Abstract
ObjectiveTo evaluate clinical outcomes and treatment effectiveness of status epilepticus finally resolved by nonbenzodiazepine antiepileptic drugs (AEDs).MethodsAll consecutive SE episodes observed from September 1, 2013, to September 1, 2018, and resolved by AEDs were considered. Diagnosis and classification of SE followed the 2015 ILAE proposal. Nonconvulsive status (NCSE) diagnosis was confirmed according to the Salzburg EEG criteria. The modified Rankin Scale and deaths at 30 days from onset were used to evaluate outcomes.ResultsA total of 277 status episodes (mean age 71 years; 61% female) were treated and resolved by antiepileptic drugs after 382 treatment trials. 68% of the SE resolved after AED use as first/second treatment line, while subsequent trials with AEDs gave an additional 32% resolution. A return to baseline conditions was observed in 48% of the patients, while overall mortality was 19% without significant changes across the study years. Mortality was higher in NCSE than in convulsive SE (22.5% vs 12.9%; P < .05), while mortality did not differ in SE episodes resolved by a first/second AED trial (17.2%) versus SE resolved by successive treatment trials (18.9%). The resolution rate of intravenous AEDs was 82% for valproate, 77% for lacosamide, 71% for phenytoin, and 62% for levetiracetam. No significant differences were found in head‐to‐head comparison, but for the valproate‐levetiracetam one that was related to NCSE episodes in which valproate resulted to be effective in 86% of the trials while levetiracetam in 62% (P < .002).SignificanceA high short‐term mortality, stable over time, was observed in SE despite resolution of seizures, especially in SE with nonconvulsive semiology. Comparative AED efficacy showed no significant differences except for higher resolution rate for valproate versus levetiracetam in NCSE.
Highlights
Status epilepticus (SE) is a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms which can lead to abnormally prolonged seizures.[1]
We evaluated the clinical outcomes and treatment effectiveness of nonbenzodiazepine intravenous antiepileptic drugs (AEDs) in a cohort of consecutive status epilepticus episodes that were resolved by AEDs
We considered a trial with one specific AED a success in stopping SE when (a) the AED was the last drug administered within 72 hours prior to the clinical and/or EEG resolution of SE and (b) the SE did not recur during the entire hospital observation of the patient.[30]
Summary
Status epilepticus (SE) is a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms which can lead to abnormally prolonged seizures.[1]. Randomized controlled trials (RCTs) have demonstrated that intravenous lorazepam[9,10] or intramuscular midazolam[11] is the most efficient option in early status After their failure, SE is considered to be established (ESE), requiring the administration of antiepileptic drugs (AEDs) given intravenously. Considering the few high-class RCTs, clinical practice is still influenced by experts' opinions, and while clinical guidelines emphasize the need for rapid control of benzodiazepine-resistant SE, they do not provide guidance regarding the choice of medication on the basis of either efficacy or safety.[20,21,22,23,24] To fill this gap, very recently the results of the Established Status Epilepticus Treatment Trial (ESETT), a randomized, blinded, adaptive trial that compared the efficacy and safety of levetiracetam, fosphenytoin, and valproate in children and adults with benzodiazepine-refractory convulsive status epilepticus, have been published.[25] The three study drugs showed the same efficacy leading to seizure cessation at 60 minutes in about half of the patients. While almost all RCTs on benzodiazepine-resistant SE are
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