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Jha R, Blitz SE, Chua MMJ, Warren AEL, Lee JW, Rolston JD. Surgical management of status epilepticus: A systematic review. Epilepsia Open 2024. [PMID: 38456595 DOI: 10.1002/epi4.12924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/07/2023] [Accepted: 02/09/2024] [Indexed: 03/09/2024] Open
Abstract
Status Epilepticus (SE), unresponsive to medical management, is associated with high morbidity and mortality. Surgical management is typically considered in these refractory cases. The best surgical approach for affected patients remains unclear; however, given the lack of controlled trials exploring the role of surgery. We performed a systematic review according to PRIMSA guidelines, including case reports and series describing surgical interventions for patients in SE. Cases (157 patients, median age 12.9 years) were followed for a median of 12 months. Patients were in SE for a median of 21 days before undergoing procedures including: focal resection (36.9%), functional hemispherectomy (21%), lobar resection (12.7%), vagus nerve stimulation (VNS) (12.7%), deep brain stimulation (DBS) (6.4%), multiple subpial transection (MST) (3.8%), responsive neurostimulation (RNS) (1.9%), and cortical stimulator placement (1.27%), with 24 patients undergoing multiple procedures. Multiple SE semiologies were identified. 47.8% of patients had focal seizures, and 65% of patients had focal structural abnormalities on MRI. SE persisted for 36.8 ± 47.7 days prior to surgical intervention. SE terminated following surgery in 81.5%, terminated with additional adjuncts in 10.2%, continued in 1.9%, and was not specified in 6.4% of patients. Long-term seizure outcomes were favorable, with the majority improved and 51% seizure-free. Eight patients passed away in follow-up, of which three were in SE. Seizures emerging from one hemisphere were both more likely to immediately terminate (OR 4.7) and lead to long-term seizure-free status (OR 3.9) compared to nonunilateral seizures. No other predictors, including seizure focality, SE duration, or choice of surgical procedure, were predictors of SE termination. Surgical treatment of SE can be effective in terminating SE and leading to sustained seizure freedom, with many different procedures showing efficacy if matched appropriately with SE semiology and etiology. PLAIN LANGUAGE SUMMARY: Patients with persistent seizures (Status Epilepticus) that do not stop following medications can be treated effectively with surgery. Here, we systematically review the entirety of existing literature on surgery for treating status epilepticus to better identify how and when surgery is used and what patients do after surgery.
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Affiliation(s)
- Rohan Jha
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sarah E Blitz
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Melissa M J Chua
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Aaron E L Warren
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jong Woo Lee
- Department of Neurology, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - John D Rolston
- Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Jia R, Zhu G, Zhao R, Li T, Jiang W, Cui X. Hydrogen treatment reduces electroencephalographic activity and neuronal death in rats with refractory status epilepticus by inhibiting membrane NR2B phosphorylation and oxidative stress. J Int Med Res 2024; 52:3000605241235589. [PMID: 38546233 PMCID: PMC10981235 DOI: 10.1177/03000605241235589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/09/2024] [Indexed: 04/01/2024] Open
Abstract
OBJECTIVE To investigate the effects of hydrogen therapy on epileptic seizures in rats with refractory status epilepticus and the underlying mechanisms. METHODS Status epilepticus was induced using pilocarpine. The effects of hydrogen treatment on epilepsy severity in model rats were then monitored using Racine scores and electroencephalography (EEG), followed by western blot of plasma membrane N-methyl-D-aspartate receptor subtype 2B (NR2B) and phosphorylated NR2B expression. We also generated a cellular epilepsy model using Mg2+-free medium and used polymerase chain reaction to investigate the neuroprotective effects of hydrogen. RESULTS There were no significant differences in Racine scores between the hydrogen and control groups. EEG amplitudes were lower in the hydrogen treatment group than in the control group. In epilepsy model rats, hippocampal cell membrane NR2B expression and phosphorylation increased gradually over time. Although hippocampal cell membrane NR2B expression was not significantly different between the two groups, NR2B phosphorylation levels were significantly lower in the hydrogen group. Hydrogen treatment also increased superoxide dismutase, mitochondrial (SOD2) expression. CONCLUSIONS Hydrogen treatment reduced EEG amplitudes and NR2B phosphorylation; it also decreased neuronal death by reducing oxidative stress. Hydrogen may thus be a potential treatment for refractory status epilepticus by inhibiting membrane NR2B phosphorylation and oxidative stress.
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Affiliation(s)
- Ruihua Jia
- Department of Neurology, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Gemin Zhu
- Department of Neurology, Xi’an Central Hospital, Xi’an, China
| | - Rui Zhao
- Department of Neurology, Shaanxi Provincial People’s Hospital, Xi’an, China
| | - Tian Li
- School of Basic Medicine, Fourth Military Medical University, Xi’an, China
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Xiaoli Cui
- Department of Neurology, Shaanxi Provincial People’s Hospital, Xi’an, China
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Straka B, Koblížek M, Splítková B, Valkovičová R, Krsková L, Kalinová M, Vlčková M, Zámečník J, Laššuthová P, Sedláčková L, Staněk D, Maulisová A, Tichý M, Kynčl M, Kršek P. A 5-year-old boy with super- refractory status epilepticus and RANBP2 variant warranting life-saving hemispherotomy. Epilepsia Open 2024; 9:424-431. [PMID: 37943122 PMCID: PMC10839359 DOI: 10.1002/epi4.12863] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/05/2023] [Indexed: 11/10/2023] Open
Abstract
Focal cortical dysplasia (FCD) represents the most common cause of drug-resistant epilepsy in adult and pediatric surgical series. However, genetic factors contributing to severe phenotypes of FCD remain unknown. We present a patient with an exceptionally rapid development of drug-resistant epilepsy evolving in super-refractory status epilepticus. We performed multiple clinical (serial EEG, MRI), biochemical (metabolic and immunological screening), genetic (WES from blood- and brain-derived DNA), and histopathological investigations. The patient presented 1 month after an uncomplicated varicella infection. MRI was negative, as well as other biochemical and immunological examinations. Whole-exome sequencing of blood-derived DNA detected a heterozygous paternally inherited variant NM_006267.4(RANBP2):c.5233A>G p.(Ile1745Val) (Chr2[GRCh37]:g.109382228A>G), a gene associated with a susceptibility to infection-induced acute necrotizing encephalopathy. No combination of anti-seizure medication led to a sustained seizure freedom and the patient warranted induction of propofol anesthesia with high-dose intravenous midazolam and continuous respiratory support that however failed to abort seizure activity. Brain biopsy revealed FCD type IIa; this finding led to the indication of an emergency right-sided hemispherotomy that rendered the patient temporarily seizure-free. Postsurgically, he remains on antiseizure medication and experiences rare nondisabling seizures. This report highlights a uniquely severe clinical course of FCD putatively modified by the RANBP2 variant. PLAIN LANGUAGE SUMMARY: We report a case summary of a patient who came to our attention for epilepsy that could not be controlled with medication. His clinical course progressed rapidly to life-threatening status epilepticus with other unusual neurological findings. Therefore, we decided to surgically remove a piece of brain tissue in order to clarify the diagnosis that showed features of a structural brain abnormality associated with severe epilepsy, the focal cortical dysplasia. Later, a genetic variant in a gene associated with another condition, was found, and we hypothesize that this genetic variant could have contributed to this severe clinical course of our patient.
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Affiliation(s)
- Barbora Straka
- Department of Paediatric NeurologyMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
| | - Miroslav Koblížek
- Department of Pathology and Molecular MedicineMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
| | - Barbora Splítková
- Department of Paediatric NeurologyMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
| | - Radka Valkovičová
- Department of Paediatric NeurologyMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
| | - Lenka Krsková
- Department of Pathology and Molecular MedicineMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
| | - Markéta Kalinová
- Department of Pathology and Molecular MedicineMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
- Present address:
University Hospital Královské VinohradyŠrobárova 1150/50Prague 10100 34Czech Republic
| | - Markéta Vlčková
- Department of Biology and Medical GeneticsMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
| | - Josef Zámečník
- Department of Pathology and Molecular MedicineMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
| | - Petra Laššuthová
- Department of Paediatric NeurologyMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
| | - Lucie Sedláčková
- Department of Paediatric NeurologyMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
| | - David Staněk
- Second Faculty of Medicine, Charles UniversityPragueCzech Republic
- Present address:
DNAnexus Czech RepublicPernerova 697/35, KarlínPrague186 00Czech Republic
| | - Alice Maulisová
- Department of Clinical PsychologyMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
| | - Michal Tichý
- Department of NeurosurgeryMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
| | - Martin Kynčl
- Department of RadiologyMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
| | - Pavel Kršek
- Department of Paediatric NeurologyMotol University Hospital and Second Faculty of Medicine, Charles UniversityPragueCzech Republic
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Sogano J, Kosugi K, Okano A, Nihei Y, Watanabe N, Nakahara J, Toda M. Probable Sporadic Creutzfeldt-Jakob Disease Presenting as Refractory Status Epilepticus in a Poststroke Epilepsy Patient: A Case Report. NMC Case Rep J 2023; 10:349-354. [PMID: 38249433 PMCID: PMC10796903 DOI: 10.2176/jns-nmc.2023-0166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/11/2023] [Indexed: 01/23/2024] Open
Abstract
In this study, we report on a case of probable sporadic Creutzfeldt-Jakob disease (sCJD) diagnosed after a difficult course of status epilepticus (SE) in a patient with poststroke epilepsy. The patient was admitted with progressive cognitive decline and convulsive SE; therefore, it was initially thought that the patient had developed SE due to nonadherence to antiseizure medication (ASM) use, but despite treatment with ASMs after admission, no improvement was noted in consciousness disturbance or lateralized periodic discharges (LPDs) on electroencephalogram (EEG) examination. After a refractory course, the progression of LPDs to generalized periodic discharges (GPDs) on EEG and abnormal magnetic resonance imaging (MRI) findings met the diagnostic criteria of sCJD. Even if the patient had epilepsy, such as poststroke epilepsy, as in this case, it is essential to consider other underlying causes, including CJD in cases of superrefractory SE.
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Affiliation(s)
- Junki Sogano
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Kenzo Kosugi
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
| | - Atsushi Okano
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshihiro Nihei
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Narumi Watanabe
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Toda
- Department of Neurosurgery, Keio University School of Medicine, Tokyo, Japan
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Bechri I, Shimi A, Derkaoui A, Khatouf M. Status Epilepticus in a Tertiary Care Hospital in Morocco: A Retrospective Analysis. Cureus 2023; 15:e50591. [PMID: 38222150 PMCID: PMC10788123 DOI: 10.7759/cureus.50591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2023] [Indexed: 01/16/2024] Open
Abstract
Background Status epilepticus (SE) is a common neurologic emergency with high rates of mortality and morbidity. Objective To analyze the clinical characteristics, causes, management, and outcomes of patients with SE in a tertiary care hospital in Morocco. Methods A retrospective study was conducted from January 2019 to December 2021, including all patients admitted to the medico-surgical general intensive care unit (ICU) with a diagnosis of SE. We recorded demographic characteristics, SE clinical history, management, causes, and discharge outcomes. Results Overall, 82 patients with SE were included, the median age was 39.5 years (18-95), 61% of the patients were male, the majority of semiology was convulsive SE (93%, N: 77), epilepsy of unknown cause was the most common diagnosis (41.2%, N: 34), and the most known etiology was acute/subacute cerebrovascular events (12 patients, 14.4%). All patients received benzodiazepines, 96.4% of them received phenobarbital as a second line of treatment, 65 patients required anesthesia, 52 patients developed one complication at least - the most common complication being systemic infection, and the mortality rate was noted to be 38% among patients with SE (N: 31). In this study, the factors associated with mortality were ischemic stroke (as an etiology of SE (p=0.048), history of epilepsy (p=0.005), poor therapeutic adherence (p=0.001), cardiovascular complications, presence of multiple complications (p=0.0001), pneumonia (p=0.0001), and the recurrence of SE (p=0.050). Conclusions We provide a single-center retrospective analysis of admissions in SE and note that mortality among SE patients is high in our settings. Improving prehospital emergency care and implementing elective ICU admission for patients at high risk could improve the mortality rate.
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Affiliation(s)
- Ibrahim Bechri
- Anesthesiology and Intensive Care Department, Hassan II University Hospital, Fez, MAR
| | - Abdelkrarim Shimi
- Anesthesiology and Intensive Care Department, Hassan II University Hospital, Fez, MAR
| | - Ali Derkaoui
- Anesthesiology and Intensive Care Department, Hassan II University Hospital, Fez, MAR
| | - Mohammed Khatouf
- Anesthesiology and Intensive Care Department, Hassan II University Hospital, Fez, MAR
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Yang JH, Scanlon N, Woo W, LaBuzetta JN, Gonzalez C, Broderick L, Doherty T, Riedl M, Dunn-Pirio A. Refractory Status Epilepticus Associated With a Pathogenic Variant in TNFRSF13B. Cureus 2023; 15:e48222. [PMID: 38054159 PMCID: PMC10694393 DOI: 10.7759/cureus.48222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2023] [Indexed: 12/07/2023] Open
Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a rare epileptic syndrome characterized by new-onset refractory status epilepticus preceded by a febrile illness. Limited literature exists regarding the relationship between primary immunodeficiencies and immune-mediated epilepsy, and the relationship between new-onset refractory status epilepticus and common variable immunodeficiency (CVID) is not well-understood. We present a case of a 21-year-old female with a history of recurrent sinus infections, asthma, thrombocytopenia, atrioventricular nodal reentrant tachycardia, and neonatal seizures who presented with fever and new-onset status epilepticus. She was ultimately diagnosed with a heterozygous variant in TNFRSF13B c.311G>A (p.Cys104Tyr), which encodes for a tumor necrosis factor receptor implicated in CVID.
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Affiliation(s)
- Jennifer H Yang
- Neurosciences, University of California San Diego, San Diego, USA
- Pediatric Neurology, Rady Children's Hospital San Diego, San Diego, USA
| | - Nicholas Scanlon
- Allergy and Immunology, University of California San Diego, San Diego, USA
| | - Wonhee Woo
- Allergy and Immunology, Kaiser Permanente San Jose Medical Center, San Jose, USA
| | | | - Cynthia Gonzalez
- Neurosciences, University of California San Diego, San Diego, USA
| | - Lori Broderick
- Allergy and Immunology, University of California San Diego, San Diego, USA
| | - Taylor Doherty
- Allergy and Immunology, University of California San Diego, San Diego, USA
| | - Marc Riedl
- Allergy and Immunology, University of California San Diego, San Diego, USA
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Calvano J, Paluska MR, Armijo AJ, Petersen TR, Soneru C, Broman A, Lopez-Hernandez G. Propofol-Related Infusion Syndrome in a Child With Refractory Status Epilepticus: Successful Resuscitation With Veno-Arterial Extracorporeal Membrane Oxygenation, Continuous Renal Replacement Therapy, and Therapeutic Plasma Exchange. Cureus 2023; 15:e47866. [PMID: 37908691 PMCID: PMC10613782 DOI: 10.7759/cureus.47866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2023] [Indexed: 11/02/2023] Open
Abstract
Propofol is used for sedation, anxiolysis, anesthesia induction, and as an anticonvulsant. In cases of refractory status epilepticus (RSE), propofol is more efficient than barbiturates. We present a case of a 3-year-old female with RSE who developed propofol-related infusion syndrome (PRIS) despite low dosage after failed attempts with multiple anti-epileptic drips and bolus therapies. Careful consideration must be made before initiating propofol administration for RSE. We discuss our PRIS treatment approach with extracorporeal membrane oxygenation, therapeutic plasma exchange, and continuous renal replacement therapy leading to our patient recovering to baseline and being discharged home from the hospital.
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Affiliation(s)
- Joshua Calvano
- Department of Anesthesiology and Critical Care, University of New Mexico School of Medicine, Albuquerque, USA
| | - Matthew R Paluska
- Department of Anesthesiology, Rocky Vista University College of Osteopathic Medicine, Englewood, USA
| | - Arthur J Armijo
- Department of Graduate Medical Education, Healthcare Corporation of America/HealthOne, Lone Tree, USA
| | - Timothy R Petersen
- Department of Graduate Medical Education, University of New Mexico School of Medicine, Albuquerque, USA
- Department of Anesthesiology and Critical Care, University of New Mexico School of Medicine, Albuquerque, USA
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, USA
| | - Codruta Soneru
- Department of Anesthesiology and Critical Care, University of New Mexico School of Medicine, Albuquerque, USA
| | - Alia Broman
- Department of Pediatrics, University of Colorado School of Medicine, Denver Health Medical Center, Denver, USA
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Yang X, Xu G, Chong Z, Liang Y, Du J, Zhao L, Chen W. Lennox-Gastaut syndrome characterized by super- refractory status epilepticus treated with high-dose anesthetics: A case report. Medicine (Baltimore) 2023; 102:e35233. [PMID: 37773787 PMCID: PMC10545281 DOI: 10.1097/md.0000000000035233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/24/2023] [Indexed: 10/01/2023] Open
Abstract
RATIONALE Super-refractory status epilepticus is a serious illness with high morbidity and mortality, which is defined as an SE that continues or recurs 24 hours or more after the onset of anesthesia. Anesthetic agents can be either pro-convulsant or anticonvulsant or both. PATIENT CONCERNS Epilepsy occurred at the age of 3 years. At the age of 4 years, generalized tonic-clonic seizure occurred for the first time. The patient was hospitalized at the age of 27 and 28 years for treating status epilepticus. At the age of 33 years, antiepileptic drugs were stopped due to poor appetite. In an early morning, the patient was found delirious with reduced speech. DIAGNOSIS Occasionally, the patient blinked his eyelids, or deflected his eyeballs to 1 side. When propofol was lowered to 10 mL/H, the epileptic wave reduced obviously. Afterwards, the patient opened his eyes autonomously and his consciousness gradually recovered. The patient could answer questions, and the limbs had voluntary movements. The patient breathing also gradually recovered, and his urine gradually returned to pale yellow from green. After anesthetic was stopped for 10 days, the patient lost his consciousness again. The patient eyes turned upward frequently, which was relieved in 1 to 2 seconds with an attack once every 2 to 5 minutes. INTERVENTIONS Clonazepam was gradually reduced to 2 mg qn, and the patient gradually woke up during this process. The patient was also treated with levetiracetam 1.5 g bid, oxcarbazepine 0.6 g bid, topiramate 50 mg bid and valproate 0.4 g tid. OUTCOMES After 1 month follow-up, status epilepticus did not appear again. LESSONS Propofol aggravated the tonic seizures. As tonic seizures occur during natural sleep and after sleep induced by various narcotic drugs, the decrease of consciousness level induced by excessive sedation of narcotic drugs has been suggested as the reason for poor seizure control.
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Affiliation(s)
- Xiaoqian Yang
- Department of Neurology, Liaocheng People’s Hospital, Liaocheng, Shandong Province, P.R. China
| | - Guangjun Xu
- Department of Neurology, Liaocheng People’s Hospital, Liaocheng, Shandong Province, P.R. China
| | - Zonglei Chong
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong Province, P.R. China
| | - Yangyang Liang
- Department of Neurology, Liaocheng People’s Hospital, Liaocheng, Shandong Province, P.R. China
| | - Jingwei Du
- Department of Neurology, Liaocheng People’s Hospital, Liaocheng, Shandong Province, P.R. China
| | - Lin Zhao
- Department of Neurology, Dong'e County People’s Hospital, Donge County, Liaocheng, Shandong Province, P.R. China
| | - Wei Chen
- Department of Neurology, Liaocheng People’s Hospital, Liaocheng, Shandong Province, P.R. China
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Thomschewski A, Giovannini G, Gaspard N, Steinbrenner M, Wickström R, Jacobs J. Editorial: Advances in diagnosing and treating new-onset refractory status epilepticus (NORSE). Front Neurol 2023; 14:1270702. [PMID: 37712084 PMCID: PMC10499399 DOI: 10.3389/fneur.2023.1270702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 09/16/2023] Open
Affiliation(s)
- Aljoscha Thomschewski
- Department of Neurology, Christian-Doppler University Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Giada Giovannini
- Unitá di Neurologia, Azienda Ospedaliera Universitaria di Modena, Modena, Italy
| | - Nicolas Gaspard
- Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Mirja Steinbrenner
- Clinic for Neurology With Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Ronny Wickström
- Department of Women's and Children's Health, Karolinska Institutet, Solna, Sweden
| | - Julia Jacobs
- Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
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Bellingham EE, Hammond CG, Sahhar HS, Rishmawi SE. Multimodal Management of Febrile Infection-Related Epilepsy Syndrome in a 17-Year-Old Male. Cureus 2023; 15:e44412. [PMID: 37791156 PMCID: PMC10544845 DOI: 10.7759/cureus.44412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 10/05/2023] Open
Abstract
New-onset refractory status epilepticus (NORSE) is a clinical presentation, not a specific diagnosis, in which healthy people are suddenly struck by prolonged seizures that do not respond to at least two anti-seizure drugs and do not have a clear structural, toxic, or metabolic cause.Febrile infection-related epilepsy syndrome (FIRES) is considered a sub-category of NORSE. Our patient is a 17-year-old male admitted to the pediatric ward after a self-limited convulsive episode at home, noted to occur following five days of upper respiratory infection symptoms accompanied by fever. After multiple generalized tonic-clonic seizures necessitating treatment, he went into status epilepticus despite multiple antiepileptic drugs. The possibility of FIRES had been considered from the onset of refractory status epilepticus; as a result, an intensive multimodal treatment regimen was proactively implemented with some clinical improvement.
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Affiliation(s)
- Erin E Bellingham
- Pediatrics Department, Edward Via College of Osteopathic Medicine - Louisiana Campus, Monroe, USA
| | - Caroline G Hammond
- Pediatrics Department, Edward Via College of Osteopathic Medicine - Carolinas Campus, Spartanburg, USA
| | - Hanna S Sahhar
- Pediatric Intensive Care Unit, Spartanburg Regional Healthcare System, Spartanburg, USA
| | - Sami E Rishmawi
- Pediatric Intensive Care Unit, Spartanburg Regional Healthcare System, Spartanburg, USA
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11
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Besha A, Adamu Y, Mulugeta H, Zemedkun A, Destaw B. Evidence-based guideline on management of status epilepticus in adult intensive care unit in resource-limited settings: a review article. Ann Med Surg (Lond) 2023; 85:2714-2720. [PMID: 37363462 PMCID: PMC10289780 DOI: 10.1097/ms9.0000000000000625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/27/2023] [Indexed: 06/28/2023] Open
Abstract
Status epilepticus (SE) is a life-threatening condition associated with at least 5 min of continuous seizures or repeated seizures without regaining consciousness between episodes. It is a medical emergency with significant morbidity and mortality. The most common causes of SE are previous seizures, stroke, trauma, metabolic disorders, and central nervous system tumor. The aim of this review was to systematically review articles and ultimately develop evidence-based guidelines for the management of SE in resource-limited settings. Methods This review was presented under the Protocol for Systematic Reviews and Meta-Analyses (PRISMA). A literature search was performed in PubMed, Google Scholar, Cochrane, and Medline databases from 2007 to 2021. The keywords for the literature search were (SE or controlled clinical trial) AND (SE or randomized controlled trial), (SE or multicenter trial) AND (SE or meta-analysis) AND (SE or crossover study). Conclusion SE is an urgent medical emergency that requires early recognition and aggressive treatment. Medical treatment is initiated when seizures continue for more than 5 min after all stabilization measures have been taken. Based on the available evidence, diazepam can be used as a substitute for lorazepam in the treatment of SE. Ketamine is effective when given before other anesthetics as a third-line treatment in refractory and very refractory epilepsy. Propofol reduced the number of days of mechanical ventilation in the treatment of SE and has better seizure control than thiopental. Music has been recommended as an adjunctive therapy for epilepsy medication.
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Affiliation(s)
- Aschalew Besha
- Department of Anesthesia, College of Medicine and Health Sciences, Hawassa University, Hawassa
| | - Yayeh Adamu
- Department of Anesthesiology, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Hailemariam Mulugeta
- Department of Anesthesiology, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Abebayehu Zemedkun
- Department of Anesthesiology, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
| | - Belete Destaw
- Department of Anesthesiology, College of Medicine and Health Sciences, Dilla University, Dilla, Ethiopia
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12
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Jarvis R, Josephine Ng SF, Nathanson AJ, Cardarelli RA, Abiraman K, Wade F, Evans-Strong A, Fernandez-Campa MP, Deeb TZ, Smalley JL, Jamier T, Gurrell IK, McWilliams L, Kawatkar A, Conway LC, Wang Q, Burli RW, Brandon NJ, Chessell IP, Goldman AJ, Maguire JL, Moss SJ. Direct activation of KCC2 arrests benzodiazepine refractory status epilepticus and limits the subsequent neuronal injury in mice. Cell Rep Med 2023; 4:100957. [PMID: 36889319 PMCID: PMC10040380 DOI: 10.1016/j.xcrm.2023.100957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/17/2022] [Accepted: 02/06/2023] [Indexed: 03/09/2023]
Abstract
Hyperpolarizing GABAAR currents, the unitary events that underlie synaptic inhibition, are dependent upon efficient Cl- extrusion, a process that is facilitated by the neuronal specific K+/Cl- co-transporter KCC2. Its activity is also a determinant of the anticonvulsant efficacy of the canonical GABAAR-positive allosteric: benzodiazepines (BDZs). Compromised KCC2 activity is implicated in the pathophysiology of status epilepticus (SE), a medical emergency that rapidly becomes refractory to BDZ (BDZ-RSE). Here, we have identified small molecules that directly bind to and activate KCC2, which leads to reduced neuronal Cl- accumulation and excitability. KCC2 activation does not induce any overt effects on behavior but prevents the development of and terminates ongoing BDZ-RSE. In addition, KCC2 activation reduces neuronal cell death following BDZ-RSE. Collectively, these findings demonstrate that KCC2 activation is a promising strategy to terminate BDZ-resistant seizures and limit the associated neuronal injury.
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Affiliation(s)
- Rebecca Jarvis
- Discovery, Neuroscience, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Shu Fun Josephine Ng
- Department of Neuroscience, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Anna J Nathanson
- Department of Neuroscience, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Ross A Cardarelli
- Department of Neuroscience, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Krithika Abiraman
- Department of Neuroscience, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Fergus Wade
- Department of Neuroscience, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Aidan Evans-Strong
- Department of Neuroscience, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Marina P Fernandez-Campa
- Department of Neuroscience, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Tarek Z Deeb
- Department of Neuroscience, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Joshua L Smalley
- Department of Neuroscience, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Tanguy Jamier
- Discovery, Neuroscience, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Ian K Gurrell
- Discovery, Neuroscience, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Lisa McWilliams
- Discovery Biology, Discovery Sciences, R&D, AstraZeneca, Cambridge, UK
| | - Aarti Kawatkar
- Discovery Biology, Discovery Sciences, R&D, AstraZeneca, Boston, MA, USA
| | - Leslie C Conway
- Department of Neuroscience, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Qi Wang
- Discovery, Neuroscience, BioPharmaceuticals R&D, AstraZeneca, Boston, MA, USA
| | - Roland W Burli
- Discovery, Neuroscience, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Nicholas J Brandon
- Discovery, Neuroscience, BioPharmaceuticals R&D, AstraZeneca, Boston, MA, USA
| | - Iain P Chessell
- Discovery, Neuroscience, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Aaron J Goldman
- Department of Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Jamie L Maguire
- Department of Neuroscience, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Stephen J Moss
- Department of Neuroscience, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA; Department of Neuroscience, Physiology and Pharmacology, University College London, London WC1 6BT, UK.
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13
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Shi X, Wang Y, Wang X, Kang X, Yang F, Yuan F, Jiang W. Long-term outcomes of adult cryptogenic febrile infection-related epilepsy syndrome (FIRES). Front Neurol 2023; 13:1081388. [PMID: 36686522 PMCID: PMC9848432 DOI: 10.3389/fneur.2022.1081388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/09/2022] [Indexed: 01/05/2023] Open
Abstract
Background Cryptogenic febrile infection-related epilepsy syndrome (FIRES) is a rare but catastrophic encephalopathic condition. We aimed to investigate the long-term outcome in adult cryptogenic FIRES. Methods This was a retrospective study based on the prospective database in the neuro-intensive care unit of a tertiary hospital in China. Consecutive adult patients with cryptogenic FIRES between July 2007 to December 2021 were included. Long-term outcomes included function independence, the development of drug-resistant epilepsy (DRE), remote recurrent status epilepticus (SE), anti-seizure medications (ASMs), and changes in the brain Magnetic Resonance Imaging (MRI). Results A total of 11 adult patients with cryptogenic FIRES were identified from 270 patients with SE. Four (36%) patients died in the hospital, with three of them withdrawing treatments, and one patient died 12 months after discharge. After the follow-up ranging from 12 to 112 months, 6 (55%) patients were still alive, and all of them achieved functional independence [modified Rankin Scale (mRS) 0-3]. 45% (5/11) patients developed DRE, 18% (2/11) had remote recurrent SE, and 55% (6/11) were on polytherapy with ASMs at the last follow-up. Most of the patients with initial normal or abnormal MRI had abnormalities in the hippocampus at follow-up, and most of the other MRI abnormalities found in the acute stage disappeared over time. Conclusion The outcome of adult cryptogenic FIRES is daunting. More than one-third of patients die in the hospital. Survivors of cryptogenic FIRES may regain functional independence, but they usually develop DRE and receive polytherapy of ASMs for a long time.
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Affiliation(s)
- Xiaojing Shi
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yuanyuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiaogang Kang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fang Yuan
- Department of Neurology, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China,Fang Yuan ✉
| | - Wen Jiang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China,*Correspondence: Wen Jiang ✉
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14
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DeVine MN, Gordon SE, Press CA. Use of Continuous Ketamine Infusion as an Adjunctive Agent in Young Infants With Refractory and Super Refractory Status Epilepticus: A Case Series. J Pediatr Pharmacol Ther 2023; 28:161-166. [PMID: 37139250 PMCID: PMC10150903 DOI: 10.5863/1551-6776-28.2.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/24/2022] [Indexed: 05/05/2023]
Abstract
Continuous ketamine infusions have been studied as an adjunctive agent for refractory status epilepticus (RSE) and super refractory status epilepticus (SRSE) in older children and adults. However, minimal information exists on the efficacy, safety, and dosing for continuous ketamine in young infants. We present the clinical course of 3 young infants with RSE and SRSE who received continuous ketamine in conjunction with other antiseizure medications. The condition of these patients was refractory to an average of 6 antiseizure medications before initiation of continuous ketamine infusion. For each patient, a continuous ketamine infusion was initiated at a rate of 1 mg/kg/hr with 1 patient requiring titration to a maximum of 6 mg/kg/hr. In 1 case, the concomitant use of continuous ketamine allowed for a reduction in the benzodiazepine continuous infusion rate. In all cases, ketamine was well tolerated especially in the setting of hemodynamic instability. Ketamine may provide a safe adjunct in the acute setting in severe RSE and SRSE. This is the first case series to document the use of continuous ketamine as a treatment modality in young infants with RSE or SRSE secondary to various underlying etiologies, without adverse events. Further studies are needed to evaluate the long-term safety and efficacy of continuous ketamine in this patient population.
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Affiliation(s)
| | - Sharon E. Gordon
- Department of Pharmacy (MND, SEG), Children's Hospital Colorado, Aurora, CO
| | - Craig A. Press
- Department of Pediatrics (CAP), Section Child Neurology, University of Colorado Anschutz School of Medicine, Aurora, CO
- Department of Pediatrics and Neurology (CAP), University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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15
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Caranzano L, Novy J, Rossetti AO. Ketamine in adult super- refractory status epilepticus: Efficacy analysis on a prospective registry. Acta Neurol Scand 2022; 145:737-742. [PMID: 35274736 PMCID: PMC9310735 DOI: 10.1111/ane.13610] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 11/28/2022]
Abstract
Background Status epilepticus (SE) persisting despite two anti‐seizures medications (ASM) and anesthetics is labeled super refractory (SRSE), correlating with important morbidity and mortality. Its treatment relies on expert opinions. Due to its pharmacological properties, ketamine (KET) has received increasing attention, but data are essentially retrospective. Aims To describe an unselected cohort of adults receiving KET for SRSE. Methods Analysis of a prospective registry of consecutive SE episodes, identifying SRSE patients receiving ketamine (KET). Comparison with recent adult series including more than 10 patients. Results Eleven patients received KET after a median of 4 days (range: 2–20); median dose was 5 mg/kg/h (range: 2.5–15). KET provided permanent SE control in three (27%). Previous series, using KET administration delays and doses similar to our cohort, report KET efficacy in 28–96% of cases. Conclusions We found a lower SE control rate than existing literature, whose data are, however, often retrospective, potentially selecting patients with less severe SE forms or responding to KET. This might explain outcome differences, as KET administration modalities were comparable with our cohort. Since randomized controlled studies are lacking on this subject, the analysis of this prospective, unselected cohort, if confirmed, suggests a current overestimation of KET efficacy in SRSE.
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Affiliation(s)
- Leonardo Caranzano
- Department of Clinical Neurosciences, Neurology Service Lausanne University Hospital and University of Lausanne Lausanne Switzerland
| | - Jan Novy
- Department of Clinical Neurosciences, Neurology Service Lausanne University Hospital and University of Lausanne Lausanne Switzerland
| | - Andrea O. Rossetti
- Department of Clinical Neurosciences, Neurology Service Lausanne University Hospital and University of Lausanne Lausanne Switzerland
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16
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Nath M, Shah YD, Theroux LM, Petrides G, Karkare S, Sanghani SN, Kothare SV. A Role for Electroconvulsive Therapy in the Management of New Onset Refractory Status Epilepticus (NORSE) in a Young Child. Neurol India 2021; 69:1374-1379. [PMID: 34747817 DOI: 10.4103/0028-3886.329559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
New-onset refractory status epilepticus (NORSE) describes prolonged or recurring new onset seizures which fail to respond to antiseizure medications. NORSE poses a challenge in diagnosis and treatment, and limited high-quality evidence exists to guide management. The efficacy of Electroconvulsive therapy (ECT) in aborting refractory status epilepticus has been described in case reports, but its application remains uncommon, particularly in young children. We describe a case of NORSE in a 3-year old child in which ECT played an important role in aborting status epilepticus, facilitating the diagnosis and surgical excision of an underlying focal cortical dysplasia. Although further research is needed, our case suggests that ECT can be a valuable tool in the treatment of refractory status epilepticus in children.
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Affiliation(s)
- Manan Nath
- Cohen Children's Medical Center, New York; Zucker School of Medicine at Hofstra/Northwell, USA
| | - Yash D Shah
- Cohen Children's Medical Center, New York; Zucker School of Medicine at Hofstra/Northwell, USA
| | - Liana M Theroux
- Cohen Children's Medical Center, New York; Zucker School of Medicine at Hofstra/Northwell, USA
| | - Georgios Petrides
- Zucker Hillside Hospital, Northwell Health; Zucker School of Medicine at Hofstra/Northwell, USA
| | - Shefali Karkare
- Cohen Children's Medical Center, New York; Zucker School of Medicine at Hofstra/Northwell, USA
| | - Sohag N Sanghani
- Zucker Hillside Hospital, Northwell Health; Zucker School of Medicine at Hofstra/Northwell, USA
| | - Sanjeev V Kothare
- Cohen Children's Medical Center, New York; Zucker School of Medicine at Hofstra/Northwell, USA
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17
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Lumley LA, Marrero-Rosado B, Rossetti F, Schultz CR, Stone MF, Niquet J, Wasterlain CG. Combination of antiseizure medications phenobarbital, ketamine, and midazolam reduces soman-induced epileptogenesis and brain pathology in rats. Epilepsia Open 2021; 6:757-769. [PMID: 34657398 PMCID: PMC8633481 DOI: 10.1002/epi4.12552] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/07/2021] [Accepted: 10/12/2021] [Indexed: 12/16/2022] Open
Abstract
Objective Cholinergic‐induced status epilepticus (SE) is associated with a loss of synaptic gamma‐aminobutyric acid A receptors (GABAAR) and an increase in N‐methyl‐D‐aspartate receptors (NMDAR) and amino‐3‐hydroxy‐5‐methyl‐4‐isoxazolepropionic acid receptors (AMPAR) that may contribute to pharmacoresistance when treatment with benzodiazepine antiseizure medication is delayed. The barbiturate phenobarbital enhances inhibitory neurotransmission by binding to a specific site in the GABAAR to increase the open state of the channel, decrease neuronal excitability, and reduce glutamate‐induced currents through AMPA/kainate receptors. We hypothesized that phenobarbital as an adjunct to midazolam would augment the amelioration of soman‐induced SE and associated neuropathological changes and that further protection would be provided by the addition of an NMDAR antagonist. Methods We investigated the efficacy of combining antiseizure medications to include a benzodiazepine and a barbiturate allosteric GABAAR modulator (midazolam and phenobarbital, respectively) to correct loss of inhibition, and ketamine to reduce excitation caused by increased synaptic localization of NMDAR and AMPAR, which are NMDA‐dependent. Rats implanted with transmitters to record electroencephalographic (EEG) activity were exposed to soman and treated with atropine sulfate and HI‐6 one min after exposure and with antiseizure medication(s) 40 minutes after seizure onset. Results The triple therapy combination of phenobarbital, midazolam, and ketamine administered at 40 minutes after seizure onset effectively prevented soman‐induced epileptogenesis and reduced neurodegeneration. In addition, dual therapy with phenobarbital and midazolam or ketamine was more effective than monotherapy (midazolam or phenobarbital) in reducing cholinergic‐induced toxicity. Significance Benzodiazepine efficacy is drastically reduced with time after seizure onset and inversely related to seizure duration. To overcome pharmacoresistance in severe benzodiazepine‐refractory cholinergic‐induced SE, simultaneous drug combination to include drugs that target both the loss of inhibition (eg, midazolam, phenobarbital) and the increased excitatory response (eg, ketamine) is more effective than benzodiazepine or barbiturate monotherapy.
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Affiliation(s)
- Lucille A Lumley
- Neuroscience Department, U.S. Army Medical Research Institute of Chemical Defense (USAMRICD), Aberdeen Proving Ground, Maryland, USA
| | - Brenda Marrero-Rosado
- Neuroscience Department, U.S. Army Medical Research Institute of Chemical Defense (USAMRICD), Aberdeen Proving Ground, Maryland, USA
| | - Franco Rossetti
- Military Psychiatry and Neuroscience Department, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Caroline R Schultz
- Neuroscience Department, U.S. Army Medical Research Institute of Chemical Defense (USAMRICD), Aberdeen Proving Ground, Maryland, USA
| | - Michael F Stone
- Neuroscience Department, U.S. Army Medical Research Institute of Chemical Defense (USAMRICD), Aberdeen Proving Ground, Maryland, USA
| | - Jerome Niquet
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Claude G Wasterlain
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,Epilepsy Research Laboratory (151), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
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18
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L'Erario M, Roperto RM, Rosati A. Sevoflurane as bridge therapy for plasma exchange and Anakinra in febrile infection-related epilepsy syndrome. Epilepsia Open 2021; 6:788-792. [PMID: 34596364 PMCID: PMC8633474 DOI: 10.1002/epi4.12545] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/31/2021] [Accepted: 09/28/2021] [Indexed: 01/14/2023] Open
Abstract
Febrile infection–related epilepsy syndrome (FIRES) is a devastating immune inflammatory–mediated epileptic encephalopathy. Herein, we discuss a previously healthy 8‐year‐old boy with FIRES in whom high dosages of conventional and nonconventional anesthetics were ineffective in treating SE, as were ketogenic diet, intravenous corticosteroids, and immunoglobulins. After 29 days of prolonged SRSE, the patient was successfully treated with sevoflurane paired with plasma exchange, for a total of five days, thus obtaining a stable EEG suppression burst pattern with no adverse events. Anakinra at the dosage of 100 mg b.i.d. was started seven days after sevoflurane and plasma exchange had been discontinued and was effective in ensuring non‐recurrence of SE. Sevoflurane as bridge therapy for immunosuppressive treatment could be considered an early, safe, and effective option in treating convulsive SE in which an autoimmune‐inflammatory etiology can reasonably be hypothesized.
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Affiliation(s)
| | - Rosa Maria Roperto
- Nephrology Department, Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Anna Rosati
- Paediatric Neurology Unit, Meyer Children's Hospital, University of Florence, Florence, Italy
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19
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Kapoor D, Sidharth, Garg D, Malhotra RK, Kumar V, Sharma S. Utility of the END-IT Score to Predict the outcome of Childhood Status Epilepticus: A Retrospective Cohort Study. Ann Indian Acad Neurol 2021; 24:390-395. [PMID: 34447003 PMCID: PMC8370170 DOI: 10.4103/aian.aian_1319_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/23/2021] [Accepted: 02/21/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: Scoring systems to predict outcomes in pediatric status epilepticus (SE) are limited. We sought to assess usefulness of the END-IT score in pediatric SE. Methodology: We conducted a retrospective study at a tertiary hospital in New Delhi, India. Children aged 1 month–18 years who presented with seizure for ≥5 min/actively convulsing to emergency were enrolled. END-IT score was calculated and correlated with outcome at discharge using Pediatric Overall Performance Category (POPC) scale, in-hospital mortality, and progression to refractory and super-refractory SE (SRSE). Results: We enrolled 140 children (mean age 5.8 years; 67.1% males). Seven children died and 15 had unfavorable outcomes. The predictive accuracy of END-IT at a cutoff of > 2: for unfavorable outcome (POPC score ≥3) was: sensitivity 0.73 (95% CI: 0.45–0.92), specificity 0.94 (95% CI: 0.89–0.98), PPV 0.61 (95% CI: 0.36–0.83), NPV 0.97 (95% CI: 0.92–0.99), positive likelihood ratio (13.09), F1 score (0.666); for death: sensitivity 0.86 (95% CI: 0.42–0.99), specificity 0.91 (95% CI: 0.85–0.95), PPV 0.33 (95% CI: 0.13–0.59), NPV 0.99 (95% CI: 0.96–1.00), F1 score (0.48); for RSE: sensitivity 0.80 (95%CI: 0.28–0.99), specificity 0.90 (95% CI: 0.83–0.94), PPV 0.22 (95% CI: 0.06–0.48) NPV 0.99 (95% CI: 0.96–1.00), F1 score (0.35); for SRSE: sensitivity 0.67 (95% CI: 0.22–0.96) specificity 0.75 (95% CI: 0.66–0.82), PPV 0.22 (95% CI: 0.06–0.48) NPV 0.98 (95% CI: 0.94–0.99), F1 score (0.33). Conclusion: We demonstrate utility of the END-IT score to predict short-term outcomes as well as progression to refractory and SRSE for the first time among children with SE.
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Affiliation(s)
- Dipti Kapoor
- Department of Pediatrics (Neurology Division), Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, India
| | - Sidharth
- Department of Pediatrics (Neurology Division), Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, India
| | - Divyani Garg
- Department of Neurology, Lady Hardinge Medical College and Smt. SK Hospital, New Delhi, India
| | - Rajiv K Malhotra
- Delhi Cancer Registry, BR Ambedkar IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Virendra Kumar
- Department of Pediatrics (Neurology Division), Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, India
| | - Suvasini Sharma
- Department of Pediatrics (Neurology Division), Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, India
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20
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Rachfalska N, Pietruszewski J, Paprocka J. Dramatic Course of Paediatric Cryptogenic Febrile Infection-Related Epilepsy Syndrome with Unusual Chronic Phase Presentation-A Case Report with Literature Study. Brain Sci 2021; 11:1030. [PMID: 34439649 DOI: 10.3390/brainsci11081030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/03/2022] Open
Abstract
Febrile Infection-Related Epilepsy Syndrome (FIRES) is a catastrophic, extremely rare epileptic encephalopathy. It strikes previously healthy school-aged children and is usually cryptogenic. Its dramatic onset with refractory status epilepticus is always preceded by a nonspecific febrile illness. The seizure activity in FIRES may last for several weeks with little to no response to antiepileptic treatment, usually resulting in the usage of anaesthetics. This acute phase is followed by a chronic, refractory epilepsy and cognitive deficit, that persist for the rest of the patient’s life. Still to this day no definite cause has been described. In this study we review the current finding in FIRES and describe a case of a 4-year-old patient with a dramatic course of the acute phase in FIRES and unusual presentation of the chronic phase, which is dominated by extrapyramidal symptoms such as dystonia. This case highlights that the clinical presentation of FIRES may differ from those frequently described in literature.
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21
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Dozières-Puyravel B, Höhn S, Auvin S. Considering safety and patient tolerance in the use of ketogenic diet in the management of refractory and super- refractory status epilepticus: a systematic review. Expert Rev Neurother 2021; 21:1303-1308. [PMID: 34275391 DOI: 10.1080/14737175.2021.1956905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Early use of the ketogenic diet (KD) is described as having a particular interest for super-refractory status epilepticus and febrile infection-related epilepsy syndrome. The authors conducted a systematic review of the available data on the KD for refractory and super-refractory status epilepticus. AREAS COVERED Following a systematic bibliographic search, the authors found 15 published papers: 2 prospective and 13 retrospective studies. Most often, the primary aim of the retrospective studies was the efficacy evaluation of the KD for refractory or super-refractory status epilepticus. Four studies focused on the use of KD for NORSE/FIRES. These initial studies suggested that KD was effective in these conditions, and that it showed mild and manageable side effects. EXPERT OPINION The published studies provided enough preliminary data to validate the feasibility and safety of the use of KD for refractory and super-refractory status epilepticus. Further studies demonstrating the efficacy of the KD in these indications are needed. Possible design and endpoints are discussed.
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Affiliation(s)
- Blandine Dozières-Puyravel
- Service de Neurologie Pédiatrique, Hôpital Robert-Debré, APHP, Paris, France.,Université de Paris, Paris, France
| | - Sophie Höhn
- Service de Neurologie Pédiatrique, Hôpital Robert-Debré, APHP, Paris, France.,Université de Paris, Paris, France
| | - Stéphane Auvin
- Service de Neurologie Pédiatrique, Hôpital Robert-Debré, APHP, Paris, France.,Université de Paris, Paris, France.,Institut Universitaire de France (IUF), Paris, France
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22
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Alolayan YS, McKinley K, Bhatia R, Alkhachroum A. Review and Updates on the Treatment of Refractory and Super Refractory Status Epilepticus. J Clin Med 2021; 10:3028. [PMID: 34300194 DOI: 10.3390/jcm10143028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 06/30/2021] [Accepted: 07/03/2021] [Indexed: 02/07/2023] Open
Abstract
Refractory and super-refractory status epilepticus (RSE and SRSE) are life-threatening conditions requiring prompt initiation of appropriate treatment to avoid permanent neurological damage and reduce morbidity and mortality. RSE is defined as status epilepticus that persists despite administering at least two appropriately dosed parenteral medications, including a benzodiazepine. SRSE is status epilepticus that persists at least 24 h after adding at least one appropriately dosed continuous anesthetic (i.e., midazolam, propofol, pentobarbital, and ketamine). Other therapeutic interventions include immunotherapy, neuromodulation, ketogenic diet, or even surgical intervention in certain cases. Continuous electroencephalogram is an essential monitoring tool for diagnosis and treatment. In this review, we focus on the diagnosis and treatment of RSE and SRSE.
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23
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Sculier C, Barcia Aguilar C, Gaspard N, Gaínza-Lein M, Sánchez Fernández I, Amengual-Gual M, Anderson A, Arya R, Burrows BT, Brenton JN, Carpenter JL, Chapman KE, Clark J, Gaillard WD, Glauser TA, Goldstein JL, Goodkin HP, Gorman M, Lai YC, McDonough TL, Mikati MA, Nayak A, Peariso K, Riviello J, Rusie A, Sperberg K, Stredny CM, Tasker RC, Tchapyjnikov D, Vasquez A, Wainwright MS, Wilfong AA, Williams K, Loddenkemper T. Clinical presentation of new onset refractory status epilepticus in children (the pSERG cohort). Epilepsia 2021; 62:1629-1642. [PMID: 34091885 PMCID: PMC8362203 DOI: 10.1111/epi.16950] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/09/2021] [Accepted: 05/11/2021] [Indexed: 01/14/2023]
Abstract
Objective We aimed to characterize the clinical profile and outcomes of new onset refractory status epilepticus (NORSE) in children, and investigated the relationship between fever onset and status epilepticus (SE). Methods Patients with refractory SE (RSE) between June 1, 2011 and October 1, 2016 were prospectively enrolled in the pSERG (Pediatric Status Epilepticus Research Group) cohort. Cases meeting the definition of NORSE were classified as "NORSE of known etiology" or "NORSE of unknown etiology." Subgroup analysis of NORSE of unknown etiology was completed based on the presence and time of fever occurrence relative to RSE onset: fever at onset (≤24 h), previous fever (2 weeks–24 h), and without fever. Results Of 279 patients with RSE, 46 patients met the criteria for NORSE. The median age was 2.4 years, and 25 (54%) were female. Forty (87%) patients had NORSE of unknown etiology. Nineteen (48%) presented with fever at SE onset, 16 (40%) had a previous fever, and five (12%) had no fever. The patients with preceding fever had more prolonged SE and worse outcomes, and 25% recovered baseline neurological function. The patients with fever at onset were younger and had shorter SE episodes, and 89% recovered baseline function. Significance Among pediatric patients with RSE, 16% met diagnostic criteria for NORSE, including the subcategory of febrile infection‐related epilepsy syndrome (FIRES). Pediatric NORSE cases may also overlap with refractory febrile SE (FSE). FIRES occurs more frequently in older children, the course is usually prolonged, and outcomes are worse, as compared to refractory FSE. Fever occurring more than 24 h before the onset of seizures differentiates a subgroup of NORSE patients with distinctive clinical characteristics and worse outcomes.
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Affiliation(s)
- Claudine Sculier
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Neurology, Erasmus Hospital, Free University of Brussels, Brussels, Belgium
| | - Cristina Barcia Aguilar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Child Neurology, La Paz University Hospital, Autonomous University of Madrid, Madrid, Spain
| | - Nicolas Gaspard
- Department of Neurology, Erasmus Hospital, Free University of Brussels, Brussels, Belgium.,Neurology Department, Comprehensive Epilepsy Center, Yale University School of Medicine, New Haven, CT, USA
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Faculty of Medicine, Institute of Pediatrics, Austral University of Chile, Valdivia, Chile.,Children's Neuropsychiatry Service, San Borja Arriarán Clinical Hospital, University of Chile, Santiago, Chile
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Child Neurology, SJD Barcelona Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Pediatric Neurology Unit, Department of Pediatrics, Son Espases University Hospital, University of the Balearic Islands, Palma, Spain
| | - Anne Anderson
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Ravindra Arya
- Division of Pediatric Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brian T Burrows
- Department of Pediatrics, Barrows Neurological Institute, Phoenix Children's Hospital, University of Arizona School of Medicine, Phoenix, AZ, USA.,Department of Neurology, Mayo Clinic, Scottsdale, AZ, USA
| | - James N Brenton
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jessica L Carpenter
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Kevin E Chapman
- Departments of Pediatrics and Neurology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Justice Clark
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - William D Gaillard
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Tracy A Glauser
- Division of Pediatric Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joshua L Goldstein
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Northwestern University Feinberg, School of Medicine, Chicago, IL, USA
| | - Howard P Goodkin
- Department of Neurology and Pediatrics, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Mark Gorman
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Yi-Chen Lai
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Tiffani L McDonough
- Division of Neurology and Epilepsy, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mohamad A Mikati
- Division of Pediatric Neurology, Duke University Medical Center, Duke University, Durham, NC, USA
| | - Anuranjita Nayak
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Katrina Peariso
- Division of Pediatric Neurology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - James Riviello
- Section of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Allison Rusie
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Northwestern University Feinberg, School of Medicine, Chicago, IL, USA
| | - Katherine Sperberg
- Center for Neuroscience, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Coral M Stredny
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert C Tasker
- Department of Neurology, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dmitry Tchapyjnikov
- Division of Neurology and Epilepsy, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Alejandra Vasquez
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Child and Adolescent Neurology, Mayo Clinic, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Mark S Wainwright
- Division of Pediatric Neurology, Department of Neurology, University of Washington, Seattle, WA, USA
| | - Angus A Wilfong
- Division of Pediatric Neurology, Department of Child Health, Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Korwyn Williams
- Division of Pediatric Neurology, Department of Child Health, Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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24
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Wu CK, Culbertson CJ, Von Stein EL, Walia S, Krishnamohan P, Threlkeld ZD. Cryptogenic new-onset refractory status epilepticus (NORSE) following blood transfusion in a patient with severe anemia. Epileptic Disord 2021; 23:403-6. [PMID: 33881399 DOI: 10.1684/epd.2021.1267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
New-onset refractory status epilepticus (NORSE) is a rare neurological emergency in which a patient without prior seizure disorder develops seemingly unprovoked status epilepticus refractory to treatment. We report the case of a middle-aged woman who developed NORSE after receiving multiple blood transfusions for subacute blood loss anemia secondary to menorrhagia. Although the mechanism is unclear, we propose that sudden changes in blood viscosity and vasogenic tone resulted in cortical edema and irritation. Although seizures have been documented in patients who undergo blood transfusion and develop posterior reversible encephalopathy syndrome (PRES), there was no radiographic evidence of PRES in this case. This is the first reported case of cryptogenic NORSE following blood transfusion.
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25
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Alhashem AT, AlSalem KH, Sabihah SJ, Alfaraj D. Moyamoya Syndrome Presenting as Refractory Status Epilepticus in a 32-Year-Old Female. Cureus 2021; 13:e13624. [PMID: 33816023 PMCID: PMC8010915 DOI: 10.7759/cureus.13624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Moyamoya disease (MMD) is a rare cerebrovascular occlusion condition characterized by progressive stenosis in the terminal portion of the internal carotid arteries on both sides. The measured incidence of MMD is 0.086 per 100,000 people. MMD has variable neurological manifestations, however, seizure is a significant manifestation of MMD with few reported studies. The combination of sickle cell disease (SCD) and MMD confers a much higher risk of ischemic stroke. In this paper, we describe a 32-year-old female with a known case of SCD taking tramadol for a vaso-occlusive crisis, who was presented to the emergency department by a family member due to a low level of consciousness. Despite ongoing management, the patient developed multiple seizure attacks and intubation was performed. A computed tomography (CT) brain angiogram was performed, and the diagnosis of MMD was made. The patient was shifted to the intensive care unit (ICU) and in spite of the ongoing management in the ICU, the patient died. In this case, we highlight the importance of considering MMD as a differential diagnosis when dealing with an SCD patient who developed refractory status epilepticus.
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Affiliation(s)
- Ali T Alhashem
- Emergency Medicine, King Faisal University, Al Hofuf, SAU
| | | | | | - Dunya Alfaraj
- Emergency Medicine, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, SAU
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26
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Roynard P, Bilderback A, Dewey CW. Intravenous Ketamine Bolus(es) for the Treatment of Status Epilepticus, Refractory Status Epilepticus, and Cluster Seizures: A Retrospective Study of 15 Dogs. Front Vet Sci 2021; 8:547279. [PMID: 33681317 PMCID: PMC7925624 DOI: 10.3389/fvets.2021.547279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 01/07/2021] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Patrick Roynard
- Long Island Veterinary Specialists, Department of Neurology/Neurosurgery, Plainview, NY, United States
| | - Ann Bilderback
- VCA Northwest Veterinary Specialists, Clackamas, OR, United States
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27
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Koessler M, Haberlandt E, Karall D, Baumann M, Höller A, Scholl‐Bürgi S. Ketogenic diet in a patient with refractory status epilepticus due to POLG mutation. JIMD Rep 2021; 57:3-8. [PMID: 33473333 PMCID: PMC7802623 DOI: 10.1002/jmd2.12169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 11/11/2022] Open
Abstract
We present a 16-year-old female patient with POLG syndrome, treated with ketogenic diet after she presented with refractory status epilepticus. Initially, benefit of the ketogenic diet could be seen, but the outcome was fatal, with death 3 months after presenting symptoms. Additionally, we give a literature review of the utility of ketogenic diet in patients with POLG disease.
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Affiliation(s)
- Miriam Koessler
- Department of Pediatrics I, NeuropediatricsMedical University of InnsbruckInnsbruckAustria
| | | | - Daniela Karall
- Department of Pediatrics IInherited Metabolic Disorders, Medical University of InnsbruckInnsbruckAustria
| | - Matthias Baumann
- Department of Pediatrics I, NeuropediatricsMedical University of InnsbruckInnsbruckAustria
| | - Alexander Höller
- Department of Pediatrics IInherited Metabolic Disorders, Medical University of InnsbruckInnsbruckAustria
| | - Sabine Scholl‐Bürgi
- Department of Pediatrics IInherited Metabolic Disorders, Medical University of InnsbruckInnsbruckAustria
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28
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Yuan F, Lu A, Wu S, Wang L. Refractory Status Epilepticus Responsive to Electroacupuncture at Shuigou Acupoint: A Case Report. Front Neurol 2020; 11:580777. [PMID: 33329323 PMCID: PMC7734353 DOI: 10.3389/fneur.2020.580777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/04/2020] [Indexed: 11/30/2022] Open
Abstract
Refractory status epilepticus (RSE) is a critical and intractable neurological emergency. Around 55% of RSE episodes still persist despite high dose of continuous infusion of anesthetics. It's a clinical urgency and challenge to search for novel alternative treatments to control RSE as soon as possible. Here, we reported a case of RSE in a 67-year-old woman with varicella-zoster virus encephalitis. She had persistent non-convulsive SE despite the continuous infusion of midazolam. On the basis of fundamental treatments, she was given electroacupuncture at Shuigou acupoint for 10 min. An immediate EEG suppression was seen after the electroacupuncture treatment and lasted for 9 min, and lasting epileptic discharges (> 10 s) and clinical seizures were not observed any more. Midazolam was withdrawn gradually 24 h later. This case report may bring an alternative treatment for RSE.
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Affiliation(s)
- Fang Yuan
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Aili Lu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shibiao Wu
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lixin Wang
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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29
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Carroll E, Neumann H, Aguero-Rosenfeld ME, Lighter J, Czeisler BM, Melmed K, Lewis A. Post-COVID-19 inflammatory syndrome manifesting as refractory status epilepticus. Epilepsia 2020; 61:e135-e139. [PMID: 32944946 PMCID: PMC7537028 DOI: 10.1111/epi.16683] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/13/2020] [Accepted: 08/14/2020] [Indexed: 01/21/2023]
Abstract
There have been multiple descriptions of seizures during the acute infectious period in patients with COVID‐19. However, there have been no reports of status epilepticus after recovery from COVID‐19 infection. Herein, we discuss a patient with refractory status epilepticus 6 weeks after initial infection with COVID‐19. Extensive workup demonstrated elevated inflammatory markers, recurrence of a positive nasopharyngeal SARS‐CoV‐2 polymerase chain reaction, and hippocampal atrophy. Postinfectious inflammation may have triggered refractory status epilepticus in a manner similar to the multisystemic inflammatory syndrome observed in children after COVID‐19.
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Affiliation(s)
- Elizabeth Carroll
- Department of Neurology, NYU Langone Medical Center, New York, New York
| | - Henry Neumann
- Department of Medicine, NYU Langone Medical Center, New York, New York
| | | | - Jennifer Lighter
- Department of Pediatrics, NYU Langone Medical Center, New York, New York
| | - Barry M Czeisler
- Department of Neurology, NYU Langone Medical Center, New York, New York.,Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Kara Melmed
- Department of Neurology, NYU Langone Medical Center, New York, New York.,Department of Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, New York.,Department of Neurosurgery, NYU Langone Medical Center, New York, New York
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30
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Vossler DG, Bainbridge JL, Boggs JG, Novotny EJ, Loddenkemper T, Faught E, Amengual-Gual M, Fischer SN, Gloss DS, Olson DM, Towne AR, Naritoku D, Welty TE. Treatment of Refractory Convulsive Status Epilepticus: A Comprehensive Review by the American Epilepsy Society Treatments Committee. Epilepsy Curr 2020; 20:245-264. [PMID: 32822230 PMCID: PMC7576920 DOI: 10.1177/1535759720928269] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Purpose: Established tonic–clonic status epilepticus (SE) does not stop in one-third
of patients when treated with an intravenous (IV) benzodiazepine bolus
followed by a loading dose of a second antiseizure medication (ASM). These
patients have refractory status epilepticus (RSE) and a high risk of
morbidity and death. For patients with convulsive refractory status
epilepticus (CRSE), we sought to determine the strength of evidence for 8
parenteral ASMs used as third-line treatment in stopping clinical CRSE. Methods: A structured literature search (MEDLINE, Embase, CENTRAL, CINAHL) was
performed to identify original studies on the treatment of CRSE in children
and adults using IV brivaracetam, ketamine, lacosamide, levetiracetam (LEV),
midazolam (MDZ), pentobarbital (PTB; and thiopental), propofol (PRO), and
valproic acid (VPA). Adrenocorticotropic hormone (ACTH), corticosteroids,
intravenous immunoglobulin (IVIg), magnesium sulfate, and pyridoxine were
added to determine the effectiveness in treating hard-to-control seizures in
special circumstances. Studies were evaluated by predefined criteria and
were classified by strength of evidence in stopping clinical CRSE (either as
the last ASM added or compared to another ASM) according to the 2017
American Academy of Neurology process. Results: No studies exist on the use of ACTH, corticosteroids, or IVIg for the
treatment of CRSE. Small series and case reports exist on the use of these
agents in the treatment of RSE of suspected immune etiology, severe
epileptic encephalopathies, and rare epilepsy syndromes. For adults with
CRSE, insufficient evidence exists on the effectiveness of brivaracetam
(level U; 4 class IV studies). For children and adults with CRSE,
insufficient evidence exists on the effectiveness of ketamine (level U; 25
class IV studies). For children and adults with CRSE, it is possible that
lacosamide is effective at stopping RSE (level C; 2 class III, 14 class IV
studies). For children with CRSE, insufficient evidence exists that LEV and
VPA are equally effective (level U, 1 class III study). For adults with
CRSE, insufficient evidence exists to support the effectiveness of LEV
(level U; 2 class IV studies). Magnesium sulfate may be effective in the
treatment of eclampsia, but there are only case reports of its use for CRSE.
For children with CRSE, insufficient evidence exists to support either that
MDZ and diazepam infusions are equally effective (level U; 1 class III
study) or that MDZ infusion and PTB are equally effective (level U; 1 class
III study). For adults with CRSE, insufficient evidence exists to support
either that MDZ infusion and PRO are equally effective (level U; 1 class III
study) or that low-dose and high-dose MDZ infusions are equally effective
(level U; 1 class III study). For children and adults with CRSE,
insufficient evidence exists to support that MDZ is effective as the last
drug added (level U; 29 class IV studies). For adults with CRSE,
insufficient evidence exists to support that PTB and PRO are equally
effective (level U; 1 class III study). For adults and children with CRSE,
insufficient evidence exists to support that PTB is effective as the last
ASM added (level U; 42 class IV studies). For CRSE, insufficient evidence
exists to support that PRO is effective as the last ASM used (level U; 26
class IV studies). No pediatric-only studies exist on the use of PRO for
CRSE, and many guidelines do not recommend its use in children aged <16
years. Pyridoxine-dependent and pyridoxine-responsive epilepsies should be
considered in children presenting between birth and age 3 years with
refractory seizures and no imaging lesion or other acquired cause of
seizures. For children with CRSE, insufficient evidence exists that VPA and
diazepam infusion are equally effective (level U, 1 class III study). No
class I to III studies have been reported in adults treated with VPA for
CRSE. In comparison, for children and adults with established convulsive SE
(ie, not RSE), after an initial benzodiazepine, it is likely that loading
doses of LEV 60 mg/kg, VPA 40 mg/kg, and fosphenytoin 20 mg PE/kg are
equally effective at stopping SE (level B, 1 class I study). Conclusions: Mostly insufficient evidence exists on the efficacy of stopping clinical CRSE
using brivaracetam, lacosamide, LEV, valproate, ketamine, MDZ, PTB, and PRO
either as the last ASM or compared to others of these drugs.
Adrenocorticotropic hormone, IVIg, corticosteroids, magnesium sulfate, and
pyridoxine have been used in special situations but have not been studied
for CRSE. For the treatment of established convulsive SE (ie, not RSE), LEV,
VPA, and fosphenytoin are likely equally effective, but whether this is also
true for CRSE is unknown. Triple-masked, randomized controlled trials are
needed to compare the effectiveness of parenteral anesthetizing and
nonanesthetizing ASMs in the treatment of CRSE.
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Affiliation(s)
| | - Jacquelyn L Bainbridge
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | | | - Edward J Novotny
- 384632University of Washington, Seattle, WA, USA.,Seattle Children's Center for Integrative Brain Research, Seattle, WA, USA
| | | | | | | | - Sarah N Fischer
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO, USA
| | - David S Gloss
- Charleston Area Medical Center, Charleston, West Virginia, VA, USA
| | | | - Alan R Towne
- 6889Virginia Commonwealth University, Richmond, VA, USA
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31
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Hotait M, Nasreddine W, El-Khoury R, Dirani M, Nawfal O, Beydoun A. FARS2 Mutations: More Than Two Phenotypes? A Case Report. Front Genet 2020; 11:787. [PMID: 32774346 PMCID: PMC7387725 DOI: 10.3389/fgene.2020.00787] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/02/2020] [Indexed: 12/04/2022] Open
Abstract
FARS2, a nuclear gene, encodes the mitochondrial phenylalanyl-tRNA synthetase (mtPheRS). Previous reports have described two distinct phenotypes linked to FARS2 gene mutation: an early onset epileptic encephalopathy and spastic paraplegia. This report describes a distinctive phenotype of FARS2-linked, juvenile onset refractory epilepsy, caused by a hemizygous mutation in a compound heterozygous state (p.V197M and exon 2 microdeletion). A 17-year- old woman with normal development presented with a super refractory focal motor status epilepticus. Only an emergency life-saving surgery aborted her status after all therapeutic interventions, including anesthesia, failed to control her seizures. Pathological and biochemical activities on muscle biopsy showed mitochondrial proliferation with enhanced isolated activities of complexes II and IV, suggestive of a compensatory mechanism for the bioenergetic deficiency. Postoperatively, the patient started experiencing focal aware motor seizures originating from the contralateral hemisphere after being seizure free for a few months. This report suggests a third phenotypic manifestation of FARS2 gene mutation.
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Affiliation(s)
- Mostafa Hotait
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Wassim Nasreddine
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Riyad El-Khoury
- Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maya Dirani
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Omar Nawfal
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ahmad Beydoun
- Department of Neurology, American University of Beirut Medical Center, Beirut, Lebanon
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32
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Kafle DR, Avinash AJ, Shrestha A. Predictors of outcome in refractory generalized convulsive status epilepticus. Epilepsia Open 2020; 5:248-254. [PMID: 32524050 PMCID: PMC7278539 DOI: 10.1002/epi4.12394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/18/2020] [Accepted: 03/26/2020] [Indexed: 12/03/2022] Open
Abstract
Objective Refractory status epilepticus is a serious condition in which seizure continues despite use of two antiepileptic medications. Retrospective studies have shown that 29%‐43% of SE patients progress into RSE despite treatment. Mortality following RSE is high. We aimed to evaluate the predictors of outcome in patients with RSE at a tertiary care center. Methods Sixty‐eight consecutive patients with RSE who presented to our hospital between February 2018 and January 2020 were evaluated for outcome. Result In our study 28(41.2%), patients who failed to respond to first‐ and second‐line antiepileptic drug responded to the third‐line antiepileptic drug thus avoiding mechanical ventilation and intravenous anesthesia. Low GCS at admission (P < .001), need for mechanical ventilation and intravenous anesthesia (P = .018), and long duration of RSE before recovery (P = .035) were strongly associated with worse outcome. Duration of RSE before starting treatment (P = .147), previous history of seizure (P = .717), and age of the patient (P = .319) did not influence the outcome. Significance In our study, we prospectively evaluated patients with RSE and followed them for one month after discharge from the hospital. Unlike some of the previous studies, we identified an interesting finding whereby a significant proportion of the patients responded to the third‐line antiepileptic drug and thus avoiding the complications related to mechanical ventilation.
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El Houssaini K, Bernard C, Jirsa VK. The Epileptor Model: A Systematic Mathematical Analysis Linked to the Dynamics of Seizures, Refractory Status Epilepticus, and Depolarization Block. eNeuro 2020; 7:ENEURO.0485-18.2019. [PMID: 32066612 PMCID: PMC7096539 DOI: 10.1523/eneuro.0485-18.2019] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 10/10/2019] [Accepted: 10/28/2019] [Indexed: 11/21/2022] Open
Abstract
One characteristic of epilepsy is the variety of mechanisms leading to the epileptic state, which are still largely unknown. Refractory status epilepticus (RSE) and depolarization block (DB) are other pathological brain activities linked to epilepsy, whose patterns are different and whose mechanisms remain poorly understood. In epileptogenic network modeling, the Epileptor is a generic phenomenological model that has been recently developed to describe the dynamics of seizures. Here, we performed a detailed qualitative analysis of the Epileptor model based on dynamical systems theory and bifurcation analysis, and investigate the dynamic evolution of "normal" activity toward seizures and to the pathological RSE and DB states. The mechanisms of the transition between states are called bifurcations. Our detailed analysis demonstrates that the generic model undergoes different bifurcation types at seizure offset, when varying some selected parameters. We show that the pathological and normal activities can coexist within the same model under some conditions, and demonstrate that there are many pathways leading to and away from these activities. We here archive systematically all behaviors and dynamic regimes of the Epileptor model to serve as a resource in the development of patient-specific brain network models, and more generally in epilepsy research.
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Affiliation(s)
- Kenza El Houssaini
- Aix Marseille University, INSERM, INS, Institut de Neurosciences des Systèmes, 13005 Marseille, France
| | - Christophe Bernard
- Aix Marseille University, INSERM, INS, Institut de Neurosciences des Systèmes, 13005 Marseille, France
| | - Viktor K Jirsa
- Aix Marseille University, INSERM, INS, Institut de Neurosciences des Systèmes, 13005 Marseille, France
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Kundrick E, Marrero-Rosado B, Stone M, Schultz C, Walker K, Lee-Stubbs RB, de Araujo Furtado M, Lumley LA. Delayed midazolam dose effects against soman in male and female plasma carboxylesterase knockout mice. Ann N Y Acad Sci 2020; 1479:94-107. [PMID: 32027397 DOI: 10.1111/nyas.14311] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/13/2020] [Accepted: 01/19/2020] [Indexed: 01/30/2023]
Abstract
Chemical warfare nerve agent exposure leads to status epilepticus that may progress to epileptogenesis and severe brain pathology when benzodiazepine treatment is delayed. We evaluated the dose-response effects of delayed midazolam (MDZ) on toxicity induced by soman (GD) in the plasma carboxylesterase knockout (Es1-/- ) mouse, which, similar to humans, lacks plasma carboxylesterase. Initially, we compared the median lethal dose (LD50 ) of GD exposure in female Es1-/- mice across estrous with male mice and observed a greater LD50 during estrus compared with proestrus or with males. Subsequently, male and female GD-exposed Es1-/- mice treated with a dose range of MDZ 40 min after seizure onset were evaluated for survivability, seizure activity, and epileptogenesis. GD-induced neuronal loss and microglial activation were evaluated 2 weeks after exposure. Similar to our previous observations in rats, delayed treatment with MDZ dose-dependently increased survival and reduced seizure severity in GD-exposed mice, but was unable to prevent epileptogenesis, neuronal loss, or gliosis. These results suggest that MDZ is beneficial against GD exposure, even when treatment is delayed, but that adjunct therapies to enhance protection need to be identified. The Es1-/- mouse GD exposure model may be useful to screen for improved medical countermeasures against nerve agent exposure.
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Affiliation(s)
- Erica Kundrick
- US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland
| | - Brenda Marrero-Rosado
- US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland
| | - Michael Stone
- US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland
| | - Caroline Schultz
- US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland
| | - Katie Walker
- US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland
| | - Robyn B Lee-Stubbs
- US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland
| | | | - Lucille A Lumley
- US Army Medical Research Institute of Chemical Defense, Aberdeen Proving Ground, Maryland
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Tatlidil I, Ture HS, Akhan G. Factors affecting mortality of refractory status epilepticus. Acta Neurol Scand 2020; 141:123-131. [PMID: 31550052 DOI: 10.1111/ane.13173] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 08/23/2019] [Accepted: 09/21/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study was to determine the factors affecting the mortality of refractory status epilepticus (RSE) in comparison with non-refractory status epilepticus (non-RSE). MATERIAL-METHOD Included in this retrospective study were 109 status epilepticus cases who were hospitalized in the neurological intensive care unit Katip Celebi University. Fifty-two were RSE and 57 were non-RSE. All clinical data were gathered from the hospital archives. Factors which may cause mortality were categorized for statistical analysis. RESULTS While elderly age, continuous clinical seizure activity, absence of former seizure, infection, prolonged stay of ICU, anesthesia, and cardiac comorbidity were significantly related to mortality in the RSE subgroup, potentially fatal accompanying diseases were significantly related to mortality in the non-RSE subgroup. No significant relationship was found between mortality and refractoriness. Multivariate analysis revealed that a Glasgow Coma Score (GCS) at presentation of 8 or lower was the independent predictor of mortality both in the general SE population (P = .017) and in the RSE subgroup (P = .007). Intubation (P = .011) and hypotension (P = .011) were the other independent predictors of mortality in the general SE population. No independent predictor of mortality was detected in the non-RSE subgroup. DISCUSSION/CONCLUSION Intubation, hypotension, and a low GCS at presentation could be the main factors which could alert clinicians of an increased risk of mortality in SE patients. Although non-RSE and RSE had similar rates of mortality in the ICU, the mortality-related factors of SE vary in the RSE and the non-RSE subgroups.
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Affiliation(s)
- Isil Tatlidil
- Department of Neurology Malatya Research and Training Hospital Malatya Turkey
| | - Hatice S. Ture
- Department of Neurology Katip Celebi University İzmir Turkey
| | - Galip Akhan
- Department of Neurology Katip Celebi University İzmir Turkey
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Jang Y, Kim DW, Yang KI, Byun JI, Seo JG, No YJ, Kang KW, Kim D, Kim KT, Cho YW, Lee ST. Clinical Approach to Autoimmune Epilepsy. J Clin Neurol 2020; 16:519-529. [PMID: 33029957 PMCID: PMC7541993 DOI: 10.3988/jcn.2020.16.4.519] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 12/20/2022] Open
Abstract
Autoimmune epilepsy is a newly emerging area of epilepsy. The concept of “autoimmune” as an etiology has recently been revisited thanks to advances in autoimmune encephalitis and precision medicine with immunotherapies. Autoimmune epilepsy presents with specific clinical manifestations, and various diagnostic approaches including cerebrospinal fluid analysis, neuroimaging, and autoantibody tests are essential for its differential diagnosis. The diagnosis is often indeterminate despite performing a thorough evaluation, and therefore empirical immunotherapy may be applied according to the judgment of the clinician. Autoimmune epilepsy often manifests as new-onset refractory status epilepticus (NORSE). A patient classified as NORSE should receive empirical immunotherapy as soon as possible. On the other hand, a morecautious, stepwise approach is recommended for autoimmune epilepsy that presents with episodic events. The type of autoimmune epilepsy is also an important factor to consider when choosing from among various immunotherapy options. Clinicians should additionally take the characteristics of antiepileptic drugs into account when using them as an adjuvant therapy. This expert opinion discusses the diagnostic and treatment approaches for autoimmune epilepsy from a practical point of view.
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Affiliation(s)
- Yoonhyuk Jang
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Dong Wook Kim
- Department of Neurology, Konkuk University School of Medicine, Seoul, Korea
| | - Kwang Ik Yang
- Department of Neurology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, Korea
| | - Jung Ick Byun
- Department of Neurology, Kyunghee University Hospital at Gangdong, Seoul, Korea
| | - Jong Geun Seo
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Young Joo No
- Department of Neurology, Samsung Noble County, Yongin, Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Chonnam National University School of Medicine, Gwangju, Korea
| | - Daeyoung Kim
- Department of Neurology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Keun Tae Kim
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Yong Won Cho
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, Korea.
| | - Soon Tae Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea.
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Lumley L, Miller D, Muse WT, Marrero‐Rosado B, de Araujo Furtado M, Stone M, McGuire J, Whalley C. Neurosteroid and benzodiazepine combination therapy reduces status epilepticus and long-term effects of whole-body sarin exposure in rats. Epilepsia Open 2019; 4:382-396. [PMID: 31440720 PMCID: PMC6698686 DOI: 10.1002/epi4.12344] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/26/2019] [Accepted: 05/19/2019] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Our objective was to evaluate the protective efficacy of the neurosteroid pregnanolone (3α-hydroxy-5β pregnan-20-one), a GABAA receptor-positive allosteric modulator, as an adjunct to benzodiazepine therapy against the chemical warfare nerve agent (CWNA) sarin (GB), using whole-body exposure, an operationally relevant route of exposure to volatile GB. METHODS Rats implanted with telemetry transmitters for the continuous measurement of cortical electroencephalographic (EEG) activity were exposed for 60 minutes to 3.0 LCt50 of GB via whole-body exposure. At the onset of toxic signs, rats were administered an intramuscular injection of atropine sulfate (2 mg/kg) and the oxime HI-6 (93.6 mg/kg) to increase survival rate and, 30 minutes after seizure onset, treated subcutaneously with diazepam (10 mg/kg) and intravenously with pregnanolone (4 mg/kg) or vehicle. Animals were evaluated for GB-induced status epilepticus (SE), spontaneous recurrent seizures (SRS), impairment in spatial memory acquisition, and brain pathology, and treatment groups were compared. RESULTS Delayed dual therapy with pregnanolone and diazepam reduced time in SE in GB-exposed rats compared to those treated with delayed diazepam monotherapy. The combination therapy of pregnanolone with diazepam also prevented impairment in the Morris water maze and reduced the neuronal loss and neuronal degeneration, evaluated at one and three months after exposure. SIGNIFICANCE Neurosteroid administration as an adjunct to benzodiazepine therapy offers an effective means to treat benzodiazepine-refractory SE, such as occurs following delayed treatment of GB exposure. This study is the first to present data on the efficacy of delayed pregnanolone and diazepam dual therapy in reducing seizure activity, performance deficits and brain pathology following an operationally relevant route of exposure to GB and supports the use of a neurosteroid as an adjunct to standard anticonvulsant therapy for the treatment of CWNA-induced SE.
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Affiliation(s)
- Lucille Lumley
- US Army Medical Research Institute of Chemical DefenseAberdeen Proving GroundMaryland
| | - Dennis Miller
- US Army Combat Capabilities Development Command Chemical Biological CenterAberdeen Proving GroundMaryland
| | - William T. Muse
- US Army Combat Capabilities Development Command Chemical Biological CenterAberdeen Proving GroundMaryland
| | - Brenda Marrero‐Rosado
- US Army Medical Research Institute of Chemical DefenseAberdeen Proving GroundMaryland
| | | | - Michael Stone
- US Army Medical Research Institute of Chemical DefenseAberdeen Proving GroundMaryland
| | - Jeffrey McGuire
- US Army Combat Capabilities Development Command Chemical Biological CenterAberdeen Proving GroundMaryland
| | - Christopher Whalley
- US Army Combat Capabilities Development Command Chemical Biological CenterAberdeen Proving GroundMaryland
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Chen Z, Zhang Y. A patient with juvenile-onset refractory status epilepticus caused by two novel compound heterozygous mutations in FARS2 gene. Int J Neurosci 2019; 129:1094-1097. [PMID: 31329004 DOI: 10.1080/00207454.2019.1634071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
FARS2 encodes mitochondrial phenylalanyl transfer ribonucleic acid (RNA) synthetase and is implicated in autosomal recessive combined oxidative phosphorylation deficiency 14. The clinical manifestation can be divided into early onset epileptic phenotype and spastic paraplegia phenotype. The purpose of this study was to report a case of juvenile manifesting refractory epilepsy caused by two novel compound heterozygous mutations in the FARS2 gene. Microscopic and histochemical examination as well as next-generation sequencing and reconstruction of the three-dimensional structure of FARS2 protein were performed. A 17-year-old man with no developmental delays suffered from generalized tonic-clonic convulsion since 12 years of age and developed refractory status epilepticus 5 years later. No specific etiology was found following brain imaging, muscle biopsy and metabolic studies. DNA sequencing identified two novel compound heterozygous mutations in FARS2, (p.V197M and p.F402S), derived from each parents, respectively. These mutations affected the structure or thermodynamic stability of the protein. This is a case report of juvenile-onset refractory epilepsy caused by two novel compound heterozygous mutations in the FARS2 gene. This case confirms and expands the clinicalphenotype and the genotypic spectrum of the FARS2 gene.
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Affiliation(s)
- Zhongyun Chen
- Department of Neurology, Xuanwu Hospital, Capital Medical University , Beijing , China
| | - Yan Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University , Beijing , China
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Abstract
Febrile infection-related epilepsy syndrome (FIRES) is a catastrophic epileptic syndrome that strikes previously healthy children aged 3-15 years and has an unknown pathogenesis and few treatments. These children experience a nonspecific febrile illness that is followed by prolonged refractory status epilepticus. Although the etiology is unknown, FIRES has a biphasic presentation, with the acute phase beginning as seizure activity lasting 1-12 weeks, then followed by the chronic phase, which is characterized by refractory seizures that cluster every 2-4 weeks, and may continue to be multifocal and independent. Treatment of FIRES is difficult, typically unresponsive to antiepileptic drugs. Some children resolve temporarily with drug-induced burst suppression comas. Other therapies such as a ketogenic diet have limited benefit. The outcome varies with the length of the acute phase and is usually poor, with up to 30% of cases ending in death and 66-100% of survivors having intellectual disability. The authors present a case of a 6-year-old child presenting with FIRES and refractory status epilepticus, which continued despite multidrug therapy. The patient underwent immunomodulatory therapy with the eventual resolution of status, but she developed a chronic, moderately severe encephalopathy, including intractable epilepsy. This case highlights the challenges of FIRES and the potential of immunomodulatory therapies for children with this disorder.
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Affiliation(s)
- Kristy Fox
- a Neurodiagnostics and Sleep Science Program , University of North Carolina, Chapel Hill , Chapel Hill , North Carolina
| | - Mary Ellen Wells
- a Neurodiagnostics and Sleep Science Program , University of North Carolina, Chapel Hill , Chapel Hill , North Carolina
| | - Michael Tennison
- b Department of Neurology, School of Medicine , University of North Carolina , Chapel Hill, Chapel Hill , North Carolina
| | - Bradley Vaughn
- b Department of Neurology, School of Medicine , University of North Carolina , Chapel Hill, Chapel Hill , North Carolina
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Muhlhofer WG, Layfield S, Lowenstein D, Lin CP, Johnson RD, Saini S, Szaflarski JP. Duration of therapeutic coma and outcome of refractory status epilepticus. Epilepsia 2019; 60:921-934. [PMID: 30957219 DOI: 10.1111/epi.14706] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 03/09/2019] [Accepted: 03/11/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Examine the association of duration of therapeutic coma (TC) with seizure recurrence, morbidity, and mortality in refractory status epilepticus (RSE). Define an optimal window for TC that provides sustained seizure control and minimizes complications. METHODS Retrospective, observational cohort study involving patients who presented with RSE to the University of Alabama at Birmingham or the University of California at San Francisco from 2010 to 2016. Relationship of duration of TC with primary and secondary outcomes was evaluated using two-sample t tests, simple linear regression, and chi-square tests. Multivariable linear and logistic regression models were used to identify independent predictors. Predictive ability of TC for seizure recurrence was quantified using a receiver-operating characteristic curve. Youden index was used to determine an optimal cutoff value. RESULTS Multivariable analysis of clinical and treatment characteristics of 182 patients who were treated predominantly with propofol as anesthetic agent showed that longer duration of the first trial of TC (27.2 vs 15.6 hours) was independently associated with a higher chance of seizure recurrence following the first weaning attempt (P = 0.038) but not with poor functional neurologic outcome upon discharge, in-hospital complications, or mortality. Furthermore, higher doses of anesthetic utilized during the first trial of TC were independently associated with fewer in-hospital complications (P = 0.003) and associated with a shorter duration of mechanical ventilation and total length of stay. Duration of TC was identified as an independent predictor of seizure recurrence with an optimal cutoff point at 35 hours. SIGNIFICANCE This study suggests that a shorter duration yet deeper TC as treatment for RSE may be more effective and safer than the currently recommended TC duration of 24-48 hours. Prospective and randomized trials should be conducted to validate these assertions.
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Affiliation(s)
- Wolfgang G Muhlhofer
- Department of Neurology/Epilepsy Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Stephen Layfield
- Department of Neurology, Case Western Reserve University Hospitals, Cleveland, Ohio
| | - Daniel Lowenstein
- Department of Neurology, University of California San Francisco, San Francisco, California
| | - Chee Paul Lin
- Center for Clinical and Translational Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert D Johnson
- Informatics Institute, Center for Clinical and Translational Science, University of Alabama at Birmingham, Birmingham, Alabama
| | - Shalini Saini
- Information Technology Department at School of Medicine Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jerzy P Szaflarski
- Department of Neurology/Epilepsy Center, University of Alabama at Birmingham, Birmingham, Alabama
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Strzelczyk A, Knake S, Kälviäinen R, Santamarina E, Toledo M, Willig S, Rohracher A, Trinka E, Rosenow F. Perampanel for treatment of status epilepticus in Austria, Finland, Germany, and Spain. Acta Neurol Scand 2019; 139:369-376. [PMID: 30613951 PMCID: PMC6590284 DOI: 10.1111/ane.13061] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/10/2018] [Accepted: 12/30/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Novel treatments are needed to control treatment-resistant status epilepticus (SE). We report a summary of clinical cases where perampanel was used in established SE, refractory SE (RSE), or super-refractory SE (SRSE). METHODS Medical records were retrospectively reviewed for perampanel administration in SE at five European hospitals between 2011 and 2015. RESULTS Of 1319 patients identified as experiencing SE, 52 (3.9%) received perampanel. Median latency from SE onset to perampanel initiation was 10 days. Patients with SE had previously failed benzodiazepines (when received) and a median of five other antiepileptic drugs (AEDs). Median initial perampanel dose was 6 mg/d, up-titrated to a median maximum dose of 10 mg/d. Perampanel was the last drug added in 32/52 (61.5%) patients, with response attributed to perampanel in 19/52 (36.5%) patients. A greater proportion of perampanel non-responders had SRSE (51.5%; 17/33) vs perampanel responders (31.6%; 6/19), and had failed a higher mean number of AEDs before initiating perampanel (5.9 vs 5.1, respectively). Most commonly reported adverse effects during perampanel treatment were dizziness (n = 1 [1.9%]) and somnolence (n = 1 [1.9%]). No serious adverse effects were documented, and none led to discontinuation of perampanel. CONCLUSIONS Perampanel was administered to patients with established SE, RSE, or SRSE at greater initial doses than those administered in clinical practice to patients with epilepsy. The SE cases reported here represent a refractory and heterogeneous population, and rate of seizure cessation attributed to perampanel treatment (36.5%) represents a notable response. These data should be confirmed in a larger patient population.
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Affiliation(s)
- Adam Strzelczyk
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main; Goethe University; Frankfurt am Main Germany
- Department of Neurology, Epilepsy Center Hessen; Philipps University; Marburg Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER); Goethe University; Frankfurt am Main Germany
| | - Susanne Knake
- Department of Neurology, Epilepsy Center Hessen; Philipps University; Marburg Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER); Goethe University; Frankfurt am Main Germany
| | - Reetta Kälviäinen
- School of Medicine; University of Eastern Finland; Kuopio Finland
- Epilepsy Center/Neuro Center; Kuopio University Hospital; Kuopio Finland
| | | | - Manuel Toledo
- Epilepsy Unit; Hospital Vall d’Hebron; Barcelona Spain
| | - Sophia Willig
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main; Goethe University; Frankfurt am Main Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER); Goethe University; Frankfurt am Main Germany
| | - Alexandra Rohracher
- Department of Neurology, Christian Doppler Klinik; Paracelsus Medical University; Salzburg Austria
- Centre for Cognitive Neuroscience; University of Salzburg; Salzburg Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Klinik; Paracelsus Medical University; Salzburg Austria
- Centre for Cognitive Neuroscience; University of Salzburg; Salzburg Austria
- Department of Public Health, Health Services Research and Health Technology Assessment; UMIT - University for Health Sciences, Medical Informatics and Technology; Hall in Tirol Austria
| | - Felix Rosenow
- Department of Neurology, Epilepsy Center Frankfurt Rhine-Main; Goethe University; Frankfurt am Main Germany
- LOEWE Center for Personalized Translational Epilepsy Research (CePTER); Goethe University; Frankfurt am Main Germany
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Abstract
Status epilepticus (SE) has a high mortality rate and is one of the most common neurologic emergencies. Fast progression of this neurologic emergency and lack of response to traditional antiepileptic drugs (AEDs) in most cases has challenged clinicians to use new agents. This article evaluates the efficacy and safety of AEDs released to the market after 2000 for SE, refractory status epilepticus (RSE), and super-refractory status epilepticus (SRSE). The PubMed database was searched for clinical trials published between January 2000 and July 2018 using the search terms status epilepticus, refractory status epilepticus, super refractory status epilepticus, brivaracetam, clobazam, cannabidiol, eslicarbazepine, lacosamide, perampanel, rufinamide, stiripentol, and zonisamide. Trials that evaluated these agents in adults with SE, RSE, and SRSE were included. Brivaracetam use was identified in two retrospective reviews with success rates of 27% and 57%. One unsuccessful case report of cannabidiol use in SE was found. Four clobazam studies were identified in SE and RSE with success rates ranging from 25-100%. No evidence for the use of eslicarbazepine and zonisamide was found. Using the search terms for lacosamide identified 38 articles: 1 systematic review, 5 prospective studies, 15 retrospective reviews, and 17 case reports. Success rates and dosing varied, but studies that included focal or partial types of SE showed higher success rates. Five articles were identified regarding perampanel use in this setting. Three were retrospective reviews with success rates ranging from 17-60%, and two were case reports. Only one case report regarding the use of rufinamide was found; rufinamide titrated up to 4.4 mg/day allowed discontinuation of barbiturate and clobazam. One case report and two case series of stiripentol were found with reported efficacy between 60% and 100% in SRSE. Evidence is currently insufficient to support the use of these agents in this setting.
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Affiliation(s)
- Salia Farrokh
- Johns Hopkins Hospital, Division of Critical Care and Surgery Pharmacy, Baltimore, Maryland
| | - John Bon
- Department of Pharmacy, Summa Health System, Akron, Ohio
| | | | - Eljim Tesoro
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois
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Rao SK, Mahulikar A, Ibrahim M, Shah A, Seraji-Bozorgzad N, Mohamed W. Inadequate benzodiazepine dosing may result in progression to refractory and non-convulsive status epilepticus. Epileptic Disord 2018; 20:265-9. [PMID: 30113012 DOI: 10.1684/epd.2018.0987] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Status epilepticus (SE) is defined as ongoing seizures lasting longer than five minutes or multiple seizures without recovery. Benzodiazepines (BZDs) are first-line agents for the management of SE. Our objective was to evaluate BZD dosing in SE patients and its effects on clinical/electrographic outcomes. A retrospective analysis was conducted from a prospective database of SE patients admitted to a university-based neurocritical care unit. The initial presentation and progression to refractory SE (RSE) and non-convulsive SE (NCSE) with coma was evaluated. Outcome measures included length of stay (LOS), rates of intubation, ventilator-dependent days, and Glasgow outcome scale (GOS). The lorazepam equivalent (LE) dosage of BZDs administered was calculated and we analysed variations in progression if 4 mg or more of LE (adequate BZDs) was administered. Among 100 patients, the median dose of LE was 3 mg (IQR: 2-5 mg). Only 31% of patients received adequate BZDs. Only 18.9% of patients with NCSE without coma received adequate BZDs (p=0.04). Among patients progressing to RSE, 75.4% had not received adequate BZDs (p=0.04) and among patients developing NCSE with coma, 80.6% did not receive adequate BZDs (p=0.07). Escalating doses of BZDs were associated with a decrease in cumulative incidences of RSE (correlation coefficient r=-0.6; p=0.04) and NCSE with coma (correlation coefficient r=-0.7; p=0.003). Outcome measures were not influenced by BZD dosing. The majority of our patients were not adequately dosed with BZDs. Inadequate BZD dosing progressed to RSE and had a tendency to lead to NCSE with coma. Our study demonstrates the need to develop a hospital-wide protocol to guide first responders in the management of SE.
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Ryan CS, Fine AL, Cohen AL, Schiltz BM, Renaud DL, Wirrell EC, Patterson MC, Boczek NJ, Liu R, Babovic-Vuksanovic D, Chan DC, Payne ET. De Novo DNM1L Variant in a Teenager With Progressive Paroxysmal Dystonia and Lethal Super-refractory Myoclonic Status Epilepticus. J Child Neurol 2018; 33:651-658. [PMID: 29877124 PMCID: PMC8176639 DOI: 10.1177/0883073818778203] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND The dynamin 1-like gene ( DNM1L) encodes a GTPase that mediates mitochondrial and peroxisomal fission and fusion. We report a new clinical presentation associated with a DNM1L pathogenic variant and review the literature. RESULTS A 13-year-old boy with mild developmental delays and paroxysmal dystonia presented acutely with multifocal myoclonic super-refractory status epilepticus. Despite sustained and aggressive treatment, seizures persisted and care was ultimately withdrawn in the context of extensive global cortical atrophy. Rapid trio-whole exome sequencing revealed a de novo heterozygous c.1207C>T (p.R403C) pathogenic variant in DNM1L. Immunofluorescence staining of fibroblast mitochondria revealed abnormally elongated and tubular morphology. CONCLUSIONS This case highlights the diagnostic importance of rapid whole exome sequencing within a critical care setting and reveals the expanding phenotypic spectrum associated with DNM1L variants. This now includes progressive paroxysmal dystonia and adolescent-onset super-refractory myoclonic status epilepticus contributing to strikingly rapid and progressive cortical atrophy and death.
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Affiliation(s)
- Conor S Ryan
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Anthony L Fine
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Alexander L Cohen
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Brenda M Schiltz
- 2 Department of Pediatrics, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Deborah L Renaud
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Elaine C Wirrell
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
| | - Marc C Patterson
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA.,3 Department of Clinical Genomics, Mayo Clinic, Rochester, MN, USA
| | - Nicole J Boczek
- 4 Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.,5 Center for Individualized Medicine, Mayo Clinic, Rochester, MN, USA
| | - Raymond Liu
- 6 Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA, USA
| | | | - David C Chan
- 6 Division of Biology and Biological Engineering, California Institute of Technology, Pasadena, CA, USA
| | - Eric T Payne
- 1 Department of Neurology, Division of Child and Adolescent Neurology, Mayo Clinic, Rochester, MN, USA
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Rohracher A, Kalss G, Neuray C, Höfler J, Dobesberger J, Kuchukhidze G, Kreidenhuber R, Florea C, Thomschewski A, Novak HF, Pilz G, Leitinger M, Trinka E. Perampanel in patients with refractory and super- refractory status epilepticus in a neurological intensive care unit: A single-center audit of 30 patients. Epilepsia 2018; 59 Suppl 2:234-242. [PMID: 30043411 DOI: 10.1111/epi.14494] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2018] [Indexed: 11/29/2022]
Abstract
In refractory status epilepticus (SE), γ-aminobutyric acidergic drugs become less effective and glutamate plays a major role in seizure perpetuation. Data on the efficacy of perampanel (PER) in treatment of refractory SE in humans are limited. Here, we present a single-center case series of patients with refractory SE who received PER orally in an intensive care unit. We retrospectively analyzed treatment response, outcome, and adverse effects of all patients with refractory SE in our Neurological Intensive Care Unit who received add-on PER between September 2012 and February 2018. Thirty patients with refractory SE (median = 72 years, range = 18-91, 77% women) were included. In 14 patients (47%), a high-dose approach was used, with a median initial dose of 24 mg (range = 16-32). In five patients (17%), SE could be terminated after PER administration (median dose = 6 mg, range = 6-20 mg, 2/5 patients in high-dose group). Clinical response was observed after a median of 24 hours (range = 8-48 hours), whereas electroencephalogram resolved after a median of 60 hours (range = 12-72 hours). Time to treatment response tended to be shorter in patients receiving high-dose PER (median clinical response = 16 hours vs 18 hours; electroencephalographic response = 24 hours vs 72 hours), but groups were too small for statistical analysis. Continuous cardiorespiratory monitoring showed no changes in cardiorespiratory function after "standard" and "high-dose" treatment. Elevated liver enzymes without clinical symptoms were observed after a median of 6 days in seven of 30 patients (23%; 57% high dose vs 43% standard dose), of whom six also received treatment with phenytoin (PHT). Outcome was unfavorable (death, persistent vegetative state) in 13 patients (43%; 39% high dose vs 61% standard dose), and good recovery (no significant disability, moderate disability) was achieved in nine patients (56% high dose vs 44% standard dose). Oral PER in loading doses up to 32 mg were well tolerated but could terminate SE only in a few patients (5/30; 17%). Long duration of SE, route of administration, and severe underlying brain dysfunction might be responsible for the modest result. An intravenous formulation is highly desired to explore the full clinical utility in the treatment of refractory SE.
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Affiliation(s)
- Alexandra Rohracher
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Gudrun Kalss
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Caroline Neuray
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Julia Höfler
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Judith Dobesberger
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Giorgi Kuchukhidze
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria.,Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Rudolf Kreidenhuber
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Cristina Florea
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | | | - Helmut F Novak
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Georg Pilz
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Markus Leitinger
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Cognitive Neuroscience Salzburg, Salzburg, Austria
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Watson W, Louro J, Dudaryk R. Perioperative management of massive fat embolism syndrome presenting as refractory status epilepticus. Int J Crit Illn Inj Sci 2018; 8:107-110. [PMID: 29963415 PMCID: PMC6018261 DOI: 10.4103/ijciis.ijciis_63_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Fat embolism syndrome (FES) most commonly can occur after trauma in patients with long bone fractures. While the majority of FES cases present as a mild decrease in mental status, some may manifest as seizure activity. We describe a case of a young patient with traumatic fractures who developed FES leading to refractory status epilepticus and simultaneously required damage controlled orthopedic surgery. The role of imaging modalities including magnetic resonance imaging, transcranial Doppler, and transesophageal echocardiography in diagnosis is discussed, and a multidisciplinary approach to successful perioperative management is described.
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Affiliation(s)
- William Watson
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Jackson Memorial Hospital and The University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jack Louro
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Jackson Memorial Hospital and The University of Miami Miller School of Medicine, Miami, FL, USA
| | - Roman Dudaryk
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Jackson Memorial Hospital and The University of Miami Miller School of Medicine, Miami, FL, USA
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Abstract
Refractory and super-refractory status epilepticus (SE) are serious illnesses with a high risk of morbidity and even fatality. In the setting of refractory generalized convulsive SE (GCSE), there is ample justification to use continuous infusions of highly sedating medications-usually midazolam, pentobarbital, or propofol. Each of these medications has advantages and disadvantages, and the particulars of their use remain controversial. Continuous EEG monitoring is crucial in guiding the management of these critically ill patients: in diagnosis, in detecting relapse, and in adjusting medications. Forms of SE other than GCSE (and its continuation in a "subtle" or nonconvulsive form) should usually be treated far less aggressively, often with nonsedating anti-seizure drugs (ASDs). Management of "non-classic" NCSE in ICUs is very complicated and controversial, and some cases may require aggressive treatment. One of the largest problems in refractory SE (RSE) treatment is withdrawing coma-inducing drugs, as the prolonged ICU courses they prompt often lead to additional complications. In drug withdrawal after control of convulsive SE, nonsedating ASDs can assist; medical management is crucial; and some brief seizures may have to be tolerated. For the most refractory of cases, immunotherapy, ketamine, ketogenic diet, and focal surgery are among several newer or less standard treatments that can be considered. The morbidity and mortality of RSE is substantial, but many patients survive and even return to normal function, so RSE should be treated promptly and as aggressively as the individual patient and type of SE indicate.
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Affiliation(s)
- Samhitha Rai
- KS 457, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Frank W Drislane
- KS 457, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA.
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Vezzani A, Dingledine R, Rossetti AO. Immunity and inflammation in status epilepticus and its sequelae: possibilities for therapeutic application. Expert Rev Neurother 2018; 15:1081-92. [PMID: 26312647 DOI: 10.1586/14737175.2015.1079130] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Status epilepticus (SE) is a life-threatening neurological emergency often refractory to available treatment options. It is a very heterogeneous condition in terms of clinical presentation and causes, which besides genetic, vascular and other structural causes also include CNS or severe systemic infections, sudden withdrawal from benzodiazepines or anticonvulsants and rare autoimmune etiologies. Treatment of SE is essentially based on expert opinions and antiepileptic drug treatment per se seems to have no major impact on prognosis. There is, therefore, urgent need of novel therapies that rely upon a better understanding of the basic mechanisms underlying this clinical condition. Accumulating evidence in animal models highlights that inflammation ensuing in the brain during SE may play a determinant role in ongoing seizures and their long-term detrimental consequences, independent of an infection or auto-immune cause; this evidence encourages reconsideration of the treatment flow in SE patients.
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Affiliation(s)
- Annamaria Vezzani
- a 1 Department of Neuroscience, Mario Negri Institute for Pharmacological Research, Milano, Italy
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Zolkowska D, Wu CY, Rogawski MA. Intramuscular allopregnanolone and ganaxolone in a mouse model of treatment-resistant status epilepticus. Epilepsia 2018; 59 Suppl 2:220-227. [PMID: 29453777 DOI: 10.1111/epi.13999] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2017] [Indexed: 11/28/2022]
Abstract
Allopregnanolone (5α-pregnan-3α-ol-20-one) and its synthetic 3β-methyl analog, ganaxolone, are positive allosteric modulators of synaptic and extrasynaptic γ-aminobutyric acid (GABA)A receptors that exhibit antiseizure activity in diverse animal seizure models, including models of status epilepticus (SE). The 2 neuroactive steroids are being investigated as treatments for SE, including as a treatment for SE induced by chemical threat agents. Intramuscular injection is the preferred route of administration in the prehospital treatment of SE. The objective of this study was to assess the efficacy of intramuscular allopregnanolone and ganaxolone in the treatment of SE induced by the chemical threat agent tetramethylenedisulfotetramine (TETS). The test agents were administered 40 minutes after the onset of SE when mice are refractory to treatment. Allopregnanolone and ganaxolone (each at 3 mg/kg) terminated SE in, respectively, 92% and 75% of animals, and prevented mortality in 85% and 50% of animals; the mean times to termination of behavioral seizures were, respectively, 172 ± 16 and 447 ± 52 seconds. In a separate series of experiments, mice were dosed with the neuroactive steroids by intramuscular injection, and plasma and brain levels were sampled at various time points following injection to estimate pharmacokinetic parameters. Plasma Cmax (maximum concentration) values for allopregnanolone and ganaxolone were 645 and 550 ng/mL, respectively. Brain exposure of both steroids was approximately 3-fold the plasma exposure. Two-compartment pharmacokinetic analysis revealed that the central compartment Vd (volume of distribution), CL (clearance), t½ (terminal half-life), and F (intramuscular bioavailability) values for allopregnanolone and ganaxolone were, respectively, 4.95 L/kg 12.88 L/kg/h,16 minutes, 97%, and 5.07 L/kg, 8.35 L/kg/h, 25 minutes, 95%. Allopregnanolone and ganaxolone are effective in the treatment of TETS-induced SE when administered by the intramuscular route. Allopregnanolone is more rapidly acting and modestly more effective, possibly because it has greater potency on GABAA receptors.
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Affiliation(s)
- Dorota Zolkowska
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Chun-Yi Wu
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, USA.,Bioanalysis and Pharmacokinetics Core Facility, UC Davis Medical Center, Sacramento, CA, USA
| | - Michael A Rogawski
- Department of Neurology, School of Medicine, University of California, Davis, Sacramento, CA, USA.,Department of Pharmacology, School of Medicine, University of California, Davis, Sacramento, CA, USA
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50
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Masapu D, Gopala Krishna KN, Sanjib S, Chakrabarti D, Mundlamuri RC, Manohar N, Mariamma P, Satishchandra P, Umamaheswara Rao GS. A Comparative Study of Midazolam and Target-Controlled Propofol Infusion in the Treatment of Refractory Status Epilepticus. Indian J Crit Care Med 2018; 22:441-448. [PMID: 29962746 PMCID: PMC6020637 DOI: 10.4103/ijccm.ijccm_327_17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: The recommended treatment for refractory status epilepticus (RSE) is the use of anesthetic agents, but evidence regarding the agent of choice is lacking. This study was designed to compare target-controlled infusion of propofol versus midazolam for the treatment of RSE regarding seizure control and complications. Methods: This prospective, randomized study recruited 23 adult patients with RSE due to any etiology and treated with either propofol or midazolam titrated to clinical seizure cessation and gradual tapering thereafter. The primary outcome measure was seizure control and the secondary outcomes were duration of the Intensive Care Unit stay and duration of mechanical ventilation, occurrence of super RSE (SRSE), and complications. Results: We recruited 23 patients (male:female = 18:5) into this study (propofol Group-11; midazolam Group-12). Overall, seizure control was noted in 34.8%, with successful seizure control in 45% of patients in the propofol group and 25% in midazolam group (P = 0.4). Mortality was similar in both the groups (propofol group [8/11; 72.7%] compared to the midazolam group [7/12; 58.3%] [P = 0.667]). The duration of hospital stay was significantly shorter in the propofol group compared to midazolam (P = 0.02). The overall incidence of SRSE was 69.5% in this study. The complication rate was not significantly different between the groups. Conclusions: The choice of anesthetic agent does not seem to affect the overall outcome in RSE and SRSE. Target-controlled propofol infusion was found to be equal in its efficacy to midazolam for the treatment of RSE. High mortality might be due to SRSE secondary to the underlying brain pathology.
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Affiliation(s)
- Dheeraj Masapu
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - K N Gopala Krishna
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Sinha Sanjib
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dhrithiman Chakrabarti
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - R C Mundlamuri
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Nitin Manohar
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - P Mariamma
- Department of Biostatistics, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - P Satishchandra
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - G S Umamaheswara Rao
- Department of Neuroanaesthesia and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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