Etiology and Outcome of Status Epilepticus

Abstract

Source: Asadi-Pooya AA, Poordast A. Etiologies and outcomes of status epilepticus in children. Epilepsy Behav. 2005;7:502–505.The authors retrospectively studied the etiology and outcome of status epilepticus (SE) in 135 children (76 boys), age range 1 month-15 years, admitted to Nemazee Hospital in Shiraz, Iran between 1999 and 2004. SE was defined as a convulsion lasting longer than 30 minutes or serial convulsions with no return of consciousness. The mean age of subjects was 4.14 ± 3.8 years: 44 (33%) were younger than 12 months, 29 (21%) were between 1–3 years old, and 62 (46%) were older than 3 years. Prolonged febrile seizure (FS) was the etiology in 69 (51%) of the patients (57% of these patients were aged <12 months; 45%, 1–3 years; and 50%, >3 years). Idiopathic SE accounted for 50 (37%) cases and was associated with the discontinuation of an anticonvulsant drug in 38 (28%). SE attributable to an underlying cause (symptomatic SE) was seen in 16 patients (11.9%): 10 with a central nervous system (CNS) infection, 4 with metabolic disorders, and 2 with trauma. Etiology did not differ significantly between age groups (P=.736) or by sex (P=.156).Fourteen (10.4%) patients died during the hospital stay, and 3 (2.2%) died within 1 month of discharge. One (0.7%) patient was in a vegetative state, 8 (5.9%) were severely disabled, and 28 (20.7%) were moderately disabled. Eighty-one patients (60%) had a good recovery. Death was attributable to a prolonged FS in 4, idiopathic SE in 6, and CNS infection in 3. Patients with symptomatic SE had the worst outcome: 63% of these patients died or had significant morbidity. In comparison, the morbidity and mortality rate was 48% in children with idiopathic SE and 29% in children with FS and SE. The mean duration of hospitalization was 7 ± 9.7 days (range 1–68 days), and length of hospitalization did not differ by etiology but was shorter for patients with good outcome.Dr. Millichap has not disclosed any financial relationships relevant to this commentary.Fever is the most common cause of SE in children, even in those older than 3 years. The outcome of SE is significantly correlated with etiology: symptomatic cases secondary to CNS infection have the worst outcome and prolonged FS the most favorable. Other studies have found similar results. In a study of adolescents and adults in the Netherlands, the underlying cause of SE (noncompliance with antiepileptic drug [AED] treatment, systemic infection) and duration of the SE were the factors most important in outcome.1 A study from the United Kingdom found that noncompliance with AED therapy or inadequate instruction regarding the use of rectal diazepam administered in the home explained the need for hospital admission of children with SE.2The risk of SE in children with an initial diagnosis of epilepsy is 9.5% according to a prospective, community-based cohort study of 613 children in New York.3 In this New York study, the risk was increased in children with a history of SE, in younger age groups, and in those with symptomatic etiology. The risk was 14% in symptomatic cases and 2.6% in the idiopathic group. The authors emphasize the importance of seizure prevention and early abortive therapy, recommending rectal diazepam in the home for patients at high risk of SE. The Epilepsy Foundation of America’s Working Group on Status Epilepticus4 has outlined a proposal for emergency department management of SE: a clear predetermined plan of action; prompt administration of appropriate AEDs in adequate doses; and attention to apnea, hypoventilation, fever and infection, or metabolic abnormalities.Most febrile seizures are benign, but the outcomes are shakier once SE occurs. The use of rectal diazepam at home3 along with clear emergency protocols for dealing with SE in emergency departments4 could result in declines in the incidence of SE in children.