Acute Symptomatic Etiology Research Articles

Uric acid is a useful marker to differentiate between responsive and refractory status epilepticus

ObjectivesEarly recognition of refractory status epilepticus (RSE) is essential to select an appropriate treatment strategy and is closely associated with the outcome. Only few studies of RSE biomarkers exist; hence, we investigated the serum levels of uric acid (UA), albumin, and C-reactive protein (CRP) as potential serologic biomarkers for RSE. Patients and MethodsConsecutive status epilepticus (SE) patients who had serial conventional blood tests in a referral hospital over a period of 10 years were retrospectively analyzed. Patients with anoxic encephalopathy, renal failure, acute stroke, and myocardial infarction were excluded. RSE was defined as seizure continuing after the first- and second-line treatments. We also assessed SE severity in all included patients using the Status Epilepticus Severity Score (STESS). General demographics and blood test findings were compared between responsive SE and RSE patients. ResultsA total of 141 patients (99 responsive and 42 refractory) were recruited from our SE registry. Compared to responsive patients, patients with RSE showed a higher STESS, lower initial albumin levels, lower initial UA levels, lower follow-up UA levels, and greater reduction of UA levels. The RSE group more frequently had acute symptomatic etiology, showed longer hospitalization, and had poorer functional outcomes compared to the responsive-SE group. All evaluated UA level parameters exhibited significant areas under the curve in receiver operating characteristic analyses, predictive of RSE. Initial UA levels, as well as changes therein, were significantly associated with RSE in multivariate logistic regression analysis. ConclusionUA levels at initial and follow-up evaluations, and changes therein differentiated responsive SE and RSE, demonstrating the feasibility of UA serum levels as a biomarker for RSE.

Convulsive status epilepticus in children: clinical profile and outcome in a tertiary care hospital

Background: The outcome of status epilepticus (SE) depends on various determinants such as age, type and duration of SE, etiology, management and associated comorbidities. This study was undertaken to describe the clinical profile and outcome of children with convulsive status epilepticus presenting to pediatric intensive care unit (PICU).Methods: Eighty-seven children between the age group 1 month to 12 years who at presentation or during the PICU stay had convulsive status epilepticus (CSE) were included in the study. Clinical profile, etiological spectrum and outcome at the end of hospital stay were analysed.Results: Median age of CSE was 4 years and 55 (63.2%) were below 5 years of age. Acute symptomatic etiology of CSE was a significant risk factor (p= 0.03) for refractory status epilepticus (RSE) which was seen in 31 patients (39%). Acute symptomatic etiology was the cause of CSE in 46 (59.2%) children. Remote symptomatic (26.4%), cryptogenic (18.4%) and progressive (2.3%) were other etiologies. Neuro-infection (29.8%) and febrile seizures (11.5%) were the most common acute symptomatic causes. Mortality and morbidity occurred in 23 (26.4%) and 8 (9.2%) patients respectively. Remaining 56 (64.6%) returned to baseline condition at the end of hospital stay. Longer duration (p= 0.03) and acute symptomatic etiology (p=0.049) were significant risk factors for mortality.Conclusions: Most common causes of CSE in children are acute symptomatic. Longer duration of status is associated with higher mortality. Hence, termination of seizure activity at the earliest, prudent management of respiratory or circulatory impairments in these children and improving the overall health care to prevent neuro-infections are important steps to improve outcome.

Etiology and outcomes of convulsive status epilepticus in children.

Objective:The study aimed to ascertain different causes and outcomes of convulsive status epilepticus in children.Methods:From January 2018 to June 2018, seventy three patients who presented with status epilepticus were studied. Data were recorded with the help of a pre-formed performa. Etiological factors and outcomes in terms of recovery, morbidity and mortality were studied.Results:Out of 73 children, forty one (56%) were males and 32(44%) were females with median age of 1.09±0.27 years. Etiologies were acute symptomatic 25(34%), febrile 19(26%), progressive encephalopathy 10(14%), remote symptomatic 10(14%) and idiopathic 7 (9%) with p-value 0.005. Status epilepticus was controlled within one hour in 42(57%), within 1-6 hours in 21(29%) and more than 6 hours in 10(14%) patients with p-value 0.027. During hospitals stay, twenty one (29%) patients recovered completely, seizure recurred in 12(16%), Twelve (16%) became mentally retarded, Twelve (16%) developed mental retardation along with seizures and 16(22%) died. Eight (10.9%) deaths were attributed to acute symptomatic etiology with p-value less than 0.001.Conclusion:This study concluded that acute symptomatic etiology was more common cause of status epilepticus as compared to other etiologies and it is associated with poorer outcomes as compared to other etiologies.

Status epilepticus in the elderly: Comparison with younger adults in a comprehensive community hospital

PurposePrevious studies on status epilepticus (SE) in the elderly were conducted in tertiary centers. We aimed to delineate the features and outcomes of elderly SE patients by comparing them to those of younger patients in a comprehensive community hospital providing primary to tertiary care. MethodsWe retrospectively investigated 197 consecutive adult SE patients admitted to our hospital. The clinical, electroencephalography, and diffusion-weighted imaging (DWI) findings of 112 elderly patients (aged ≥65 years) were compared to those of 85 younger patients (aged <65 years). ResultsCompared to that in younger patients, SE in elderly patients more frequently presented de novo (68.8% vs. 52.9%, p = 0.02); was less likely to be tonic-clonic (55.4% vs. 83.5%, p < 0.001) but more likely to be focal motor (36.6% vs. 12.9%, p < 0.001); and was more frequently refractory (30.4% vs. 14.1%, p = 0.008), particularly refractory nonconvulsive SE (13.4% vs. 4.7%, p = 0.04). Lateralized periodic discharges on electroencephalography (20.9% vs. 4.8%, p = 0.001) and SE-associated hyperintensities on DWI (27.8% vs. 13.6%, p = 0.03) were more common in the elderly than in the younger SE patients. The mortality rates did not significantly differ between the groups (6.3% vs. 3.5%, p = 0.52). The percentage of poor functional outcomes did not significantly differ between the groups in cases with acute symptomatic etiology (52.0% vs. 45.7%, p = 0.63), but was higher in elderly patients with remote symptomatic and cryptogenic etiologies (33.3% vs. 12.0%, p = 0.006). ConclusionsSE in the elderly differed from that in younger adults in the semiology, refractoriness, electroencephalography and DWI findings, and functional outcome. Outcomes were better than previously reported.

The etiology and prognosis of super-refractory convulsive status epilepticus in children

BackgroundBoth refractory convulsive status epilepticus (SE) and super-refractory SE are medical emergencies. However, there are limited data on super-refractory SE in children. Thus, this study focuses on characterizing the demographics, outcomes, and prognostic factors for super-refractory SE in children. MethodsThis study was a retrospective analysis of super-refractory SE treated in a tertiary referral center in Taiwan. The functional outcome was evaluated by modified Rankin scale (mRS). Significant functional decline was defined as an mRS difference (before hospital admission and at discharge) of more than 2. The variates and the follow-up mRS values were then analyzed statistically. ResultsWe enrolled 134 patients with 191 episodes of convulsive SE and identified 30 patients with 38 episodes of convulsive super-refractory SE. The incidence of convulsive super-refractory SE in the group with SE was 19.9%, and the age ranged from 2.5 months to 17 years. In-hospital mortality was 13.3%, which was much lower than that of adult cohorts. Newly acquired epilepsy and cognitive deficit occurred in 100% and 88.5%, respectively. Newly acquired epilepsy, as a sequel of super-refractory SE, was observed in all 18 patients (100%) who survived and had no history of epilepsy. Significant functional decline (mRS difference of more than 2) at discharge occurred in 76.7%. Poor functional outcome was associated with acute symptomatic etiology (P < 0.001) and the number of anesthetic agents (P = 0.002). The functional outcome improved after 1 year of follow-up in our population. ConclusionsSuper-refractory SE is associated with significant morbidity and mortality in children. However, the in-hospital mortality rate is much lower compared with adults. The functional outcome in children is associated with acute symptomatic etiology and the number of anesthetic agents and may improve after long-term follow-up.

New-onset seizure presenting as status epilepticus: Etiology and clinical characteristics in a cohort of 236 children

PurposeEvaluation of the etiology, clinical characteristics and outcome of the first status epilepticus (fSE) event in children. MethodThe patients with fSE hospitalized in our Institute from 1995 to 2011 were included. The etiology was characterized as either known (symptomatic) or unknown (cryptogenic). Outcome was assessed at the end of hospitalization. Logistic regression analyses were used to assess predictors of the outcome, with odds ratio adjusted by age as a measure effect. ResultsThe study included 236 patients with a median age of 2.0 years (IQR 4.0). Etiology was identified as secondary to: defined electroclinical syndromes 108 (45.8), acute symptomatic conditions 63 (26.7%), unknown 24 (10.1%), progressive encephalopathy 23 (9.7%), or remote symptomatic 18 (7.6%). Recurrence rate was 16.9%, neurological consequences were in 24.6% and case-fatality ratio was 4.7%. The main predictors were for: a) death – progressive encephalopathy (OR = 14.68, 95% CI 4.06–23.11. p = 0.001); b) neurological sequelae – acute symtomatic (OR 3.44, 95% CI 4.82–6.47) p = 0.001, remote symptomatic (OR = 13.84, 95% CI 4.34–44.12. p = 0.001), progressive encephalopathy (OR = 3.94, 95% CI 1.64–9.56. p = 0.002), seizure duration >60 min (OR = 0.44, 95% CI 0.24–0.81. p = 0.001); c) seziure recurrence – acute symptomatic etiology (OR = 3.59, 95% CI 41.76–7.21. p = 0.001), seizure duration >60 min (OR = 0.30, 95% CI 0.15–0.61. p = 0.001). ConclusionsIn children with fSE, exploring acute disorders and immediate etiological treatment is essential. The outcome of fSE is favorable concerning the recurrence rate, while neurological sequelae are seen in one quarter of the patients. The etiology and fSE duration are the main determinants of outcome.

Status Epilepticus in Our Patients, 15-Years Follow-Up Study

Introduction: Status epilepticus (SE) is the second most frequent neurological emergency. The purpose of this study was to analyse clinical presentation, causes and outcome of SE. Aim of the Study: The aim was to establish clinical characteristics, etiology and the outcome of status epilepticus as well as sex and age distribution in patients hospitalized at the Clinic of Neurology UCC RS in a 15-year follow-up. Patients and Methods: In this prospective 15-year study, all patients with SE admitted to the University Clinical Center of Republic of Srpska, Clinic of Neurology, were treated in the period of 15 years (2003-2017). Demographic and clinical data were collected. Results: In the aforesaid period, 124 patients with SE were treated, and there were 71 man (57%) with mean age of 59 years and 54 woman (43%), with mean age of 52.5 years. Primarily generalized tonic-clonic SE was identified in 70 (56%) and 44 (35.2%) patients, retrospectively. Simple partial SE occurred in 10 (8%) patients. 62% of the patients had previously had epilepsy while 38% had not. The main underlying causes were noncompliance to treatment in the first group (n=56; 72%) and cerebrovascular disease (n=36; 75%) in the second group. Overall mortality rate was 11.2% , which correlated with acute symptomatic etiology and patients of older age (mean: 73 years). Conclusion: Epileptic patients are at greater risk to develop SE. However, in patients with no prior history of epilepsy and acute neurological problems SE may also occur. Cerebrovascular disease was the most common cause of SE in those with the initial seizure. Noncompliance to treatment was the major cause in patients with preexisting epilepsy.

Updates in Refractory Status Epilepticus.

Refractory status epilepticus is defined as persistent seizures despite appropriate use of two intravenous medications, one of which is a benzodiazepine. It can be seen in up to 40% of cases of status epilepticus with an acute symptomatic etiology as the most likely cause. New-onset refractory status epilepticus (NORSE) is a recently coined term for refractory status epilepticus where no apparent cause is found after initial testing. A large proportion of NORSE cases are eventually found to have an autoimmune etiology needing immunomodulatory treatment. Management of refractory status epilepticus involves treatment of an underlying etiology in addition to intravenous anesthetics and antiepileptic drugs. Alternative treatment options including diet therapies, electroconvulsive therapy, and surgical resection in case of a focal lesion should be considered. Short-term and long-term outcomes tend to be poor with significant morbidity and mortality with only one-third of patients reaching baseline neurological status.

Cerebrospinal fluid findings in non-infectious status epilepticus

ObjectiveIctal activity itself can cause pathological cerebrospinal fluid (CSF) findings. However, data regarding pathological CSF findings caused by SE itself to date remain scarce. We here evaluated the frequency and specificity of pathological CSF findings in non-infectious SE. MethodsWe performed a retrospective analysis of CSF samples in adult patients with episodes of non-infectious SE, who had been admitted to the Department of Neurology, University Hospital of Cologne. The following parameters were assessed: cell count, protein, and lactate content, CSF/serum glucose quotient (QGlc), disturbances of blood-brain-barrier function assessed by CSF/serum albumin quotient (QAlb), and qualitative intrathecal IgG synthesis assessed by unmatched oligoclonal bands in CSF. ResultsWe analysed 54 episodes of non-infectious SE in which CSF had been obtained. CSF pleocytosis was infrequent (6%). Elevated CSF protein content was present in 44% of all cases, whereas elevated CSF lactate content was found in 23% of the cases. A decreased QGlc was present in 9%. Dysfunction of blood-brain-barrier (BBBD) was the most frequent pathological finding, amounting to 55%. Unmatched oligoclonal bands in CSF were seen in 10% of non-infectious SE.Further analysis revealed that elevated CSF protein content was found predominantly in recfractory SE (p = 0.04). Elevated CSF lactate content was associated with shorter latency between onset of SE and CSF retrieval (p = 0.004), positive history of epilepsy (p = 0.02) and an acute symptomatic etiology (p = 0.04). BBBD was also present more often in acute symptomatic SE (p = 0.001) and was the sole pathological CSF parameter associated with clinical outcome: presence of BBBD was associated with a less favorable outcome (p = 0.02). SignificanceNon-infectious SE itself does not commonly cause CSF pleocytosis. Data suggest that the detection of CSF pleocytosis should prompt further diagnostics for an underlying infectious or neoplastic etiology. In contrast, elevation of CSF protein content and BBBD were found frequently in non-infectious SE.

Prognosis of status epilepticus in elderly patients.

To evaluate the clinical features and prognosis of status epilepticus (SE) in patients above 70years old. Retrospective analysis of all patients ≥70 years old with SE registered prospectively during 4years. Follow-up after discharge was performed. Ninety patients were evaluated. Acute symptomatic etiology was the most prevalent. The mean number of antiepileptic drugs (AEDs) used was 2.7±1.2, and 21% of the patients required sedation. A poor outcome was considered when death (31.1%) or developing of new neurological impairment at discharge (32.2%) occurred. After multivariate analysis, four variables predicted a poor outcome: acute symptomatic etiology (OR: 6.320; 95% CI: 1.976-20.217; P=.002), focal motor SE type (OR: 9.089; 95% CI: 2.482-33.283; P=.001), level of consciousness (OR: 4.596; 95% CI: 1.903-11.098; P=.001), and SE duration >12hours (OR: 3.763; 95% CI: 1.130-12.530; P=.031). Independent predictive factors of mortality were SE duration >12hours (OR: 4.306; 95% CI: 1.044-17.757; P=.043), modified Status Epilepticus Severity Score (mSTESS) (OR: 2.216; 95% CI: 1.313-3.740; P=.003), and development of complications (OR: 3.334; 95% CI: 1.004-11.070, P=.049). Considering long-term mortality, age (HR 1.036; 95% CI 1.001-1.071; P=.044), a potentially fatal underlying cause (HR 2.609; 95% CI 1.497- 4.548; P=.001), and mSTESS score >4 (HR 1.485; 95% CI 1.158-1.903; P=.002) remained as predictive factors. There was no association between sedation and the number of AEDs used with outcome at discharge or long-term mortality (P>.05). SE above 70years old has a high morbimortality. Prognosis is not related to treatment aggressiveness.

Status epilepticus-related etiology, incidence and mortality: A meta-analysis

Status epilepticus (SE) is a severe medical condition. To determine its epidemiology and outcome of SE, we performed a meta-analysis to investigate the etiology, incidence and mortality of SE. We searched PubMed and Embase between Jan 1, 2000, and Oct 31, 2016, with no regional restrictions, for observational studies of the etiology, incidence and mortality of SE. Forty-three studies were included in the meta-analysis. The pooled crude annual incidence rate, the pooled case fatality rate and the pooled crude annual mortality rate of SE were 12.6/100,000 (95% CI: 10.0–15.3), 14.9% (95% CI: 11.7–118.7) and 0.98/100,000 (95% CI: 0.74–1.22), respectively. Elderly subjects with SE had a higher case fatality rate (28.4% (95% CI: 17.7–42.3)) and crude annual incidence rate (27.1% (95% CI: 15.8–38.2)). The most important etiology-specific attributable fraction of patients with SE was acute symptomatic etiology (OR 0.411, 95% CI: 0.315–0.507). Age and economic income contributed to differences in SE incidence and short-term case fatality rate.

Clinical profile and outcome of refractory convulsive status epilepticus in older children from a developing country

PurposeThe current study evaluates the etiology, clinical course and outcome of refractory convulsive status epilepticus (CSE) in older children. MethodsRetrospective analysis of data of 73 children with CSE, aged ≥2 and ≤12 years was performed. Odds ratios were calculated between variables for clinical course and outcome. Mortality of the group was analyzed using survival analysis. ResultsThirty three (45.2%) children progressed to refractory status epilepticus (RSE). The most common etiology for CSE was acute symptomatic in 44 (60.3%) of which 37 had presumed CNS infections. The odds of progressing to RSE were higher in children with acute symptomatic etiology (OR 2.62; CI – 95%; 0.99–7.14; p=0.041). Progression to RSE increased the chances of severe sepsis by six times (OR 6.08; CI – 95%; 1.19–31.02; p=0.036) and acidosis by nearly 15 times (OR 14.77; CI – 95%; 1.19–31.02; p=0.020). Overall mortality was 13.7%, higher in RSE (21.2% vs.7.5%). Amongst the 63 surviving children followed for 1 year from discharge, progression to RSE increased the odds of disability by seven times (OR 7.08; CI 29.31; p=0.004). ConclusionAcute symptomatic etiology was the commonest cause of CSE among older children from developing country and increased the odds of progressing to RSE. RSE was significantly associated with disability at 1 year from discharge.

Refractory Convulsive Status Epilepticus in Children: Etiology, Associated Risk Factors and Outcome.

Refractory status epilepticus (RSE) is a life-threatening disease in children wherein the patient's convulsive seizures do not respond to adequate initial anticonvulsants. RSE is associated with high rate of mortality and morbidity. This study was aimed to survey the risk factors leading status epilepticus (SE) to RSE in children, and their early outcome. Patients with SE hospitalized in Tabriz Children's Hospital, Iran were studied during the years 2007 and 2008 with regard to their clinical profile, etiology, the treatment methods available to them and their outcome upon release from the hospital. Among 132 patients with SE, 53 patients (40.15%) suffered from RSE. Acute symptomatic etiology was a risk factor responsible for developing RSE in the patient (P=0.004). Encephalitis was the most common etiology of acute symptomatic SE. There was no significant relationship observed between RSE and the patients' age, gender, date of initial drug intake and type of seizure. The mortality rate was 8.3% and a new neurological deficit occurred in 25.7% of cases. None of RSE with encephalitis returned to the baseline status. Mortality and morbidity rates were significantly higher in children with RSE than in those with SE (P=0.006). Etiology of SE significantly influenced prognosis of it with significant incidence of RSE in acute symptomatic group. Because acute neurological insult such as encephalitis and meningitis are common causes of RSE in children, properly management of them is necessary to avoid permanent brain damage.

The demise of Archbishop Wolf Dietrich--A historical note on a fatal status epilepticus documented at Salzburg in 1617.

Wolf Dietrich of Raitenau (WD) ruled the archiepiscopal Salzburg from March 2nd 1587 to December 17th 1611. He was condemned by his successor Archbishop Markus Sittikus of Hohenems to spend his last years imprisoned at the Fortress Hohensalzburg, where he died on January 16th 1617. This historical note describes the causes of his death. The original Latin handwriting, including the detailed medical history and the autopsy of the Archbishop's body performed by his personal physician, was analyzed in conjunction with historical handwritings provided by St. Peter's Abbey, Salzburg handwriting assigned to Markus Sittikus. Wolf Dietrich of Raitenau had his first well-documented left hemispheric stroke in winter 1604/05. He had palsy of his right arm, was unable to write, and, therefore, used a stamp instead of his signature until October 1605. After another stroke, right hemispheric in origin with persisting palsy of his left arm ["leva corporis pars iam pridem simili ex apoplectico assultu in paralysin resoluta"], he developed symptomatic epilepsy with recurring seizures ["epileptico insultu quo etiam alias correptus est"]. On January 15th 1617, he suffered from a secondarily generalized convulsive status epilepticus ["toto corpore convellitur epileptico insultu"] with stertorous breathing and distortion of his face ["spuma stertore insigni faciei perversione"] and was unconscious for 8h. He recovered from coma and showed dysphagia, buccofacial apraxia ["abolitam diglutiendi facultatem"], reversible speech disturbance ["accisa etiam verba loqui"], and left-sided hemiplegia ["leva corporis pars… immobilis prorsus est reddita"]. The following day, he had speech disturbances, and he died at noon. His autopsy showed large but intact liver ["hepar magnum sanum"] and heart ["cor magnum in quo lapsus nullus"]. There was intrapulmonal mucus ["pituita imbutus"], and part of the lungs adhered to its pleura. He had five kidney stones and a partly cirrhotic spleen. The cause of his death was assumed to be intracerebral ["causa mortis in capite requienda fuisset"]. The terminal suffering of Wolf Dietrich of Raitenau is the first witnessed case report on a fatal status epilepticus in Salzburg. Most likely, he suffered from vascular epilepsy due to a right hemispheric stroke, leading to status epilepticus with left-sided Todd's palsy and speech disturbances. An acute symptomatic etiology of this disease cannot be ruled out, as for religious reasons, the Archbishop's brain was not autopsied. Meticulous medical reporting including autopsy was already available in Salzburg in 1617, and the symptomatic etiology of epilepsy was diagnosed correctly. This article is part of a Special Issue entitled "Status Epilepticus".

Predictors of Outcome of Convulsive Status Epilepticus Among an Egyptian Pediatric Tertiary Hospital.

Convulsive status epilepticus is a common neurologic emergency in pediatrics. We aimed to study the etiology, clinical features, and prognostic factors among pediatric patients with convulsive status epilepticus. Seventy patients were included in this cohort study from pediatric emergency department of the specialized Children Hospital of Cairo University. The outcome was evaluated using the Glasgow Outcome Score. Acute symptomatic etiology was the most common cause of convulsive status epilepticus. Refractory convulsive status epilepticus was observed more significantly in cases caused by acute symptomatic etiologies. The outcome was mortality in 26 (37.1%) patients, severe disability in 15 (21.4%), moderate disability in 17 (24.3%), and good recovery in 12 (17.1%) patients. The significant predictor of mortality was lower modified Glasgow Coma Scale score on admission, whereas lower modified Glasgow Coma Scale score on admission and refractory convulsive status epilepticus were the significant predictors for disability and mortality.

Induction of burst suppression or coma using intravenous anesthetics in refractory status epilepticus

General anesthetic-induced coma therapy has been recommended for the treatment of refractory status epilepticus (RSE). However, the influence of electroencephalographic (EEG) burst suppression (BS) on outcomes still remains unclear. This study investigated the impact of intravenous anesthetic-induced BS on the prognosis of RSE using a retrospective analysis of all consecutive adult patients who received intravenous anesthetic treatment for RSE at the Seoul National University Hospital between January 2006 and June 2011. Twenty-two of the 111 episodes of RSE were enrolled in this study. Of the 22 RSE patients, 12 (54.5%) were women and 18 (81.4%) exhibited generalized convulsive status epilepticus. Sixteen patients (72.7%) were classified as having acute symptomatic etiology, including three patients with anoxic encephalopathy, and others with remote symptomatic etiology. Only two patients (9.1%) had a favorable Status Epilepticus Severity Score (0–2) at admission. All patients received midazolam (MDZ) as a primary intravenous anesthetic drug for RSE treatment; three (13.6%) received MDZ and propofol, and one (4.5%) received MDZ and pentobarbital. The rates of mortality and poor outcome at discharge were 13.6% (n=3) and 54.5% (n=12), respectively. While BS was achieved in six (27.5%) patients, it was not associated with mortality or poor outcome. Induced BS was associated with prolonged hospital stay in subgroup analysis when excluding anoxic encephalopathy. Our results suggest that induction of BS for treating RSE did not affect mortality or outcome at discharge and may lead to an increased length of hospital stay.

Prognosis and predictors of outcome of refractory generalized convulsive status epilepticus in adults treated in neurointensive care unit

ObjectiveTo evaluate the etiological profile, clinical characteristics and outcome of patients with refractory generalized convulsive status epilepticus treated in Neurological Intensive Care Unit (NICU). MethodsIn this open cohort study, data of 126 patients, aged 18 years and above, with convulsive status epilepticus (SE) admitted in NICU was collected. Status epilepticus was defined as seizures lasting for more than five minutes without regaining consciousness. Refractory SE (RSE) was defined as SE refractory to 2 antiepileptic drugs and requiring anesthetic agents for seizure control. Survival and regression analysis were done to analyze the outcome and factors predicting outcome respectively in the study population. ResultsOut of 126 patients, 81 patients had non -refractory status epilepticus (NRSE); 45 (35.7%) had RSE. Acute symptomatic etiology was noted in 58.6% of entire cohort. Significantly higher percentage of patients with RSE had an etiology of CNS infections than NRSE group (44.4% vs. 23.5%; P=0.0171). Amongst the CNS infections, viral encephalitis was significantly higher in RSE than NRSE patients (31% vs. 6.2%; P=0.0004). All the patients with RSE required mechanical ventilation. Overall mortality was 19%. The mortality in RSE was 42% (19 out of 45), significantly higher when compared to NRSE where only 6% (5 out of 81) died. On logistic regression, the only predictor of death was fever with an odds ratio of 8.55 (P=0.024). ConclusionCNS infections, especially viral encephalitis and complications of mechanical ventilation were significantly higher in adult RSE patients. Although mortality is higher in adult patients with RSE, etiology does not contribute to mortality; however fever predicts mortality in these patients. Aggressive management of underlying etiology and prevention of systemic complications may improve outcome in adult RSE patients.

Etiology and prognosis of non-convulsive status epilepticus

Although non-convulsive status epilepticus (NCSE) is an important type of epilepsy, it is not often recognized. In order to analyze the clinical characteristics and outcome in patients with NCSE, we examined the medical records of patients with NCSE admitted to the Seoul National University Hospital between June 2005 and October 2008. The clinical details and electroencephalography records of 34 adult NCSE patients (aged over 16years) were collected. Their mean age was 47years (standard deviation 20years, range, 16–87years), and 20 were female. Twenty-seven patients (79.4%) showed decreased awareness with acute onset, and seven (20.6%) were obtunded or comatose. Ten patients (29.4%) had a history of epilepsy, and four (11.8%) had a history of stroke. NCSE was etiologically attributed to acute medical or neurological problems in 25 patients (73.5%), was cryptogenic in three (8.8%), and was secondary to underlying epilepsy in six (17.7%). Acute symptomatic etiology was associated with poor recovery (p=0.048), with all unresponsive patients in this acute symptomatic group. Eight (23.5%) of the 34 NCSE patients did not recover or died, whereas nine (26.5%) recovered. Our study shows that the presence of acute symptoms or central nervous system infection is associated with poor outcome, suggesting that a high level of vigilance is required to identify and prevent complications.

Clinical characteristics and factors associated with in hospital mortality of convulsive status epilepticus in adult patients admitted to neurointensive care unit

BackgroundStatus epilepticus (SE) is a common neurological emergency; convulsive SE has a distribution with peaks in children and elderly than adult population. AimTo determine the clinical characteristics and factors associated with in hospital mortality in adult patients admitted to the neurointensive care unit (NICU). MethodsA retrospective analysis of the clinical characteristics and outcome of adult patients (aged 18 years and above, below 60 years) with CSE admitted into the NICU was performed. The outcome was classified as alive or death in NICU. The differences between the alive and dead patients for data collected were analyzed using t tests and chi-square test for continuous and categorical variables respectively. Spearman correlations were used to analyze association between the variables, where r > 0.3 and p < 0.05 were considered significant. ResultsA total of 105 adult patients formed the inclusion criteria and were included for data analysis. Forty two out of the 105 patients were women. Sixty one (58%) of the 105 patients had acute symptomatic etiology while 17.1% patients were known epileptics; acute symptomatic etiology increased risk of mortality 5.28 times (95% confidence interval (CI): 1.44–19.35) (p = <0.01). Thirty eight (36.1%) patients progressed to refractory SE. The mortality in the entire cohort was 19%. Complications of prolonged mechanical ventilation and refractory status epilepticus showed strong and significant association with mortality (r > 0.300; p < 0.0001). Mortality was significantly higher in patients with acute symptomatic etiology and than other etiologies (85.0% vs 54.1%; p = 0.011). ConclusionAcute symptomatic etiology was the most common cause of SE in adults. While requirement for mechanical ventilation and refractory SE were the major factors associated with mortality, acute symptomatic etiology increased the risk of mortality in adult patients with SE.

Should we treat patients with impaired consciousness and periodic patterns on EEG?

PurposeThe significance of periodic EEG patterns in patients with impaired consciousness is controversial. We aimed to determine if treating these patterns influences clinical outcome. MethodWe studied all patients who had periodic discharges on their EEG recordings from January 2007 to December 2009. Patients with clinical seizures within the preceding 24h, or with unequivocal electrographical seizure activity were excluded. Logistic regression was performed to analyze for factors associated with (a) mortality (b) functional status (c) resolution of EEG pattern. ResultsOf the 4246 patients who had EEG, 111 (2.6%) had periodic EEG patterns. 64 met inclusion criteria. In adjusted analysis, higher mortality was associated with acute symptomatic etiology (OR 17.74, 95% CI 1.61–196.07, p=0.019), and presence of clinical seizures (OR 4.73, 95% CI 1.10–20.34, p=0.037). For each unit decrement of GCS, the odds of inpatient mortality and a poorer functional state on discharge increased by 23% (95% CI 7–37%, p=0.009) and 33% (95% CI 9–51%, p=0.011) respectively. Administration of abortive therapy was an independent risk factor for poorer functional status on discharge (adjusted OR 41.39, 95% CI 2.88–594.42, p=0.006), while patients with history of pre-existing cerebral disease appeared more likely to return to baseline functional status on discharge (unadjusted OR 5.00, 95% CI 1.40–17.86, p=0.013). ConclusionTreatment of periodic EEG patterns does not independently improve clinical outcome of patients with impaired conscious levels. Occurrence of seizures remote to the time of EEG and lower GCS scores independently predict poor prognoses.