associated with cost-effective management at the sole level IV epilepsy center of Central New York (CNY).

METHODS

We searched for patients aged 18 years or older admitted at our center's hospitals from February 2018 to November 2019 with the discharge diagnosis of SE. Seventy-seven individuals with definite SE were included. We constructed models to determine the main factors that impact the refractoriness of SE, the clinical outcome, and the estimated cost of hospitalization.

RESULTS

The rate of SE-related disability was 20.8% and the all-cause mortality 36.4%. Our analysis showed that initial anti-seizure medication (ASM) choice did not have a significant influence on the clinical outcome; nor did it affect the refractoriness of SE. Likewise, our anesthetic regimen did not alter the disease course or outcome. In line with prior studies, we demonstrated that age carried a negative predictive value to the SE-related disability and mortality (CI95% [-0.02, 0], p < 0.001). Interestingly, we found that use of midazolam (CI95% [-20.8, -0.08], p = 0.05) and anoxic brain injury as the underlying etiology (CI95% [-33.5, -1.59], p = 0.03) were marginally associated with shorter hospitalizations and reduced cost. The latter might reflect the rapidly-deteriorating course of anoxic brain injury, complicated by its higher likelihood of refractoriness (CI95% [0.14, 0.79], p = 0.006), and consequently, the decision to withdraw care.

CONCLUSION

Taken together, we described the demographics, management, and prognosis of SE locally and further defined the potential determinants for the cost-effective care. We found that similar to other studies, age was the main determinant factor in prognosis. We also noticed that midazolam usage was associated with shorter hospital stay, suggesting that strategic use of midazolam may reduce the direct cost of management of SE. These findings can be adopted to optimize SE management in CNY.

Emergent Management of Status Epilepticus

OBJECTIVE

Status epilepticus is a neurologic emergency that can be life- threatening. The key to effective management is recognition and prompt initiation of treatment. Management of status epilepticus requires a patient-specific-approach framework, consisting of four axes: (1) semiology, (2) etiology, (3) EEG correlate, and (4) age. This article provides a comprehensive overview of status epilepticus, highlighting the current treatment approaches and strategies for management and control.

LATEST DEVELOPMENTS

Administering appropriate doses of antiseizure medication in a timely manner is vital for halting seizure activity. Benzodiazepines are the first-line treatment, as demonstrated by three randomized controlled trials in the hospital and prehospital settings. Benzodiazepines can be administered through IV, intramuscular, rectal, or intranasal routes. If seizures persist, second-line treatments such as phenytoin and fosphenytoin, valproate, or levetiracetam are warranted. The recently published Established Status Epilepticus Treatment Trial found that all three of these drugs are similarly effective in achieving seizure cessation in approximately half of patients. For cases of refractory and super-refractory status epilepticus, IV anesthetics, including ketamine and γ-aminobutyric acid-mediated (GABA-ergic) medications, are necessary. There is an increasing body of evidence supporting the use of ketamine, not only in the early phases of stage 3 status epilepticus but also as a second-line treatment option.

ESSENTIAL POINTS

As with other neurologic emergencies, "time is brain" when treating status epilepticus. Antiseizure medication should be initiated quickly to achieve seizure cessation. There is a need to explore newer generations of antiseizure medications and nonpharmacologic modalities to treat status epilepticus.

Temperature Control in Acute Brain Injury: An Update

Temperature control in severe acute brain injury (SABI) is a key component of acute management. This manuscript delves into the complex role of temperature management in SABI, encompassing conditions like traumatic brain injury (TBI), acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), aneurysmal subarachnoid hemorrhage (aSAH), and hypoxemic/ischemic brain injury following cardiac arrest. Fever is a common complication in SABI and is linked to worse neurological outcomes due to increased inflammatory responses and intracranial pressure (ICP). Temperature management, particularly hypothermic temperature control (HTC), appears to mitigate these adverse effects primarily by reducing cerebral metabolic demand and dampening inflammatory pathways. However, the effectiveness of HTC varies across different SABI conditions. In the context of post-cardiac arrest, the impact of HTC on neurological outcomes has shown inconsistent results. In cases of TBI, HTC seems promising for reducing ICP, but its influence on long-term outcomes remains uncertain. For AIS, clinical trials have yet to conclusively demonstrate the benefits of HTC, despite encouraging preclinical evidence. This variability in efficacy is also observed in ICH, aSAH, bacterial meningitis, and status epilepticus. In pediatric and neonatal populations, while HTC shows significant benefits in hypoxic-ischemic encephalopathy, its effectiveness in other brain injuries is mixed. Although the theoretical basis for employing temperature control, especially HTC, is strong, the clinical outcomes differ among various SABI subtypes. The current consensus indicates that fever prevention is beneficial across the board, but the application and effectiveness of HTC are more nuanced, underscoring the need for further research to establish optimal temperature management strategies. Here we provide an overview of the clinical evidence surrounding the use of temperature control in various types of SABI.

Clinical Outcomes and Systemic Complications Related to the Severity and Etiology of Status Epilepticus Using a Common Data Model

BACKGROUND

Status epilepticus (SE) is a critical neurological emergency in patients with neurological and nonneurological diseases. Mortality rises with SE severity. However, whether brain injury or systemic organ dysfunction causes death after SE remains unclear. We studied clinical outcomes and systemic dysfunctions associated with SE using standardized data from the common data model. This model includes clinical evaluations and treatments that provide real-world evidence for standard practice.

METHODS

This retrospective cohort study used the common data model database of a single tertiary academic medical center. Patients diagnosed with SE (corresponding to G41 of the International Classification of Diseases 10 and administration of antiseizure medication) between January 1, 2001, and January 1, 2018, were enrolled. Demographics, classifications of SE severity, and outcomes were collected as operational definitions by using a common data model format. Systemic complications were defined based on the Sequential Organ Failure Assessment criteria.

RESULTS

The electronic medical records of 1,825,196 patients were transformed into a common data model, and 410 patients were enrolled. The proportion of patients classified as having nonrefractory SE was 65.4% (268/410), followed by refractory (28.5%, 117/410) and super-refractory SE (6.1%, 25/410). Patients with more severe SE had longer intensive care unit and hospital stays. Renal dysfunction and thrombocytopenia were higher in the in-hospital death group (P = 0.002 and 0.003, respectively). In multivariable analysis, the Acute Physiology and Chronic Health Evaluation II score and platelet count were significantly different in the in-hospital death group (odds ratio, 1.169, P = 0.004; and 0.989, P = 0.043).

CONCLUSIONS

Systemic complications after SE, especially low platelet counts, were linked to worse outcomes and increased mortality in a common data model. The common data model offers expandability and comprehensive analysis, making it a potentially valuable tool for SE research.

Differential Regulation of Wnt/β-catenin Signaling in Acute and Chronic Epilepsy in Repeated Low Dose Lithium-Pilocarpine Rat Model of Status Epilepticus

Epilepsy is a chronic neurological complication characterized by unprovoked seizure episodes due to the imbalance between excitatory and inhibitory neurons. The epileptogenesis process has been reported to be involved in chronic epilepsy however, the mechanism underlying epileptogenesis remains unclear. Recent studies have shown the possible involvement of Wnt/β-catenin signaling in the neurogenesis and neuronal reorganization in epileptogenesis. In this study, we used repeated low dose lithium-pilocarpine model of status epilepsy (SE) to study the involvement of Wnt/β-catenin signaling at acute and chronic stages post SE induction. The acute study ranged from day 0 to day 28 post SE induction and the chronic study ranged from day 0 to day 56 post SE induction. Several neurobehavioral parameters and seizure score and seizure frequency was analysed until the end of the study. The proteins involved in the regulation of Wnt/β-catenin signaling and downstream cascading were analysed using western blot and quantitative real-time PCR analysis. The Wnt/β-catenin pathway was found inactive in acute SE, while the same was found activated at the chronic stage. Our findings suggest that the activated Wnt/β-catenin signaling in chronic epilepsy might be the possible mechanism underlying epileptogenesis as indicated by increased neuronal count, increased synaptic density, astrogliosis and apoptosis in chronic epilepsy. These findings can help target the Wnt/β-catenin pathway differentially depending upon the type of epilepsy. The acute stage characterized by SE can be improved by targeting GSK-3β levels and the chronic stage characterized by temporal lobe epilepsy can be improved by targeting β-catenin and disheveled proteins.

A modification to the Kuramoto model to simulate epileptic seizures as synchronization

The Kuramoto model was developed to describe the coupling of oscillators, motivated by the natural synchronization phenomena. We are interested in modeling an epileptic seizure considering it as the synchronization of action potentials using and modifying this model. In this article, we propose to modify this model, changing the constant coupling force for a function with logistic growth to simulate the onset and epileptic seizure level in an adult male rat caused by the administration of lithium-pilocarpine. Later, we select some frequencies and their respective amplitude values using an algorithm based on the fast Fourier transform (FFT) from an electroencephalography signal when the rat is in basal conditions. Then, we take these values as the natural frequencies of the oscillators in the modified Kuramoto model, considering every oscillator as a single neuron to simulate the emergence of an epileptic seizure numerically by increasing the synchronization value in the coupling function. Finally, using Dynamic Time Warping algorithm, we compare the simulated signal by the Kuramoto model with an FFT approximation of the epileptic seizure.

Management of convulsive status epilepticus: recent updates

Convulsive status epilepticus (SE) is a medical emergency associated with high morbidity and mortality. Recently, clinical trials and meta-analyses investigating medical treatment of SE have been published. Benzodiazepine is well known as the first-line treatment for SE. Recent evidence suggests the equivalence of intravenous fosphenytoin, valproate, and levetiracetam for treatment of established SE. There is lack of evidence regarding treatment for refractory SE. Intravenous midazolam is commonly used, and recent evidence supports the use of ketamine. Additional studies are needed to improve the management of convulsive SE.

Clinical impact of carbapenems in critically ill patients with valproic acid therapy: A propensity-matched analysis

Background

Valproic acid (VPA) is one of the most widely used broad-spectrum antiepileptic drugs, and carbapenems (CBPs) remain the drug of choice for severe infection caused by multidrug-resistant bacteria in critically ill patients. The interaction between VPA and CBPs can lead to a rapid depletion of serum VPA level. This may then cause status epilepticus (SE), which is associated with significant mortality. However, the prognostic impact of drug interactions in critically ill patients remains an under-investigated issue.

Objective

The aim of this study was to compare the prognosis of critically ill patients treated with VPA and concomitant CBPs or other broad-spectrum antibiotics.

Methods

Adult patients admitted to a medical center intensive care unit between January 2007 and December 2017 who concomitantly received VPA and antibiotics were enrolled. The risk of reduced VPA serum concentration, seizures and SE, mortality rate, length of hospital stay (LOS), and healthcare expenditure after concomitant administration were analyzed after propensity score matching.

Results

A total of 1,277 patients were included in the study, of whom 264 (20.7%) concomitantly received VPA and CBPs. After matching, the patients who received CBPs were associated with lower VPA serum concentration (15.8 vs. 60.8 mg/L; p &lt; 0.0001), a higher risk of seizures (51.2 vs. 32.4%; adjusted odds ratio [aOR], 2.19; 95% CI, 1.48–3.24; p &lt; 0.0001), higher risk of SE (13.6 vs. 4.7%; aOR, 3.20; 95% CI, 1.51–6.74; p = 0.0014), higher in-hospital mortality rate (33.8 vs. 24.9%; aOR, 1.57; 95% CI, 1.03–2.20; p = 0.036), longer LOS after concomitant therapy (41 vs. 30 days; p &lt; 0.001), and increased healthcare expenditure (US$20,970 vs. US$12,848; p &lt; 0.0001) than those who received other broad-spectrum antibiotics.

Conclusion

The administration of CBPs in epileptic patients under VPA therapy was associated with lower VAP serum concentration, a higher risk of seizures and SE, mortality, longer LOS, and significant utilization of healthcare resources. Healthcare professionals should pay attention to the concomitant use of VPA and CBPs when treating patients with epilepsy. Further studies are warranted to investigate the reason for the poor outcomes and whether avoiding the co-administration of VPA and CBP can improve the outcomes of epileptic patients.

[Status epilepticus-Detection and treatment in the intensive care unit]

Status epilepticus is characterized by persistent or repetitive seizures which, without successful treatment, can lead to neuronal damage, neurological deficits and death of the patient.While status epilepticus with motor symptoms can usually be clinically diagnosed, nonconvulsive status epilepticus is often clinically overlooked due to its ambiguous semiology, so that electroencephalography (EEG) recording is necessary. The treatment of status epilepticus is performed in four treatment steps, whereby a difficult to treat status epilepticus is present from the third step at the latest and intensive medical care of the patient is necessary. Timely initiation of treatment and sufficient dosage of anticonvulsive medication are decisive for the success of treatment. There is little evidence for the "late" stages of treatment. Intensive medical measures pose the risk of complications that worsen the prognosis. Especially in nonconvulsive status epilepticus, the use of anesthetics must be weighed against possible complications of mechanical ventilation.

Intermittency properties in a temporal lobe epilepsy model

Neuronal synchronization is important for communication between brain regions and plays a key role in learning. However, changes in connectivity can lead to hyper-synchronized states related to epileptic seizures that occur intermittently with asynchronous states. The activity-regulated cytoskeleton-associated protein (ARC) is related to synaptic alterations which can lead to epilepsy. Induction of status epilepticus in rodent models causes the appearance of intense ARC immunoreactive neurons (IAINs), which present a higher number of connections and conductance intensity than non-IAINs. This alteration might contribute to abnormal epileptic seizure activity. In this work, we investigated how IAINs connectivity influences the firing pattern and synchronization in neural networks. Firstly, we showed the appearance of synchronized burst patterns due to the emergence of IAINs. Second, we described how the increase of IAINs connectivity favors the appearance of intermittent up and down activities associated with synchronous bursts and asynchronous spikes, respectively. Once the intermittent activity was properly characterized, we applied the optogenetics control of the high synchronous activities in the intermittent regime. To do this, we considered that 1% of neurons were transfected and became photosensitive. We observed that optogenetics methods to control synchronized burst patterns are effective when IAINs are chosen as photosensitive, but not effective in non-IAINs. Therefore, our analyses suggest that IAINs play a pivotal role in both the generation and suppression of highly synchronized activities.

Antibiotics modulate frequency and early generation of epileptic seizures in zebrafish

Antibiotics have been used for decades to treat various bacterial infections. Apart from bactericidal activities, their potential side effects have not been much studied or evaluated. Neurotoxicity is a major concern in the case of β-lactam and fluoroquinolone families, which can result in convulsions or seizures. Here, we proposed a hypothesis to check whether antibiotic treatment can conclusively enhance anxiety-like behaviours and how seizure behavioural profile gets modulated in pentylenetetrazole (PTZ)-treated zebrafish. Zebrafish were treated with selected antibiotics such as 25 mg/L Penicillin G (PG) and Ciprofloxacin (CPFX), for 7 days and thereafter exposed to PTZ (7.5 mM) for 20 min. The data indicate that PG and CPFX-treated groups exhibited anxiety-like or stressed behavioural phenotypes in the novel tank test (6 min), and also, they were found to promote hyperactivity. Early onset of PTZ-induced seizure-like behavioural scores, the heightened intensity of seizure and reduced latency in different scores were found in PG and CPFX-administered groups. This study substantiates that PG and CPFX as potential seizure modulators in zebrafish. The zebrafish is a well-established and still expanding model organism in many fields. Here, we again reinforce zebrafish as a prominent model to investigate seizure-like neuro-behavioural entities and confirm that chronic antibiotic use has negative consequences that can exacerbate the circumstances of vertebrate species exhibiting seizure-related reactions.

A case report: New-onset refractory status epilepticus in a patient with FASTKD2-related mitochondrial disease

Objectives

New-onset refractory status epilepticus (NORSE) is associated with high morbidity and mortality. Despite extensive work-up, the underlying etiology remains unknown in 50% of affected individuals. Mitochondrial disorders represent rare causes of NORSE. Biallelic variants in FASTKD2 were reported as a cause of infantile encephalomyopathy with refractory epilepsy.

Case description

In the study, we report a previously healthy 14-year-old with a new, homozygous FASTKD2 variant presenting with NORSE. Following a seizure-free period of 7 years, he experienced another super-refractory SE and subsequently developed drug-resistant focal epilepsy, mild myopathy, optic atrophy, and discrete psychomotor slowing. Structural MRI at the time of NORSE showed right temporo-parieto-occipital FLAIR hyperintensity and diffusion restriction, with extensive right hemispheric atrophy at the age of 22 years. Whole-exome sequencing revealed a novel homozygous loss of function variant [c.(1072C>T);(1072C>T)] [p.(Arg358Ter);(Arg358Ter)] in FASTKD2 (NM_001136193), resulting in a premature termination codon in the protein-coding region and loss of function of FASTKD2. Oxidative phosphorylation (OXPHOS) in muscle and skin fibroblasts was unremarkable.

Conclusion

This is the first case of a normally developed adolescent with a new homozygous loss of function variant in FASTKD2, manifesting with NORSE. The phenotypical spectrum of FASTKD2-related mitochondrial disease is heterogeneous, ranging from recurrent status epilepticus and refractory focal epilepsy in an adolescent with normal cognitive development to severe forms of infantile mitochondrial encephalopathy. Although mitochondrial diseases are rare causes of NORSE, clinical features such as young age at onset and multi-system involvement should trigger genetic testing. Early diagnosis is essential for counseling and treatment considerations.

Epidemiology, real-world treatment and mortality of patients with status epilepticus in Germany: insights from a large healthcare database

Status epilepticus is a life-threatening emergency, and to date, few studies have reported on its long-term treatment and outcomes. This study aimed to estimate the incidence, the treatment and outcomes, the healthcare resource utilization and the costs of status epilepticus in Germany. Data from 2015 to 2019 were obtained from German claims (AOK PLUS). Patients with ≥1 status epilepticus event and no event in the preceding 12 months (baseline) were included. A subgroup of patients with an epilepsy diagnosis during baseline was also analysed. Of the 2782 status epilepticus patients (mean age = 64.3 years; 52.3% female), 1585 (57.0%) were previously diagnosed with epilepsy. The age- and sex-standardized incidence was 25.5 cases/100 000 persons in 2019. The mortality rate after 12 months was 39.8% overall (19.4% and 28.2% after 30 and 90 days, respectively) and 30.4% in the epilepsy patient subgroup. Factors associated with higher mortality were age, comorbidity status, presence of brain tumours and an acute stroke. An epilepsy-related hospitalization at onset of or 7 days prior to the status epilepticus event as well as prescription of antiseizure medication during baseline was associated with a better survival rate. Overall, 71.6% of patients (85.6% in the epilepsy subgroup) were prescribed with out-patient antiseizure medication and/or rescue medication within 12 months. All patients sustained on average 1.3 status epilepticus-related hospitalizations (20.5% had more than one) during a mean follow-up period of 545.2 days (median 514 days); total direct costs including in-patient and out-patient status epilepticus treatments were 10 826€ and 7701€ per patient-year overall and for the epilepsy patient subgroup, respectively. The majority of status epilepticus patients received an out-patient treatment in line with epilepsy guidelines, and patients previously diagnosed with epilepsy have a higher likelihood to receive it. The mortality in the affected patient population is high; risk factors were older age, higher comorbidity burden, the presence of brain tumours or an acute stroke.

PhenoExam: gene set analyses through integration of different phenotype databases

BACKGROUND

Gene set enrichment analysis (detecting phenotypic terms that emerge as significant in a set of genes) plays an important role in bioinformatics focused on diseases of genetic basis. To facilitate phenotype-oriented gene set analysis, we developed PhenoExam, a freely available R package for tool developers and a web interface for users, which performs: (1) phenotype and disease enrichment analysis on a gene set; (2) measures statistically significant phenotype similarities between gene sets and (3) detects significant differential phenotypes or disease terms across different databases.

RESULTS

PhenoExam generates sensitive and accurate phenotype enrichment analyses. It is also effective in segregating gene sets or Mendelian diseases with very similar phenotypes. We tested the tool with two similar diseases (Parkinson and dystonia), to show phenotype-level similarities but also potentially interesting differences. Moreover, we used PhenoExam to validate computationally predicted new genes potentially associated with epilepsy.

CONCLUSIONS

We developed PhenoExam, a freely available R package and Web application, which performs phenotype enrichment and disease enrichment analysis on gene set G, measures statistically significant phenotype similarities between pairs of gene sets G and G' and detects statistically significant exclusive phenotypes or disease terms, across different databases. We proved with simulations and real cases that it is useful to distinguish between gene sets or diseases with very similar phenotypes. Github R package URL is https://github.com/alexcis95/PhenoExam . Shiny App URL is https://alejandrocisterna.shinyapps.io/phenoexamweb/ .

Association between status epilepticus and cardiorespiratory comorbidity in patients with epilepsy: A population-based study

PURPOSE

This study aimed to evaluate the relationship between status epilepticus (SE) and cardiorespiratory comorbidity in patients with epilepsy.

METHODS

We conducted a population-based study using cloud-based aggregated electronic medical records from >53 million patients in the US (Explorys, IBM Watson; January 1999 to November 2020). During the study period, we identified patients with epilepsy with SE. Patients with a history of cardiac arrest, anoxic encephalopathy, and/or cerebrovascular disease were excluded. We reported the prevalences and prevalence ratios of cardiorespiratory and medical comorbidities using age- and sex-adjusted standardization.

RESULTS

We identified 494,790 patients with epilepsy and 19,190 had SE. Cardiovascular and respiratory diseases were statistically significantly more prevalent in patients with epilepsy with SE than in those without SE (adjusted prevalence ratio (APR) 1.13, prevalence 68.7% [95% confidence interval (CI): 67.6-69.9] vs 60.9% [95% CI: 60.7-61.1]) and (APR 1.25, 73.1% [95% CI: 71.8-74.3] vs 58.4% [95% CI: 58.1-58.6]), respectively. Aspiration pneumonia (APR 3.12, 0.47% [95% CI: 0.37-0.57] vs 0.15% [95% CI: 0.14-0.16]) and acute respiratory distress syndrome (APR 2.40, 0.47% [95% CI: 0.37-0.57] vs 0.20% [95% CI: 0.18-0.21]) were more prevalent in patients with epilepsy with SE. Common cardiovascular risk factors such as diabetes mellitus (APR 1.13, 17.1% [95% CI: 16.5-17.6] vs 15.1% [95% CI: 1.50-15.2]) and hypertension (APR 1.28, 10.6% [95% CI: 10.2-11.0] vs 8.31% [95% CI: 8.23-8.39]) were also more common in patients with epilepsy with SE.

CONCLUSION

In this population-based study, patients with epilepsy with SE had a statistically significantly higher prevalence of cardiorespiratory comorbidities than in those without SE.

Hyperperfusion Tmax mapping for nonconvulsive status epilepticus in the acute setting: A pilot case-control study

OBJECTIVE

Nonconvulsive status epilepticus (NCSE) is misdiagnosed in >50% of cases in the emergency department. Computed tomographic perfusion (CTP) has been implemented in the hyperacute setting to detect seizure-induced hyperperfusion. However, the diagnostic value of CTP is limited by the lack of thresholds for hyperperfusion and high interrater variability. This pilot case-control study aims at identifying the diagnostic value of reverse Tmax (rTmax) in differentiating NCSE from acute ischemic stroke in the hyperacute setting.

METHODS

We enrolled patients with NCSE (Salzburg criteria-based diagnosis) and stroke cases 1:1 matched for clinical features and time of presentation. CTP standard maps (mean transit time [MTT]-cerebral blood volume-cerebral blood flow [CBF]) and rTmax maps were elaborated and rated by two experts in CTP blinded to the final diagnosis. Hyperperfusion was adjudicated for standard CTP maps as an increase in CBF and a decrease in MTT, and for rTmax as the presence of a black area on 3-, 2-, and 1-s threshold maps. Cronbach alpha was used for interrater agreement; receiver operating curve analysis was run to measure accuracy with area under the curve.

RESULTS

Overall, 34 patients were included (17 NCSE, 17 stroke; time from onset to imaging = 2 h for both groups). People with NCSE were older and more frequently had a history of epilepsy. NCSE patients had hyperperfusion on rTmax maps in 11 of 17 cases versus zero of 17 in stroke. Intra- and interrater reliability was higher for rTmax than for standard CTP maps (κ = 1 vs. κ = .6). rTmax was 82% (95%CI = 67-97%) accurate in predicting NCSE versus stroke in the hyperacute setting. Agreement between neuroimaging and electroencephalography (EEG) was limited at a hemispheric level for standard CTP maps, whereas rTMax had agreement with EEG largely reaching the sublobar level.

SIGNIFICANCE

rTmax mapping might represent a reliable tool to spot NCSE-induced hyperperfusion with a threshold-based reproducible approach. Further studies are needed for validation and implementation in the differential diagnosis of focal neurological deficit in the hyperacute setting.

Optimal Management of Status Epilepticus in Children in the Emergency Setting: A Review of Recent Advances

Convulsive status epilepticus (CSE) is the most common neurological emergency in children and the second most common neurological emergency in adults. Mortality is low, but morbidity, including neuro-disability, learning difficulties, and a de-novo epilepsy, may be as high as 22%. The longer the duration of CSE, the more difficult it is to terminate, and the greater the risk of morbidity. Convulsive status epilepticus is usually managed using specific national or local algorithms. The first-line treatment is administered when a tonic-clonic or focal motor clonic seizure has lasted five minutes (impending or premonitory CSE). Second-line treatment is administered when the CSE has persisted after two doses of a first-line treatment (established CSE). Randomised clinical trial (RCT) evidence supports the use of benzodiazepines as a first-line treatment of which the most common are buccal or intra-nasal midazolam, rectal diazepam and intravenous lorazepam. Alternative drugs, for which there are considerably less RCT data, are intra-muscular midazolam and intravenous clonazepam. Up until 2019, phenobarbital and phenytoin (or fosphenytoin) were the preferred second-line treatments but with no good supporting RCT evidence. Robust RCT data are now available which has provided important information on second-line treatments, specifically phenytoin (or fosphenytoin), levetiracetam and sodium valproate. Lacosamide is an alternative second-line treatment but with no supporting RCT evidence. Current evidence indicates that first, buccal or intranasal midazolam or intravenous lorazepam are the most effective and the most patient and carer-friendly first-line anti-seizure medications to treat impending or premonitory CSE and second, that there is no difference in efficacy between levetiracetam, phenytoin (or fosphenytoin) or sodium valproate for the treatment of established CSE. Pragmatically, levetiracetam or sodium valproate are preferred to phenytoin (or fosphenytoin) because of their ease of administration and lack of serious adverse side-effects, including potentially fatal cardiac arrhythmias. Sodium valproate must be used with caution in children aged three and under because of the rare risk of hepatotoxicity and particularly if there is an underlying mitochondrial disorder.

Intravenous ganaxolone for the treatment of refractory status epilepticus: Results from an open-label, dose-finding, phase 2 trial

OBJECTIVE

Patients with refractory status epilepticus (RSE) have failed treatment with benzodiazepines and ≥1 second-line intravenous (IV) antiseizure medication (ASM). Guidelines recommend IV anesthesia when second-line ASMs have failed, but potential harms can outweigh the benefits. Novel treatments are needed to stop and durably control RSE without escalation to IV anesthetics. Ganaxolone is an investigational neuroactive steroid in development for RSE treatment. This study's objective was to determine the appropriate dosing for IV ganaxolone in RSE and obtain a preliminary assessment of efficacy and safety.

METHODS

This was an open-label, phase 2 trial conducted from February 19, 2018 to September 18, 2019, at three sites in the United States. Patients were aged ≥12 years, had convulsive or nonconvulsive SE, and failed to respond to ≥1 second-line IV ASM. Twenty-one patients were screened; 17 were enrolled. Patients received IV ganaxolone added to standard-of-care ASMs. Ganaxolone infusion was initiated as an IV bolus (over 3 min) with continuous infusion of decreasing infusion rates for 48-96 h followed by an 18-h taper. There were three ganaxolone dosing cohorts: low, 500 mg/day; medium, 650 mg/day; and high, 713 mg/day. The primary end point was the number of patients not requiring escalation to IV anesthetic treatment within 24 h of ganaxolone initiation.

RESULTS

Most of the 17 enrolled patients (65%) had nonconvulsive SE, and had failed a median of three prior ASMs, including first-line benzodiazepine and second-line IV ASM therapy. Median time to SE cessation following ganaxolone initiation was 5 min. No patient required escalation to third-line IV anesthetics during the 24-h period following ganaxolone initiation. Two treatment-related serious adverse events (sedation) were reported. Of the three deaths, none was considered related to ganaxolone; all occurred 9-22 days after completing ganaxolone.

SIGNIFICANCE

IV ganaxolone achieved rapid and durable seizure control in patients with RSE, and showed acceptable safety and tolerability.

Glymphatic system impairment in patients with status epilepticus

OBJECTIVE

The aim of this study was to compare the function of the glymphatic system in patients with status epilepticus (SE) with that in healthy controls by diffusion tensor image analysis along the perivascular space (DTI-ALPS) method. We also investigated the association between glymphatic system function and the clinical characteristics of SE.

METHODS

We retrospectively enrolled 28 patients with SE and 31 healthy controls matched for age and sex. All study participants underwent diffusion tensor imaging using the same 3-T MRI scanner, and the DTI-ALPS index was calculated. We compared the DTI-ALPS index between the SE group and the control group. We also evaluated the associations of the DTI-ALPS index with etiology and type of SE, age, putative duration of seizure, time interval until MRI, seizure-related changes on diffusion-weighted imaging, and any previous structural lesions.

RESULTS

The DTI-ALPS index was significantly lower in the SE group than in the control group (1.462 ± 0.297 vs. 1.632 ± 0.270, p = 0.026) and was negatively correlated with age (r =  - 0.280, p = 0.032) in the SE group. However, there were no significant between-group differences in the DTI-ALPS index according to other clinical factors.

SIGNIFICANCE

The finding of a significantly lower DTI-ALPS index in the SE group suggests that the glymphatic system is impaired in patients with SE. DTI-ALPS is a useful tool for evaluation of the function of the glymphatic system in these patients.

Mortality, Disability and Prognostic Factors of Status Epilepticus: A Nationwide Population-Based Retrospective Cohort Study

BACKGROUND AND OBJECTIVES

The outcome of status epilepticus (SE) largely varies depending on clinical characteristics. Risk stratification is necessary for tailoring the aggressiveness of treatment and predicting outcomes of individual patients with SE. In this study, we assessed differences in mortality, neurologic disability, and prognostic factors associated with SE across sociodemographic and clinical characteristics.

METHODS

We conducted a nationwide population-based retrospective cohort study using the National Health Insurance Service (NHIS) database linked with the national death and disability registries. SE was identified from admission or emergency room visits using a diagnostic code of G41 from the International Classification of Disease, 10^th Revision. Individuals with new-onset SE that occurred from January 1, 2010, to December 31, 2018, were included. Active epilepsy, refractoriness of SE, potential etiology, and comorbidities were ascertained by diagnostic codes and/or prescription records from the NHIS database as potential prognostic factors. Outcomes included 30-day and 1-year mortality and neurologic disabilities following SE. Prognostic factors for mortality were assessed by the Cox regression hazard model. We performed a subgroup analysis according to age: pediatric SE (age < 20 years old) and adult SE (age ≥ 20 years old).

RESULTS

A total of 33,814 new-onset SE patients were included (6,818 children/adolescents and 26,996 adults). The 30-day mortality was 8.5% (1.8% in pediatric SE and 10.2% in adult SE), and the 1-year mortality was 25.1% (4.6% in pediatric SE and 30.3% in adult SE). Overall, 10.7% of patients newly acquired neurologic disabilities following SE, with the highest incidence in children aged 5 to 9 years (21.3%). Intractable epilepsy developed in 0.8% of entire SE. Old age, presence of acute etiology, and refractoriness were poor prognostic factors for mortality in both pediatric and adult SE. Male sex, low economic status, no active epilepsy, and comorbidities were additional factors for a poor prognosis in adults.

CONCLUSIONS

New-onset SE was associated with substantial mortality and disability. While SE-related mortality was higher in adults, disabilities developed more commonly in children and adolescents. The major determinants of mortality differed between pediatric and adult SE.

Extreme value theory inspires explainable machine learning approach for seizure detection

Epilepsy is one of the brightest manifestations of extreme behavior in living systems. Extreme epileptic events are seizures, that arise suddenly and unpredictably. Usually, treatment strategies start by analyzing brain activity during the seizures revealing their type and onset mechanisms. This approach requires collecting data for a representative number of events which is only possible during the continuous EEG monitoring over several days. A big part of the further analysis is searching for seizures on these recordings. An experienced medical specialist spends hours checking the data of a single patient and needs assistance from the automative systems for seizure detection. Machine learning methods typically address this issue in a supervised fashion and exhibit a lack of generalization. The extreme value theory allows addressing this issue with the unsupervised machine learning methods of outlier detection. Here, we make the first step toward using this approach for the seizure detection. Based on our recent work, we specified the EEG features showing extreme behavior during seizures and loaded them to the one-class SVM, a popular outlier detection algorithm. Testing the proposed approach on 83 patients, we reported 77% sensitivity and 12% precision. In 60 patients, sensitivity was 100%. In the rest 23 subjects, we observed deviations from the extreme behavior. The one-class SVM used a single subject's data for training; therefore, it was stable against between-subject variability. Our results demonstrate an effective convergence between the extreme value theory, a physical concept, and the outlier detection algorithms, a machine learning concept, toward solving the meaningful task of medicine.

Dogs as a Natural Animal Model of Epilepsy

Epilepsy is a common neurological disease in both humans and domestic dogs, making dogs an ideal translational model of epilepsy. In both species, epilepsy is a complex brain disease characterized by an enduring predisposition to generate spontaneous recurrent epileptic seizures. Furthermore, as in humans, status epilepticus is one of the more common neurological emergencies in dogs with epilepsy. In both species, epilepsy is not a single disease but a group of disorders characterized by a broad array of clinical signs, age of onset, and underlying causes. Brain imaging suggests that the limbic system, including the hippocampus and cingulate gyrus, is often affected in canine epilepsy, which could explain the high incidence of comorbid behavioral problems such as anxiety and cognitive alterations. Resistance to antiseizure medications is a significant problem in both canine and human epilepsy, so dogs can be used to study mechanisms of drug resistance and develop novel therapeutic strategies to benefit both species. Importantly, dogs are large enough to accommodate intracranial EEG and responsive neurostimulation devices designed for humans. Studies in epileptic dogs with such devices have reported ictal and interictal events that are remarkably similar to those occurring in human epilepsy. Continuous (24/7) EEG recordings in a select group of epileptic dogs for >1 year have provided a rich dataset of unprecedented length for studying seizure periodicities and developing new methods for seizure forecasting. The data presented in this review substantiate that canine epilepsy is an excellent translational model for several facets of epilepsy research. Furthermore, several techniques of inducing seizures in laboratory dogs are discussed as related to therapeutic advances. Importantly, the development of vagus nerve stimulation as a novel therapy for drug-resistant epilepsy in people was based on a series of studies in dogs with induced seizures. Dogs with naturally occurring or induced seizures provide excellent large-animal models to bridge the translational gap between rodents and humans in the development of novel therapies. Furthermore, because the dog is not only a preclinical species for human medicine but also a potential patient and pet, research on this species serves both veterinary and human medicine.

Typical absence status epilepticus in older people: syndromic delineation

Objective We describe the clinical, electroencephalograph^ and neuroimaging findings of older patients with typical absence status epilepticus (ASE). Methods This investigation was a retrospective analysis of prospectively collected consecutive patients between January 2011 and October 2021. All patients ≥60 years with impairment of awareness and continuous generalized, rhythmic, synchronous and symmetric epileptiform discharges and normal background on video-electroencephalogram (vEEG) were included. Results Six patients were identified with a diagnosis of typical ASE. The mean age was 67 years. Five could be classified as idiopathic generalized epilepsy (IGE) though two had been erroneously categorized as cryptogenic focal epilepsy (FE). In one, the episode of ASE was thought to represent the beginning of late-onset IGE (de novo late-onset typical ASE). In all cases, ASE was controlled within the first 24 hours. Significance Typical ASE is a rare cause of confusion in the elderly population requiring urgent vEEG evaluation. It most frequently represents reactivation of a previous IGE, in effect related to patients with epilepsy with onset in childhood or adolescence, not previously diagnosed or treated, representing rather the debut of (de novo) late-onset IGE.

Anti-Obesity Medications and Investigational Agents: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This "Anti-Obesity Medications and Investigational Agents: An Obesity Medicine Association Clinical Practice Statement 2022" is intended to provide clinicians an overview of Food and Drug Administration (FDA) approved anti-obesity medications and investigational anti-obesity agents in development.

Methods

The scientific information for this Clinical Practice Statement (CPS) is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS describes pharmacokinetic principles applicable to those with obesity, and discusses the efficacy and safety of anti-obesity medications [e.g., phentermine, semaglutide, liraglutide, phentermine/topiramate, naltrexone/bupropion, and orlistat, as well as non-systemic superabsorbent oral hydrogel particles (which is technically classified as a medical device)]. Other medications discussed include setmelanotide, metreleptin, and lisdexamfetamine dimesylate. Data regarding the use of combination anti-obesity pharmacotherapy, as well as use of anti-obesity pharmacotherapy after bariatric surgery are limited; however, published data support such approaches. Finally, this CPS discusses investigational anti-obesity medications, with an emphasis on the mechanisms of action and summary of available clinical trial data regarding tirzepatide.

Conclusion

This "Anti-Obesity Medications and Investigational Agents: An Obesity Medicine Association Clinical Practice Statement 2022" is one of a series of OMA CPSs designed to assist clinicians in the care of patients with pre-obesity/obesity.

Ursolic Acid Protects Neurons in Temporal Lobe Epilepsy and Cognitive Impairment by Repressing Inflammation and Oxidation

Temporal lobe epilepsy (TLE) is characterized as an impaired ability of learning and memory with periodic and unpredictable seizures. Status epilepticus (SE) is one of the main causes of TLE. Neuroinflammation and oxidative stress are directly involved in epileptogenesis and neurodegeneration, promoting chronic epilepsy and cognitive deficit. Previous studies have shown that ursolic acid (UA) represses inflammation and oxidative stress, contributing to neuroprotection. Herein, we demonstrated that UA treatment alleviated seizure behavior and cognitive impairment induced by epilepsy. Moreover, UA treatment rescued hippocampal neuronal damage, aberrant neurogenesis, and ectopic migration, which are commonly accompanied by epilepsy occurrence. Our study also demonstrated that UA treatment remarkably suppressed the SE-induced neuroinflammation, evidenced by activated microglial cells and decreased inflammation factors, including TNF-α and IL-1β. Likewise, the expression levels of oxidative stress damage markers and oxidative phosphorylation (OXPHOS) enzyme complexes of mitochondria were also remarkably downregulated following the UA treatment, suggesting that UA suppressed the damage caused by the high oxidative stress and the defect mitochondrial function induced by SE. Furthermore, UA treatment attenuated GABAergic interneuron loss. In summary, our study clarified the notable anti-seizure and neuroprotective properties of UA in pilocarpine-induced epileptic rats, which is mainly achieved by abilities of anti-inflammation and anti-oxidation. Our study indicates the potential advantage of UA application in ameliorating epileptic sequelae.

Factors associated with the use of anesthetic drug infusion in patients with status epilepticus and their relation to outcome: a prospective study

Status epilepticus (SE) is one of the most dreadful neurological emergencies; unfortunately, studies targeting SE are still inadequate. This study aims to identify factors associated with the use of CIVAD in patients presenting with status epilepticus and detect those impact the clinical outcome. A prospective study involving 144 episodes of SE in 144 patients. Patients were categorized according to whether or not they received CIVAD. Subjects underwent clinical assessment, brain imaging, and EEG. The consciousness level was assessed using the Glasgow coma scale (GCS) and the Full outline of responsiveness (FOUR) scale. SE severity score (STESS) and Epidemiology-based mortality score (EMSE) were used as scales for outcome prediction. Continuous IV anesthetic drug infusion was initiated in 36% of patients (+ CIVAD). Such groups showed a significantly worse initial level of consciousness (< 0.001), an unstable course of seizure evolution (0.009), and all of them showed abnormal EEG patterns. A significantly higher number of patients (+ CIVAD) developed complications (< 0.001), had higher outcome prediction scores (< 0.001), and mortality rates (< 0.001) compared to those who did not need CIVAD (- CIVAD). Mortality was associated with acute symptomatic etiology and higher total doses of propofol. Among the study population, mortality among patients who received CIVAD was associated with acute symptomatic SE and prolonged propofol infusion rather than any clinical parameters or predictor scores.

The Outcome of Status Epilepticus Among Adults in Aseer Region of Saudi Arabia

Introduction

Epileptic seizure episodes can vary from brief and nearly undetectable to long periods of vigorous shaking. These episodes can result in physical injuries, occasionally including broken bones. With epilepsy, seizures tend to recur and, as a rule, have no immediate underlying cause. Status epilepticus (SE) is an attack of a seizure lasting for more than five minutes or two or more seizures without the person returning to normal between the attacks. Previous definitions used a 30-minute time limit. This study aimed to assess the clinical outcome of SE among adult patients in the Aseer region.

Materials and methods

A retrospective record-based cohort study design was conducted, targeting all accessible medical files of adult patients with SE who were admitted to the Aseer central hospital and military hospital from 2010 to 2017. Data were extracted from all complete and accessible files. Records with missing data were excluded. Clinical outcomes for the cases included were assessed and categorized into cases of complete recovery (without sequelae), cases with incomplete recovery, and death.

Results

The study included 19 adult patients with SE whose ages ranged from seven to 87 years with a mean age of 33.4 ± 22.5 years. Men made up 63.2% of the cases. Infection was the most recorded risk factor among the cases, followed by anti-epileptic drug withdrawal. Only two cases recovered with sequelae, while the remaining 17 cases recovered completely. There were no deaths.

Conclusions

The study revealed that nearly all cases recovered completely with no complications, particularly men who immediately received IV treatment. Early diagnosis and receiving treatment under careful observation via follow-up are recommended.

Epilepsy and mortality: a retrospective cohort analysis with a nested case-control study identifying causes and risk factors from primary care and linkage-derived data

OBJECTIVES

People with epilepsy (PWE) have a higher mortality rate than the general population. Epilepsy-related deaths have increased despite all-cause mortality decreasing in the general population pre-COVID-19. We hypothesised that clinical and lifestyle factors may identify people more at risk.

DESIGN

We used a retrospective cohort study to explore cause of death and a nested case-control study to identify risk factors.

SETTING

We explored factors associated with mortality using primary care population data from 1 April 2004 to 31 March 2014. Data were obtained from the Clinical Practice Research Datalink which compiles anonymised patient data from primary care in the UK. Cause of death data was supplemented from the Office of National Statistics when available.

PARTICIPANTS

The analysis included 70 431 PWE, with 11 241 registered deaths.

RESULTS

The number of deaths within the database increased by 69% between the first and last year of the study. Epilepsy was considered as a contributing cause in approximately 45% of deaths of PWE under 35. Factors associated with increased risk of death included attendance at emergency departments and/or emergency admissions (OR 3.48, 95% CI 3.19 to 3.80), antiepileptic drug (AED) polytherapy (2 AEDs: OR 1.60, 95% CI 1.51 to 1.71; 3 AEDs: OR 2.06, 95% CI 1.86 to 2.29; 4+AEDs: OR 2.62, 95% CI 2.23 to 3.08), status epilepticus (OR 2.78, 95% CI 1.64 to 4.71), depression (OR 1.67, 95% CI 1.57 to 1.76) and injuries (OR 1.54, 95% CI 1.43 to 1.67). No seizures in the prior year (OR 0.52, 95% CI 0.41 to 0.65).

CONCLUSION

Our results add to existing evidence that deaths in epilepsy are increasing. Future studies could focus on identifying PWE at high risk and addressing them with clinical interventions or better self-management. Identifying specific risk factors for younger people should be a priority as epilepsy may be a factor in close to half of deaths of PWE under 35 years of age.

Unraveling the enigma of new-onset refractory status epilepticus: a systematic review of aetiologies

BACKGROUND AND PURPOSE

New-onset refractory status epilepticus (NORSE) is a clinical presentation, neither a specific diagnosis nor a clinical entity. It refers to a patient without active epilepsy or other pre-existing relevant neurological disorder, with a NORSE without a clear acute or active structural, toxic or metabolic cause. This study reviews the currently available evidence about the aetiology of patients presenting with NORSE and NORSE-related conditions.

METHODS

A systematic search was carried out for clinical trials, observational studies, case series and case reports including patients who presented with NORSE, febrile-infection-related epilepsy syndrome or the infantile hemiconvulsion-hemiplegia and epilepsy syndrome.

RESULTS

Four hundred and fifty records were initially identified, of which 197 were included in the review. The selected studies were retrospective case-control (n = 11), case series (n = 83) and case reports (n = 103) and overall described 1334 patients both of paediatric and adult age. Aetiology remains unexplained in about half of the cases, representing the so-called 'cryptogenic NORSE'. Amongst adult patients without cryptogenic NORSE, the most often identified cause is autoimmune encephalitis, either non-paraneoplastic or paraneoplastic. Infections are the prevalent aetiology of paediatric non-cryptogenic NORSE. Genetic and congenital disorders can have a causative role in NORSE, and toxic, vascular and degenerative conditions have also been described.

CONCLUSIONS

Far from being a unitary condition, NORSE is a heterogeneous and clinically challenging presentation. The development and dissemination of protocols and guidelines to standardize diagnostic work-up and guide therapeutic approaches should be implemented. Global cooperation and multicentre research represent priorities to improve the understanding of NORSE.

Diagnosis and Management of Status Epilepticus

Seizures are among the most common neurological presentations to the emergency room. They present on a spectrum of severity from isolated new-onset seizures to acute repetitive seizures and, in severe cases, status epilepticus. The latter is the most serious, as it is associated with high morbidity and mortality. Prompt recognition and treatment of both seizure activity and associated acute systemic complications are essential to improve the overall outcome of these patients. The purpose of this review is to provide the current viewpoint on the diagnostic evaluation and pharmacological management of patients presenting with status epilepticus, and the common associated systemic complications.

Can occurrence of convulsive status epilepticus during video telemetry be predicted? Observations from an epilepsy monitoring unit

PURPOSE

The objective of the study was to evaluate the frequency, clinical, and video-electroencephalographic (VEEG) predictors of convlusive status epilepticus (CSE) in the epilepsy-monitoring unit (EMU).

METHODS

The data of all patients who had CSE in our EMU between 2008 and 2017 were reviewed. For each case, two age- and diagnosis-matched subjects who underwent VEEG and did not develop CSE were taken as internal controls. Electro-clinical data of both the groups were compared. Predictors of CSE were assessed using logistic regression analysis.

RESULTS

Out of 11,188 video-telemetries were conducted between 2008-17, forty-three events of CSE (0.38%) were recorded. On comparisons with 86 internal controls no differences were apparent on prevalence of cognitive impairment, structural lesion, number of baseline anti-seizure medications (ASM), ASM taper schedule, ictal patterns, and duration of VEEG monitoring. Inter-ictal rhythmic periodic patterns had significantly higher prevalence in cases (p = 0.028). Logistic regression analysis revealed that odds of CSE were higher with past history of SE [p = 0.008; adjusted odds ratio (OR) = 5.48 (confidence intervals {CI} 1.55-19.28)] and in presence of rhythmic spike and wave discharges [p = 0.016, OR = 33.518(CI = 1.93-581.4)]; the odds were lower if the first two seizures recorded did not evolve into CSE [p = 0.009, OR = 0.247 (CI = 0.08-0.70)] and if there was prior history of daily seizures [p = 0.02, OR = 0.250 (CI = 0.07-0.84)].

CONCLUSION

CSE is a rare yet important adverse event in EMU. Clinical predictors are more relevant in comparison to EEG variables. Extent of ASM withdrawal may not directly account for occurrence of CSE; factors inherent to a patient's epilepsy are deterministic.

PERMIT study: a global pooled analysis study of the effectiveness and tolerability of perampanel in routine clinical practice

The PERaMpanel pooled analysIs of effecTiveness and tolerability (PERMIT) study was a pooled analysis of data from 44 real-world studies from 17 countries, in which people with epilepsy (PWE; focal and generalized) were treated with perampanel (PER). Retention and effectiveness were assessed after 3, 6, and 12 months, and at the last visit (last observation carried forward). Effectiveness assessments included 50% responder rate (≥ 50% reduction in seizure frequency from baseline) and seizure freedom rate (no seizures since at least the prior visit); in PWE with status epilepticus, response was defined as seizures under control. Safety and tolerability were assessed by evaluating adverse events (AEs) and discontinuation due to AEs. The Full Analysis Set included 5193 PWE. Retention, effectiveness and safety/tolerability were assessed in 4721, 4392 and 4617, respectively. Retention on PER treatment at 3, 6, and 12 months was 90.5%, 79.8%, and 64.2%, respectively. Mean retention time on PER treatment was 10.8 months. The 50% responder rate was 58.3% at 12 months and 50.0% at the last visit, and the corresponding seizure freedom rates were 23.2% and 20.5%, respectively; 52.7% of PWE with status epilepticus responded to PER treatment. Overall, 49.9% of PWE reported AEs and the most frequently reported AEs (≥ 5% of PWE) were dizziness/vertigo (15.2%), somnolence (10.6%), irritability (8.4%), and behavioral disorders (5.4%). At 12 months, 17.6% of PWEs had discontinued due to AEs. PERMIT demonstrated that PER is effective and generally well tolerated when used to treat people with focal and/or generalized epilepsy in everyday clinical practice.

Cortical and thalamic hyper-perfusion in non-convulsive status epilepticus. Relationship between perfusion CT patterns and Salzburg EEG criteria

INTRODUCTION

Status epilepticus (SE) is a neurological emergency and in particular nonconvulsive SE (NCSE) represents a diagnostic challenge. To improve clinical decision-making, cerebral perfusion-computed tomography (PCT) has been shown as a helpful tool to support the diagnosis of focal NCSE.

MATERIALS AND METHODS

This is a monocentric retrospective study. Among the 602 cases of SE observed between September 2013 and April 2020 we included 21 patients that were studied with PCT. The perfusion maps were first visually analysed then a quantitative analysis (by regions of interest, ROI) was obtained. For each patient, the diagnostic EEG was reviewed and classified in accordance to the Salzburg Criteria for NCSE (SCC) as definite (D-NCSE) and possible (P-NCSE). Finally, we analysed the relationship between PCT and EEG patterns.

RESULTS

Hyper-perfusion was observed in 18 patients (86%), while in the remaining 3 (14%) a normo-perfused pattern was present. Hyper-perfusion was observed in 14 of the D-NCSE group (88%) and in the two patients with a P-NCSE (100%). No one among the patients with a P-NCSE had a thalamic hyper-perfusion, while among the 6 patients with continuous sustained epileptiform discharges > 2.5 Hz (pattern 1 of SCC), 4 (67%) showed cortical plus thalamic hyper-perfusion.

CONCLUSIONS

PCT could facilitate the differential diagnosis and speed-up the diagnostic process of NCSE in emergency situations. Finding cortical multi-lobar hyper-perfusion, especially if present together with homolateral thalamic hyper-perfusion in a patient with an acute-onset of motor/sensory/language deficits is highly suggestive for the presence of NCSE and is particularly related to continuous/sustained ictal patterns.

Temporal Lobe Epilepsy: What do we understand about protein alterations?

During neuronal diseases, neuronal proteins get disturbed due to changes in the connections of neurons. As a result, neuronal proteins get disturbed and cause epilepsy. At the genetic level, many mutations may take place in proteins like axon guidance proteins, leucine-rich glioma inactivated 1 protein, microtubular protein, pore-forming, chromatin remodeling, and chemokine proteins which may lead toward temporal lobe epilepsy. These proteins can be targeted in the future for the treatment purpose of epilepsy. Novel avenues can be developed for therapeutic interventions by these new insights.

Focal nonconvulsive status epilepticus in children: clinical and electroencephalographic features in 38 patients

PURPOSE

The aim of this study was to characterize clinically, etiologically, and electroencephalographically focal Nonconvulsive Status Epilepticus (NCSE) in children. Moreover, we tried to identify focal NCSE features distinguishing between different ages, NCSE etiologies, and cases of de novo onset.

METHODS

We retrospectively identified patients (aged 1 month to 18 years) who had EEG-documented focal NCSE between January 2001 and December 2019. We analyzed the clinical features, etiology, and EEG features of each event.

RESULTS

Thirty-eight patients were included in this study. NCSE had a de novo onset in 26 patients and was the first manifestation of previously undiagnosed epilepsy in 12 patients. NCSE etiology was acute symptomatic in 13 patients. Acute symptomatic NCSE events were mainly observed in hospitalized children, were usually longer, and had a significantly higher frequency of repetitive EEG patterns than other etiologies. In patients with epilepsy, the etiology of NCSE was remote symptomatic in 14, progressive in 6, and cryptogenic in 5; a definite or suspected genetic disorder was observed in 11. EEG localization was frequent in posterior regions (18 children). Eleven patients had refractory NCSE and 4 required admission to the intensive care unit.

CONCLUSION

Focal NCSE in children is more frequent in the first years of life, mainly involves posterior regions, and often has de novo onset. In the case of de novo focal NCSE both acute symptomatic NCSE and new-onset epilepsy must be considered and investigated. A higher frequency of repetitive EEG patterns and an inpatient setting are significantly associated with acute symptomatic NCSE.

The Benefits of Physical Activity in Children and Adolescents with Epilepsy: A Systematic Review

The aim of this study was to review the literature about the effect of physical activity intervention in children and adolescents with epilepsy. Articles were searched in the central electronic databases of MEDLINE, Embase, PsycAriticles, and CINAHL for the following keywords: “epilepsy,” “seizure,” “physical activity,” “physical exercise,” “exercise therapy,” “sport,” using the Boolean operator “AND” and “OR.” The quality of the selected articles was evaluated by the Physiotherapy Evidence Database scale. Out of the 22 articles selected, 18 did not involve intervention or did not have pre- and postresults and therefore were excluded from the study. The remaining four were studies from Canada and Korea which comprised two long-period interventions and were included in the analysis. Both programs demonstrated a positive effect of physical activity on variables related to psychological well-being and cognitive function. All the four articles demonstrated a lower score of quality. In conclusion, reviewed studies suggest that physical exercise program induces some benefits in children and adolescents with epilepsy. However, the noncontrolled trials and the varied analyses (quantitative vs. qualitative) make it difficult to establish a consensus about benefits of physical activity in epilepsy.

Intravenous Ketamine Bolus(es) for the Treatment of Status Epilepticus, Refractory Status Epilepticus, and Cluster Seizures: A Retrospective Study of 15 Dogs

Status epilepticus (SE) and cluster seizures (CS) are common occurrences in veterinary neurology and frequent reasons of admission to veterinary hospitals. With prolonged seizure activity, gamma amino-butyric acid (GABA) receptors (GABAa receptors) become inactive, leading to a state of pharmacoresistance to benzodiazepines and other GABAergic medications, which is called refractory status epilepticus (RSE). Prolonged seizure activity is also associated with overexpression of N-methyl-D-aspartic (NMDA) receptors. Rodent models have shown the efficacy of ketamine (KET) in treating RSE, and its use has been reported in one canine case of RSE. Boluses of KET 5 mg/kg IV have become the preferred treatment for RSE in our hospital. A retrospective study was performed to evaluate and report our experience with KET IV bolus to treat prolonged and/or repeated seizure activity in cases of canine CS, SE, and RSE. A total of 15 dogs were retrieved, for 20 hospitalizations and 28 KET IV injections over 3 years. KET IV boluses were used 12 times for RSE (9 generalized seizures, 3 focal seizures) and KET terminated the episode of RSE 12/12 times (100%); however, seizures recurred 4/12 times (33%) within ≤6 h of KET IV bolus. When used for CS apart from episodes of RSE, KET IV bolus was associated with termination of the CS episode only 4/14 times (29%). Only 4/28 (14%) KET IV boluses were associated with adverse effects imputable only to the use of KET. One dog experienced a short, self-limited seizure activity during administration of KET IV, which was most likely related to a pre-mature use of KET IV (i.e., before GABAergic resistance and NMDA receptor overexpression had taken place). This study indicates that KET 5 mg/kg IV bolus may be successful for the treatment of RSE in dogs.

Status Epilepticus: Definition, Classification, Pathophysiology, and Epidemiology

Status epilepticus (SE) is the state of continuous or repetitive seizures, which can occur with or without convulsions. Evolving definitions of SE take into account the concept that neuronal injury may occur at different times in different types of SE.SE that does not respond to initial treatment may become refractory or even super-refractory. Nonconvulsive SE is increasingly recognized in comatose patients in critical care units, with the growing use of continuous electroencephalogram monitoring. SE is a neurologic emergency that carries a high risk of mortality and morbidity.

Frequency and predictors of 30-day readmission after an index hospitalization for generalized convulsive status epilepticus: A nationwide study

OBJECTIVE

The objective of the study was to assess the frequency and factors associated with all-cause 30-day readmission among patients hospitalized with generalized convulsive status epilepticus (GCSE) in a nationwide sample in the United States.

METHODS

We used The 2014 Nationwide Readmission Database (NRD) as the data source. We included adults (age ≥18 years) with a primary discharge diagnosis of GCSE, identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 345.3. We excluded patients who died during hospitalization and those who had missing information on the length of stay (LOS). We also excluded those discharged in December 2014. We computed the overall 30-day readmission rate and compared prespecified groups by their 30-day readmission status. We applied a multiple logistic regression analysis to identify independent predictors of all-cause 30-day readmission adjusting for potential confounders.

RESULTS

Among 14,562 (weighted 31,062) adults discharged with a diagnosis of GCSE, 2520 (17.3%) were readmitted within 30 days. In multivariate analysis, patients with comorbid conditions (odds ratio (OR) for Charlson Comorbidities Index (CCI) = 1 and ≥2 was 1.12, 95% confidence interval (CI): 1.0-1.36 and 1.32, 95% CI: 1.17-1.48, respectively), LOS >6 days (OR: 1.42; 95% CI: 1.05-192), discharged against medical advice (OR: 1.45; 95% CI: 1.09-1.92), or discharged to a short-term hospital (OR: 1.39; 95% CI: 1.0-1.88), had higher odds of 30-day readmission, while there was an inverse association for those aged ≥45 years or with high income. Seizures were the most common cause associated with readmission, followed by sepsis and cerebrovascular diseases, respectively.

SIGNIFICANCE

Little is known about the frequency and predictors of early readmission after GCSE. This study showed that more than one in six patients with GCSE was readmitted within 30 days after discharge. More considerable attention to high-risk subgroups may identify opportunities to ameliorate the clinical outcome and lessen the economic burden of early readmission after GCSE.

The evolution of the pilocarpine animal model of status epilepticus

The pilocarpine animal model of status epilepticus is a well-established, clinically translatable model that satisfies all of the criteria essential for an animal model of status epilepticus: a latency period followed by spontaneous recurrent seizures, replication of behavioural, electrographic, metabolic, and neuropathological changes, as well as, pharmacoresistance to anti-epileptic drugs similar to that observed in human status epilepticus. However, this model is also characterized by high mortality rates and studies in recent years have also seen difficulties in seizure induction due to pilocarpine resistant animals. This can be attributed to differences in rodent strains, species, gender, and the presence of the multi-transporter, P-glycoprotein at the blood brain barrier. The current paper highlights the various alterations made to the original pilocarpine model over the years to combat both the high mortality and low induction rates. These range from the initial lithium-pilocarpine model to the more recent Reduced Intensity Status Epilepticus (RISE) model, which finally brought the mortality rates down to 1%. These modifications are essential to improve animal welfare and future experimental outcomes.

Neuroinflammation impact in epileptogenesis and new treatment strategy

Epilepsy is considered a major serious chronic neurological disorder, characterized by recurrent seizures. It is usually associated with a history of a lesion in the nervous system. Irregular activation of inflammatory molecules in the injured tissue is an important factor in the development of epilepsy. It is unclear how the imbalanced regulation of inflammatory mediators contributes to epilepsy. A recent research goal is to identify interconnected inflammation pathways which may be involved in the development of epilepsy. The clinical use of available antiepileptic drugs is often restricted by their limitations, incidence of several side effects, and drug interactions. So development of new drugs, which modulate epilepsy through novel mechanisms, is necessary. Alternative therapies and diet have recently reported positive treatment outcomes in epilepsy. Vitamin D (Vit D) has shown prophylactic and therapeutic potential in different neurological disorders. So, the aim of current study was to review the associations between different brain inflammatory mediators and epileptogenesis, to strengthen the idea that targeting inflammatory pathway may be an effective therapeutic strategy to prevent or treat epilepsy. In addition, neuroprotective effects and mechanisms of Vit D in clinical and preclinical studies of epilepsy were reviewed.

Etiological assessment of status epilepticus

Status epilepticus (SE) is a potentially serious condition that can affect vital and functional prognosis and requires urgent treatment. Etiology is a determining factor in the patient's functional outcome and in almost half of all cases justifies specific treatment to stop progression. Therefore, identifying and addressing the cause of SE is a key priority in SE management. However, the etiology can be difficult to identify among acute and remote causes, which can also be multiple and interrelated. The most common etiologies are the discontinuation of antiepileptic medication in patients with a prior history of epilepsy, and acute brain aggression in cases of new onset SE (cerebrovascular pathologies are the most common). The list of remaining possible etiologies includes heterogeneous pathological contexts. Refractory SE and especially New-Onset Refractory Status Epilepticus (NORSE) lead to an extension of the etiological assessment in the search for encephalitis of autoimmune or infectious origin in adults and in children, as well as a genetic pathology in children in particular. This is an overview of current knowledge of SE etiologies and a pragmatic approach for carrying out an etiological assessment based on the following steps: - Which etiological orientation is identified according to the field and clinical presentation?; - Which etiologies to look for in an inaugural SE?; - Which first-line assessment should be carried out? The place of the biological, EEG and imaging assessment is discussed; - Which etiologies to look for in case of refractory SE?

The Effect of Low-Doses of Caffeine and Taurine on Convulsive Seizure Parameters in Rats

Introduction: Caffeine, an adenosine-receptor blocker, is believed to have neuronal excitatory effects, while Taurine, a mammalian amino acid, was shown to have neuroinhibitory effects. Aim: The aim of this study was to investigate the effects of acute and chronic administration of low doses of Caffeine and Taurine on the seizure threshold in rats. Methods: Six-week-old Sprague-Dawley male rats (n = 280) were divided randomly into five groups (control, acute caffeine intake, acute taurine intake, chronic caffeine intake and chronic taurine intake), with five subgroups per group according to five different doses of Pentylenetetrazole (PTZ) injections. Each subgroup consisted of eight rats. Data was entered and analyzed using Microsoft EXCEL and Addinsoft^TM XLSTAT (Version 2012.6.06; New York, NY, USA). p-value = 0.05 was regarded as statistically significant. Results: There was a significant decrease in the latency of PTZ-induced seizures with both acute (p-value < 0.05) and chronic (p-value < 0.01) Caffeine treatment groups. Chronic exposure to Caffeine exhibited an increase in the probability of seizures (p-value < 0.05). However, acute exposure to Caffeine did not show a significant impact on the probability of seizures. Neither acute nor chronic exposures to Taurine had an effect on the probability of seizures, nor on the latency of PTZ-induced seizures. Discussion: Our study found that acute as well as chronic exposure to low doses of Caffeine (50 and 80 mg/kg) reduces the threshold, and hence increases the likelihood for seizures since it favors a state of neuronal hyper excitability through blocking of all adenosine receptors. On the other hand, acute or chronic exposure to Taurine did not show a significant effect on the PTZ-induced seizures parameters.