Status epilepticus and alcohol abuse: an analysis of 82 status epilepticus admissions

Incidence rate and risk factors of status epilepticus after stroke

Purpose To evaluate the incidence rate and risk factors for status epilepticus (SE) after stroke (PSSE), including ischaemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). Methods A meta-analysis was performed using relevant research from databases such as PubMed, Embase, Cochrane Online Library, and Clinicaltrials.gov. The quality of the studies was evaluated by using the quality evaluation criteria of the Agency for Healthcare Research and Quality (AHRQ). All data were pooled by STATA 12.0 software for meta-analysis. Results The review considered 1650 articles, and 17 articles with 2821 instances of SE among 1088087 instances of stroke were included. The incidence rate of SE after stroke was 6.90 per 1000 total strokes (95% CI: 5.58-8.22). By subgroup analysis of SE, the rates were 33.85‰ (95% CI: 13.77-53.94) for non-convulsive status epilepticus (NCSE) and 2.42‰ (95%CI: 1.66-3.19) for generalized convulsive status epilepticus (GCSE). Age, sex, and presence of atrial fibrillation showed no significant difference between the SE group and the non-SE group after stroke. Hypertension and diabetes are associated with a decreased rate of SE. However, African American race, alcohol abuse, and renal disease are associated with an increased rate of SE. Significance There were approximately 6.9 patients with status epilepticus per 1000 strokes. NCSE is more common after stroke and needs more attention. African American race, alcohol abuse and renal disease may be risk factors for PSSE.

Alcohol withdrawal upregulates mRNA encoding for CaV2.1-α1 subunit in the rat inferior colliculus

We previously reported increased current density through P-type voltage-gated Ca²⁺ channels in inferior colliculus (IC) neurons during alcohol withdrawal. However, the molecular correlate of this increased P-type channel current is currently unknown. Here, we probe changes in mRNA and protein expression of the pore-forming Ca_V2.1-α1 (P/Q-type) subunits in IC neurons during the course of alcohol withdrawal-induced seizures (AWSs). Rats received three daily doses of ethanol or the vehicle every 8 h for 4 consecutive days. The IC was dissected at various time intervals following alcohol withdrawal, and the mRNA and protein levels of the Ca_V2.1-α1 subunits were measured. In separate experiments, rats were tested for acoustically evoked seizure susceptibility 3, 24, and 48 h after alcohol withdrawal. AWSs were observed 24 h after withdrawal; no seizures were observed at 3 or 48 h or in the control-treated rats. Compared to control-treated rats, the mRNA levels of the Ca_V2.1-α1 subunit were increased 1.9-fold and 2.1-fold at 3 and 24 h, respectively; change in mRNA expression was nonsignificant at 48 h following alcohol withdrawal. Western blot analyses revealed that protein levels of the Ca_V2.1-α1 subunits were not altered in IC neurons following alcohol withdrawal. We conclude that expression of the Cacna1a mRNA increased before the onset of AWS susceptibility, suggesting that altered Ca_V2.1 channel expression may play a role in AWS pathogenesis.

Problems and controversies in status epilepticus: a review and recommendations

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.

Death from seizures induced by chronic alcohol abuse—Does it exist?

In a forensic setting, deaths due to seizures, either epileptic or other, present a well-known problem. Cause of death is rarely established on the basis of physical evidence, but on circumstantial evidence such as tongue biting or discharge of urine or faeces. Seizures have several different aetiologies, but in police reports a person known to have seizures is most likely to be reported as suffering from epilepsy. It is a well-known fact that alcoholics have seizures either due to "alcohol-induced epilepsy" or due to withdrawal from drinking. It also seems to be generally accepted that alcoholics may die from these seizures. A literature study was performed of deaths due to alcohol-induced seizures, either during withdrawal or as late-onset seizures where the aetiology was established as long time alcohol abuse and a necropsy had shown no other possible cause of death than a seizure.

RESULTS

It was not possible to find any well-documented cases. It is, however, difficult to compare cases in the literature, as there is no generally accepted classification or nomenclature of seizures related to alcohol abuse.

Seizures in alcohol-dependent patients: epidemiology, pathophysiology and management

The relationship between alcohol and seizures is complex and multifaceted. The prevalence of epilepsy in alcohol-dependent patients of western industrialised countries may be at least triple that in the general population, whereas the prevalence of alcoholism is only slightly higher in patients with epilepsy than in the general population. The seizure threshold is raised by alcohol drinking and declines on cessation of drinking. As a result, during withdrawal from alcohol, usually 6-48 hours after the cessation of drinking, seizures may occur. Alcohol acts on the brain through several mechanisms that influence seizure threshold. These include effects on calcium and chloride flux through the ion-gated glutamate NMDA and GABA receptors. During prolonged intoxication, the CNS adapts to the effects of alcohol, resulting in tolerance; however, these adaptive effects seem to be transient, disappearing after alcohol intake is stopped. Although the relationship of seizures to alcohol use is likely to be dose dependent and causal, the available clinical data do not suggest that alcohol use results in seizure genesis. However, a genetic predisposition to alcohol withdrawal seizures is possible. Other seizures in alcohol-dependent individuals may be due to concurrent metabolic, toxic, infectious, traumatic, neoplastic and cerebrovascular diseases and are frequently partial-onset seizures. Alcohol abuse is a major precipitant of status epilepticus (9-25% of cases), which may even be the first-ever seizure type. Prompt treatment of alcohol withdrawal seizures is recommended to prevent status epilepticus. During the detoxification process, primary and secondary preventative measures can be taken. A meta-analysis of controlled trials for the primary prevention of alcohol withdrawal seizures demonstrated a highly significant risk reduction for seizures with benzodiazepines and antiepileptic drugs and an increased risk with antipsychotics. A meta-analysis of randomised, placebo-controlled trials for the secondary prevention of seizures after alcohol withdrawal showed lorazepam to be effective, whereas phenytoin was ineffective. Because withdrawal seizures do not recur if the patient remains abstinent, long-term administration of antiepileptic drugs is unnecessary in abstinent patients. The first seizure not related to alcohol withdrawal should not result in permanent drug treatment in an alcohol-dependent patient, because of poor compliance and the high likelihood of remission. The treatment of alcohol dependence is more important and should be prioritised before the prevention of further seizures.

Status epilepticus arising de novo in hospitalized patients: an analysis of 41 patients

Most of the information on predisposing factors and mortality in status epilepticus (SE) arises from data obtained from patients presenting to the casualty department. However, another population which is frequently seen by consultative neurologists are medically ill patients who develop SE while in hospital. These patients are often notoriously difficult to treat once SE arises. We sought to characterize patients at risk for SE arising when they are hospitalized for other reasons. By doing this, risk factors for developing SE and prognostic indicators might be determined. We retrospectively reviewed records from three urban hospitals in the United States to identify hospitalized patients developing SE over a 1 year period. SE was defined as a clinical seizure lasting 30 minutes or longer, or repeated seizures without recovery. Patients who were admitted in SE or for an epilepsy-related problem, or who were less than 1 year old were excluded from the study. Forty-one patients with in-hospital SE were identified. There were 28 males and 13 females with an age range from 1 to 91 years (mean: 60 years, median: 65 years). The mean interval from hospital admission to the onset of status epilepticus was 26 days. Nineteen (46%) patients had a prior history of either epilepsy or symptomatic seizures, and of these, 10 were inadequately treated as judged by serum anticonvulsant levels at the time SE developed. Focal brain abnormality was present in 26 (63%) patients, the most common of which was stroke (17 patients ). Major metabolic derangements including hypoxia, electrolyte imbalance, hepatic encephalopathy, and sepsis were present in 23 (56%) patients. Eleven (27%) patients were being treated with theophylline preparations at the time SE developed. Mortality in this group of patients with in-hospital SE was 61% (25 deaths), with about one-third dying while in status, and two-thirds dying subsequently in hospital. In this retrospective study, there was no clear relationship between mortality and the duration of SE in this group of patients. In-hospital development of SE is usually related to underlying focal brain abnormality, especially stroke, in combination with systemic metabolic derangement. Prognosis is poor, and appears to be more related to underlying conditions rather than to status duration. More accurate prospective studies are warranted.

Fosphenytoin and phenytoin in patients with status epilepticus: improved tolerability versus increased costs

Tonic-clonic status epilepticus (TCSE) is the most common neurological emergency and affects approximately 60000 patients each year in the US. The risk of complications increases substantially as TCSE lasts longer than 60 minutes. Ideally, drugs used to treat this condition should be well tolerated when administered as rapid intravenous infusions and should not interfere with patients' state of consciousness or cardiovascular and respiratory functions. Because of its efficacy, absence of sedation or respiratory suppression, intravenous phenytoin has largely replaced phenobarbital (phenobarbitone) as the second agent of choice (following the administration of a benzodiazepine) in the treatment of TCSE. While the efficacy of phenytoin in the treatment of acute seizures and TCSE is well established, the parenteral formulation of phenytoin has several inherent shortcomings which compromise its tolerability and limit the rate of administration. Intravenous phenytoin has been associated with fatal haemodynamic complications and serious reactions at the injection site including skin necrosis and amputation of extremities. Fosphenytoin, a phenytoin prodrug, has the same pharmacological properties as phenytoin but none of the injection site and cardiac rhythm complications of intravenous infusions of phenytoin. While fosphenytoin costs more than intravenous phenytoin, treating the acute and chronic complications of TCSE itself, and the complications of intravenous phenytoin can also be costly. All other factors being equal, there is no doubt that fosphenytoin is better tolerated and can be delivered faster than intravenous phenytoin; 2 measures that clearly improve outcome in patients with TCSE. The tolerability of intramuscular fosphenytoin also extends its use to clinical situations where prompt administration of a nondepressing anticonvulsant is indicated but secure intravenous access and cardiac monitoring are not available, such as treatment of seizures by rescue squads in the field and serial seizures in the institutionalised, elderly and other patients with intractable epilepsy.

Epileptological emergencies in accident and emergency: a survey at St James's university hospital, Leeds

Many patients attending an Accident and Emergency (A&E) department with seizures never come into contact with a neurological service. This survey was designed to find out how many patients with epileptological emergencies come to A&E and how they are managed. Cases were identified using the computerized A&E database. The A&E records of all adult patients attending the casualty department at St James's University Hospital with emergencies related to epilepsy between 1 April and 30 September 1998 were reviewed retrospectively. Out of a total of 36 024 adults attending A&E, 190 were related to epileptological emergencies. A problem relating to a previously recognized seizure disorder was the commonest reason for attendance. Patient management was highly variable and often suboptimal. Descriptions of seizure semiology and examination findings were frequently deficient. Up to 37.5 mg of diazepam, in up to five boluses, was given. Twenty per cent of patients with a diagnosis of status epilepticus were discharged home after diazepam treatment. Neurologists only became involved in 24.2% of cases. Epileptological emergencies only make up a small proportion of cases seen in adult A&E departments. Treatment and referral guidelines should be agreed between A&E staff and neurologists. The communication between general, specialist and acute services needs to be improved.

Generalized convulsive status epilepticus: causes, therapy, and outcome in 346 patients

We report data from 346 admissions for generalized tonic-clonic convulsive status epilepticus (GC-SE); 68% had had epilepsy previously. Outcome was determined by underlying cause, SE duration of > 4 h, the presence of more than one medical complication, and the quality of therapy and management. Clonazepam (CZP), diazepam (DZP), and phenytoin (PHT) were most frequently used for treatment.

Status epilepticus related to alcohol abuse

We reviewed the case records of 249 adult patients with generalized convulsive status epilepticus (SE) examined in San Francisco General Hospital between 1977 and 1989 and identified 27 patients (10.8%) in whom alcohol abuse was the only identifiable precipitating cause of SE. In 12 patients (44% of the study group), SE was the first presentation of alcohol-related seizures. Seizures with focal features were observed in 11 patients (40.1%), but there was little correlation with localized computed tomography (CT) or EEG abnormalities. SE was controlled with phenytoin (PHT), with or without a benzodiazepine (BZD), in 18 patients (66.7%). Twenty-two patients (81.5%) were discharged with no new neurologic deficits, but time to recovery of baseline mental status was prolonged (> 12 h) in 24 patients. With regard to alcohol abuse history, study patients did not differ from a comparison group with isolated alcohol withdrawal seizures. The results indicate that alcohol abuse is a common cause of SE and that SE may be the first presentation of alcohol-related seizures. Furthermore, the outcome of patients with alcohol-related SE compares favorably with that of patients with SE due to other causes, but recovery of these patients may be complicated by a prolonged postictal state.

Alcohol-related seizures, Part II: Clinical presentation and management

Alcoholism may be society's most devastating problem short of war and malnutrition. Perhaps the most complex and preplexing medical complication of alcoholism is alcohol-related seizures. This article is a collective review designed to provide emergency physicians with an overview of the topic that is pertinent to their clinical practice. Part 1 addressed the pathophysiology, differential diagnosis, and evaluation of alcohol-related seizures. Part 2 focuses on the clinical presentation, management, and disposition. In addition, a classification of alcohol-related seizures is proposed.

Generalized convulsive status epilepticus: pathophysiology and treatment

The treatment of generalized convulsive status epilepticus according to a protocol, including a time schedule, prevents unnecessary delay and improves outcome. Based on a literature study and our own clinical experiences a treatment protocol is discussed with special emphasis on medical complications, choice of antiepileptic drugs, route of administration and a proper time schedule.

Outcome in subjects with alcohol-provoked seizures

The outcome in 165 subjects with either an unknown (n = 93) or an alcohol-related (n = 72) seizure etiology, admitted to the emergency room of a general hospital in 1977-1978, was assessed after 10 years on the basis of subsequent hospital records and death-certificate-based mortality data. Alcohol and/or drug poisoning was the most frequent cause of death in the group with alcohol-related seizures. Sixty-four percent of the deaths in this group were directly related to alcohol abuse. The crude mortality was 45.8 (expected 8.6)/100 persons/10 years in the group with alcohol-related seizures and 15.1 (expected 6.0)/100 persons/10 years in the other group, the odds ratio between the groups being 4.8. Twenty percent of those with an unknown seizure etiology were found to show alcohol-related seizures, while the seizure etiology remained unknown in 59%, and a specific etiology other than alcohol abuse was revealed in 21% during the follow-up period. We conclude that alcohol abuse is an important, though often undetected, seizure etiology carrying a poor prognosis. The difference in mortality between the groups was due more to alcoholism than to seizures. There was no difference in mortality between those with a first alcohol-related seizure and those with previous alcohol-related seizures.

Late auditory evoked potentials in alcoholics. Identifying those with a history of epileptic seizures during withdrawal

The N1-P2 wave of the auditory evoked potential was studied in 19 alcoholics, six of whom had withdrawal seizures on previous admissions. The recordings were made at 1 and 5 days after cessation of drinking. Eight nonalcoholic volunteers were used as controls. The latencies of N1 and P2 were slightly prolonged in alcoholics, but during the detoxification period they frequently shortened (p less than 0.05), occasionally attaining the values of the controls. One day after withdrawal, the amplitude of N1-P2 was consistently reduced in the alcoholics compared to the controls (p less than 0.05 and p less than 0.01), but higher in alcoholics with a seizure history compared to alcoholics without seizures (p less than 0.05 and p less than 0.001). Five days after cessation of drinking, the amplitude in the alcoholic groups always increased from the admission values (p less than 0.05 and p less than 0.01). By that time, the alcoholics with a history of withdrawal seizures had significantly (p less than 0.05 and p less than 0.01) higher amplitudes than those of the controls or the alcoholics without seizures. Large N1-P2 amplitude during alcohol withdrawal may reflect increased cerebral excitability and contribute to the identification of alcoholics with high risk for withdrawal seizures.

Status epilepticus in the elderly: etiology, seizure type and outcome

We have studied status epilepticus among 342 patients who had their first seizures after the age of 60 years. One hundred and two patients (30%) had status epilepticus. Cerebrovascular disease (35%) was the leading cause of status, followed by head trauma (21%), multifactorial etiology (11%), metabolic disorders (10%), brain tumors (8%) and CNS infection (2%). The etiology of status remained undetermined in 13 patients (13%). The majority (80%) had partial status or generalized status with focal onset. Overall mortality was 35%.

Calcium channel antagonist receptors in cerebral cortex from alcoholic patients

Exposure to ethanol for days to weeks enhances the expression of voltage-dependent Ca2+ channels in the brains of experimental animals and in cultured neural cell lines. To determine if similar changes occur in the brains of alcoholic patients, we measured the binding of (+)-[3H]PN 200-110 to cerebral cortex samples obtained at autopsy from alcoholic and non-alcoholic patients. No difference in (+)-[3H]PN 200-110 binding was observed, suggesting that ethanol-induced changes in Ca2+ channel expression are more likely to be related to acute withdrawal than to chronic ethanol exposure alone.

Alcohol, seizures, and epilepsy

Seizures, epilepsy, and alcohol are complexly interrelated. Although it is commonly perceived that patients with epilepsy experience problems with seizure control if they use alcohol, this is not confirmed by the few experimental studies that have tested the hypothesis. The last 30 years have emphasized the role of withdrawal from alcohol as a mechanism of seizure production. However, this is but one of many potential mechanisms by which seizures and epilepsy may be related to alcohol use and abuse. The rare but clear situations in which alcohol can act as a convulsant drug need further study, and mechanisms by which the long-term neurotoxic effects of alcohol lead to chronic epilepsy also need further elucidation.

Alcohol withdrawal and carbamazepine

The use of pharmacologic intervention in the management of alcohol withdrawal syndrome is briefly presented. The use of carbamazepine, a tricyclic anticonvulsant with clinical efficacy in depressive illness, in alcohol withdrawal treatment is reviewed. A comparative analysis between carbamazepine and major drugs used in alcohol withdrawal syndrome is made. This includes the evaluation of both clinical advantages and disadvantages in addition to identification of drug adverse reaction and interaction with alcohol. The mechanism of action of carbamazepine is also examined. Carbamazepine appears to possess a useful pharmacotherapeutic potential in the management of acute alcohol withdrawal syndrome, and its use in long-term treatment is suggested.