Convulsive Status Epilepticus Research Articles

Serum lactate is associated with an ICU admission in patients presenting with seizure at the emergency department.

Patients presenting with seizure at the emergency department (ED) may have morbidity and mortality. Serum lactate has been shown to be a predictor of diagnosis of seizure versus syncope and mortality in patients presenting with seizure at the ED. There is limited data on using serum lactate as a predictor of the intensive care unit (ICU) admission in patients presenting with seizure at the ED. This study aimed to evaluate if serum lactate can be a predictor of the ICU admission in this setting. This was a retrospective cohort study enrolled adult patients aged 18years or more, diagnosed with seizures or convulsive status epilepticus at the ED, and who had undergone testing for serum venous lactate. Clinical factors predictive of ICU admission were computed using logistic regression analysis. Of the 288 patients who met the study criteria, 45 patients (15.63%) required ICU admission. Two factors were independently associated with the ICU admission: convulsive status epilepticus and serum lactate. Both factors had adjusted odds ratio (95% confidence interval) of 4.793 (2.119, 10.844) and 1.008 (1.001, 1.016), respectively. Serum lactate of over 63mg/dL had specificity of 80.25% and sensitivity of 35.56% with the area under ROC curve of 63.30% (95% confidence interval of 54.77%, 71.84%). Serum lactate and convulsive status epilepticus were two predictors of ICU admission in patients presenting with seizure at the ED.

ER and doctors’ preparedness to manage status epilepticus: a multi-institutional survey from the Gaza Strip

BackgroundStatus epilepticus (SE) is a top neurological and medical emergency. Adequate staff knowledge and sufficient hospital resources are mandatory for timely management and better outcomes. This study aims to evaluate Palestinian ER doctors’ knowledge and beliefs towards SE and assess the state and availability of hospital resources needed to manage SE appropriately.MethodsThis cross-sectional study surveyed all ER doctors working in the six governmental hospitals in the Gaza Strip during June 2022. A questionnaire assessed the knowledge and beliefs toward SE and the practice of SE knowledge acquisition. Simultaneous field surveys determined the availability of essential medications and resources at each hospital and doctors’ actual awareness about the status of these resources. Linear regression determined predictors of higher knowledge scores.Results137 doctors participated (response rate 81%). Most were males, had graduated within six years of data collection, and 45.3% worked at Shifa Medical Complex. 63.5% of participants recognized the correct operational definition of status epilepticus. 85.4 and 83.9% recognized that it might cause permanent brain damage or death, respectively. Only 10.9% recognized the average mortality rate of a single convulsive SE episode. 44.5% believed that awaiting spontaneous SE resolution is a valid approach to management. Significant defects were noted in the awareness of subclinical SE, including its recognition and prevalence in ciritcally ill patients. Having a higher qualification and graduating from local medical schools predicted higher scores. In field surveys, EEG was unavailable at all hospitals, while CT scans and a neurologist physician were unavailable at two hospitals. IV phenytoin was the only second-line treatment available at all hospitals. IV valproate and levetiracetam were universally unavailable.ConclusionsThe survey revealed significant defects in Palestinian ER doctors’ knowledge and beliefs towards SE. Several hospitals also demonstrated a critical lack of resources to manage this condition appropriately. This should be addressed by the local health authorities to avoid potentially preventable SE-related mortality and morbidity.

Intravenous lacosamide for acute repetitive seizures and convulsive status epilepticus in critically ill children.

Acute repetitive seizures and convulsive status epilepticus are common neurological emergencies in critically ill children. The aim of the study was to evaluate the effectiveness and safety of intravenous lacosamide in critically ill children with acute repetitive seizures and convulsive status epilepticus. This retrospective study included children who received intravenous lacosamide for acute repetitive seizures or convulsive status epilepticus from October 2017 to September 2022 and were admitted to the pediatric intensive care unit at a tertiary medical center. Children who were newly started on intravenous lacosamide were included and divided into two groups: (a) previously healthy, and (b) history of epilepsy and receiving antiseizure medications. Efficacy was defined as the cessation of seizures within 72 h of administering lacosamide. Adverse effects were defined using predefined criteria, and most were evaluated during the first 7 days. Sixty-seven children were enrolled, including 25 (37.3%) girls and 42 (62.7%) boys with a mean age of 7.20 ± 5.66 years. Among them, 30 (44.8%) had acute repetitive seizures, and 37 (55.2%) had convulsive status epilepticus. The seizure types were focal onset (n = 34, 50.7%), generalized onset (n = 27, 40.3%), and mixed type (n = 6, 9.0%). In the previously healthy group, 9 patients had acute repetitive seizures and 23 had convulsive status epilepticus, and the rates of seizure cessation when lacosamide was used as the first to fourth choice of antiseizure medication were 100.0%, 85.7%, 40.0%, and 50.0%, respectively, compared to 73.7%, 54.5%, 100.0%, and 0.0% in the patients with epilepsy (21 had acute repetitive seizures and 14 had convulsive status epilepticus). Sixteen (23.9%) patients developed bradycardia and 1 (1.5%) patient developed a rash. The early use of intravenous lacosamide was effective with acceptable side effects in treating acute repetitive seizures and convulsive status epilepticus in critically ill children, including young infants and children less than 4 years old and those with different etiologies. Acute repetitive seizures and convulsive status epilepticus are common neurological emergencies in pediatric intensive care units (PICUs), traditional intravenous antiseizure medications (ASMs) include phenytoin, valproic acid, levetiracetam, and phenobarbital. In this study, we categorized patients based on their epilepsy history and different etiologies. We observed that early use of lacosamide, even in young infants, demonstrated good efficacy and safety.

The pharmacologic management of status epilepticus in pregnant patients: a scoping review

AbstractBackgroundStatus epilepticus (SE) is defined as 5 min or more of seizure activity or two recurrent seizures without a return to baseline. Healthcare providers encounter a challenge when a patient with SE is pregnant. SE is not only detrimental to the mother but can also put the baby at risk of severe harm. SE must be treated rapidly and therefore healthcare providers have very little time to thoroughly review the risk and benefits of available antiseizure medication in this population.AimTo evaluate the current available evidence related to the management of SE in pregnancy.DesignA literature search of PubMed, CINAHL, ProQuest Nursing & Allied Health Source, and Web of Science databases was conducted (2012–2022) using the following search terms: ‘pregnancy’, ‘pregnant women’ OR ‘gestation’ AND ‘status epilepticus’, ‘generalized status epilepticus’, ‘generalized convulsive status epilepticus’, ‘non convulsive status epilepticus’ OR ‘non‐convulsive status epilepticus’. Full‐text randomised controlled trials, clinical trials, observational studies, and case reports published in English were included. Data were extracted and the quality of the studies was evaluated using the Mixed Methods Appraisal Tool.ResultsThe literature described 29 pregnancies and 30 total foetuses. Intravenous benzodiazepine use for emergent control was reported in 45% of patients. Phenytoin and levetiracetam were primarily utilised for urgent control, with a variety of agents used for refractory SE. Ninety‐seven percent of maternal outcomes were reported as positive. The most common outcome was the birth of a healthy term infant. There were seven cases of pregnancy loss.ConclusionPublications pertaining to the treatment of SE in pregnancy are limited to case reports and small observational studies. Use of a benzodiazepine followed by levetiracetam or phenytoin is appropriate, whereas valproic acid should be utilised only when necessary due to the risk of major congenital malformation.

Scrub Typhus Meningoencephalitis Presenting as Generalized Convulsive Status Epilepticus with Basal Ganglia and Extra-limbic Cortical Involvement, Complicated by Cortical Multifocal Myoclonus

Background Scrub typhus is an acute febrile infectious disease highly prevalent in the Asia Pacific region, often referred to as the “tsutsugamushi triangle.” This mite-borne rickettsial zoonosis is caused by Orientia tsutsugamushi, an intracellular Gram-negative organism that primarily targets endothelial cells. The resulting vasculitis leads to multisystem involvement. In terms of neurological manifestations, meningoencephalitis is the most common presentation of scrub typhus. Other frequent neurological manifestations include cranial nerve paresis, transverse myelitis, and polyneuropathy. Status epilepticus, while reported, is a rare presenting feature of this infection. Although scrub typhus has been documented to present as limbic encephalitis, there have been no previous descriptions in the literature of neuroradiological patterns affecting the basal ganglia or extra-limbic cortices in this condition. Case Report We report a case of a 23-year-old previously healthy woman who presented with scrub typhus meningoencephalitis. The condition manifested as encephalitis with involvement of the basal ganglia and extra-limbic cortices. She presented with generalized convulsive status epilepticus, which was complicated by cortical multifocal myoclonus. Discussion Scrub typhus can be a significant diagnostic challenge, potentially presenting with generalized convulsive status epilepticus and mimicking both clinical and radiological features of arboviral encephalitides, such as those caused by West Nile and Japanese encephalitis viruses. Furthermore, as demonstrated in this case, its radiological presentation can resemble that of autoimmune encephalitis. Given that scrub typhus is amenable to treatment with antibiotics, such as doxycycline and azithromycin, which do not increase seizure risk, it should be considered in the differential diagnosis for patients presenting with seizures or encephalitis, especially in endemic areas.

Clinical Value of lncRNA MALAT1 and miR-154-5p in the Severity and Prognosis of Convulsive Status Epilepticus

Clinical Value of lncRNA MALAT1 and miR-154-5p in the Severity and Prognosis of Convulsive Status Epilepticus

Aetiology and Outcome of Childhood Convulsive Status Epilepticus: A tertiary care experience in Oman.

This study aimed to evaluate the aetiology, management and outcomes of convulsive status epilepticus (CSE) in children and highlight the factors influencing patient outcomes in such cases. In a retrospective study spanning the 2020-2023 period, 93 children with CSE treated at Sultan Qaboos University Hospital's emergency department (ED), high dependency unit (HDU) and intensive care unit (ICU) were analysed. The Modified Rankin Scale at discharge was used to determine CSE outcomes. Among the 93 children studied (mean age 4.84 ± 3.64 years), predominantly Omani (92.47%), 14 aetiologies were noted. Of them, acute symptomatic (37.7%) and febrile status (31.2%) were the primary causes of CSE. Diazepam was administered as the first-line treatment in 58 (67.44%) cases, with a median seizure duration of 45 minutes. Successful seizure control was achieved in 71 (76.34%) cases within 60 minutes. A return to baseline was observed in 55.9% of cases, while mortality and disability were noted in 5.38% and 38.7% of cases, respectively. For 17 cases, aetiology and duration significantly impacted patient outcomes (P <0.05). Acute symptomatic status is the most common aetiology of CSE. A longer duration of CSE is associated with higher mortality and neurological disability. Prompt and appropriate management of CSE is essential. Furthermore, identifying and treating the underlying cause of CSE is a crucial step in reducing its duration and improving patient outcomes.

Intravenous levetiracetam versus intravenous phenytoin as second Line treatment in pediatric convulsive status epilepticus- open label randomized controlled trial.

Benzodiazepines (BZDs) are recommended as the initial therapy of choice in status epilepticus (SE). The age-old second-line treatment for BZD refractory convulsive SE is intravenous phenytoin (PHT) based predominantly on nonrandomized clinical trial data. We did this study to compare the efficacy and safety of intravenous levetiracetam (LEV) and PHT as second-line antiseizure medication (ASM) for children with SE. A prospective, randomized controlled, open-label study was conducted in children 3 months to 15 years of age with SE in Pediatric Emergency. A total of 41 children were randomly allocated to either group 1 (Levetiracetam) or group 2 (Phenytoin) on the basis of computer-generated randomization. Children who were already on antiseizure medications, either LEV or PHT, or receiving these drugs outside for SE were excluded. Data analysis was done by SPSS V25. The most common age group presenting with SE was 12 months to 5 years. Clinical cessation of seizure 5 minutes after the completion of drugs was 85% (17/20) in Levetiracetam group and 90.5% (19/21) in Phenytoin group. Recurrence of seizure within 24 hours was noted in 35% (7/20) in Levetiracetam group and 38.1% (8/21) in Phenytoin group. There was no statistically significant difference noted in both the groups in terms of seizure cessation, adverse events, and recurrence. The efficacy and safety of LEV were found to be comparable to those of PHT in controlling seizure as second-line ASM in SE.

Two-year mortality and seizure recurrence following status epilepticus in Auckland, New Zealand: A prospective cohort study

PurposeTo document the 2-year mortality and seizure recurrence rate of a prospective cohort of patients identified with status epilepticus (SE). MethodsPatients presenting to any hospital in the Auckland region between April 6 2015, and April 5 2016, with a seizure lasting 10 min or longer were identified. Follow up was at 2 years post index SE episode via telephone calls and detailed review of clinical notes. ResultsWe identified 367 patients with SE over the course of one year. 335/367 (91.3 %) were successfully followed up at the 2-year mark. Two-year all-cause mortality was 50/335 (14.9 %), and 49/267 (18.4 %) when febrile SE was excluded. Two-year seizure recurrence was 197/335 (58.8 %). On univariate analyses, children (preschoolers 2 to < 5 years and children 5 to < 15 years), Asian ethnicity, SE duration <30 mins and acute (febrile) aetiology were associated with lower mortality, while older age >60 and progressive causes were associated with higher mortality on both univariate and multivariate analyses. Age < 2 years and acute aetiology were associated with lower seizure recurrence, while non convulsive status epilepticus (NCSE) with coma and a history of epilepsy were associated with higher seizure recurrence. On multivariate analyses, a history of epilepsy, as well as having both acute and remote causes were associated with higher seizure recurrence. ConclusionsAll-cause mortality in both the paediatric and adult populations at 2 years was lower than most previous reports. Older age, SE duration ≥30 mins and progressive aetiologies were associated with the highest 2-year mortality, while febrile SE had the lowest mortality. A history of epilepsy, NCSE with coma, and having both acute and remote causes were associated with higher seizure recurrence at 2 years. Future studies should focus on functional measures of outcome and long-term quality of life.

Thiamylal serum concentration for refractory convulsive status epilepticus while associated decreased concentrations of concomitant antiepileptics: a case report

BackgroundTreating refractory status epilepticus (RSE) remains a challenge. Thiamylal can be used as a second- or third-line treatment; however, its potential to induce cytochrome P450 (CYP) activity may reduce the concentration of antiepileptic drugs (AEDs) administered prior to thiamylal. This report details a case of RSE patient treated with thiamylal, with monitored concentrations of thiamylal and other AEDs.Case presentationA 72-year-old healthy man developed RSE. Despite the administration of various AEDs, his seizures were not resolved. Thiamylal was then administered at an initial bolus dose of 2.1 mg/kg, followed by a continuous infusion of 4.2–5.2 mg/kg/h. The initial thiamylal concentration was observed at 7.8 μg/mL, increasing to 35.2 μg/mL before decreasing after dose reduction and cessation. Concurrently, the concentration of concomitant carbamazepine decreased from 5.59 μg/mL to 2.1 μg/mL and recovered as thiamylal concentration decreased. Lesser impacts were noted for other AEDs.ConclusionsThis case report underscored the efficacy of thiamylal in treating RSE. However, it also highlighted the need for clinicians to closely monitor the concentrations of concurrent AEDs, especially carbamazepine, during thiamylal therapy.

Preliminary Guidelines for Resuming Electroconvulsive Therapy After a Complication of Status Epilepticus.

Electroconvulsive therapy (ECT) is an effective and safe treatment for severe major depressive disorder. However, status epilepticus is a rare yet serious complication that can occur following treatment. We present a case of a patient with severe major depression who experienced convulsive status epilepticus during the first treatment of her fourth ECT course. Electroconvulsive therapy treatment was then discontinued, and the patient underwent unsuccessful medication trials. Due to deterioration of depressive symptoms, ECT resumption was considered 3 months later after the patient had been maintained on an antiepileptic drug and no further seizures had occurred. Electroconvulsive therapy was resumed with a detailed safety protocol that included electroencephalographic monitoring before and after ECT treatment, remaining on an antiepileptic drug during the course of treatment, performing ECT in the operating room, and preparing seizure-terminating drugs before each treatment. The patient completed her ECT course with no tardive seizures or other neurological complications. We present the safety measures taken for resumption of ECT in our patient, and we offer preliminary clinical guidelines for resuming ECT after a complication of status epilepticus.

Convulsive status epilepticus and its early treatment

Convulsive status epilepticus and its early treatment

Idiopathic Hemiconvulsion Hemiplegia Epilepsy in an Eight-Year-Old Boy! Is It the Time to Revisit the HHE Definition?

AbstractIdiopathic hemiconvulsion hemiplegia epilepsy (IHHE) syndrome is characterized by the combination of unilateral convulsive status epilepticus, mainly clonic, followed by transient or permanent ipsilateral hemiplegia. It occurs in infants during the course of a nonspecific febrile illness, mainly in the first 2 years of life and in any case before the age of 4 years. Most studies have mentioned that disease occurs in children younger than 4 years. The exact cause of unilateral involvement is not clear. Occurrence of this condition beyond 4 years of age has rarely been described. We report here a previously healthy 8-year-old boy who presented with right hemiclonic seizures for almost 2 weeks occurring along with nonspecific viral illness. He had residual right hemiparesis and his magnetic resonance imaging (MRI) of the brain showed left hemispheric cortical edema with diffusion restriction. The workup for neuroinfections, mitochondriopathy, and MR angiography was negative. The child improved with injection methyl prednisolone pulse therapy along with multiple intravenous and oral antiseizure medications. This case report suggests that IHHE can also occur beyond 4 years of age, and there is a need to revise the diagnostic criteria of IHHE.

Economic assessment of convulsive status epilepticus: Investigating socioeconomic correlations in hospitalization costs and outcomes in Northern India

Economic assessment of convulsive status epilepticus: Investigating socioeconomic correlations in hospitalization costs and outcomes in Northern India

Challenges of status epilepticus management in a resource-limited setting: A review

Status epilepticus (SE) is a life-threatening neurological condition with significant mortality. Rapid management is essential to minimize the mortality and disability of SE. Two recent trials provided evidence to guide SE management in early and established stages. The Rapid Anticonvulsant Medication Prior To Arrival Trial (RAMPART, 2011) showed that intramuscular midazolam is a better alternative for early convulsive SE in prehospital settings. The Established Status Epilepticus Treatment Trial (ESETT, 2020) supported the use of sodium valproate and levetiracetam as second-line treatment for its efficacy and shorter administration time. However, there are challenges to revising the status epilepticus management in resource-limited settings, in pre-hospital, first- and second-line treatment, as well as management of refractory and super-refractory SE. These challenges included restrictions or lack of training in the administration of benzodiazepine in the prehospital setting, limited availability and accessibility of newer antiseizure medications (ASMs) in emergency departments and smaller hospitals, and low clinicians’ awareness of the latest evidence. A collaborative effort to educate, improve awareness, and make certain ASMs more readily available is recommended to achieve a better clinical outcome in SE.

The therapeutic effect of vagus nerve stimulation on super-refractory nonconvulsive status epilepticus

Super refractory status epilepticus (SRSE) is a condition in which status epilepticus persists despite 48 hours of anesthetic treatment. Nonconvulsive status epilepticus (NCSE) is characterized by seizures lasting more than 30 min on an electroencephalogram, with accompanying changes in behavior or consciousness without convulsions. Prompt treatment of NCSE is crucial, as delayed treatment may lead to additional brain damage and progression to convulsive status epilepticus. Although vagus nerve stimulation (VNS) has been approved as an adjunct treatment for drug-resistant epilepsy, it is rarely used to treat refractory status epilepticus. To the best of our knowledge, only two cases of NCSE treated with VNS have been reported to date, and these patients were successfully treated with VNS for NCSE caused by anti-NMDAR encephalitis. We report the case of a patient with posttraumatic epilepsy who developed super refractory-NCSE after convulsive status epilepticus and was successfully treated with VNS.

Status epilepticus in POLG disease: a large multinational study

We aimed to provide a detailed phenotypic description of status epilepticus (SE) in a large cohort of patients with POLG disease and identify prognostic biomarkers to improve the management of this life-threatening condition. In a multinational, retrospective study with data on patients with POLG disease from seven European countries, we identified those who had SE. The age of SE onset, accompanying clinical, laboratory, imaging and genetic findings were analysed. One hundred and ninety-five patients with genetically confirmed POLG disease were recruited, of whom 67% (130/194) had epilepsy. SE was identified in 77% (97/126), with a median age of SE onset of 7 years. SE was the presenting symptom of the disease in 43% (40/93) of those with SE, while 57% (53/93) developed SE during the disease course. Convulsive SE was reported in 97% (91/94) followed by epilepsia partialis continua in 67% (56/84). Liver impairment 78% (74/95), ataxia 69% (60/87), stroke-like episodes 57% (50/88), were the major comorbidities. In the majority (66%; 57/86) with SE this became refractory or super-refractory. The presence of seizures was associated with significantly higher mortality compared to those without (P ≤ 0.001). The median time from SE debut to death was 5 months. SE is a major clinical feature of POLG disease in early and juvenile to adult-onset disease and can be the presenting feature or arise as part of a multisystem disease. It is associated with high morbidity and mortality, with the majority of patients with SE going on to develop refractory or super-refractory SE.

Seizure control via pH manipulation: a phase II double-blind randomised controlled trial of inhaled carbogen as adjunctive treatment of paediatric convulsive status epilepticus (Carbogen for Status Epilepticus in Children Trial (CRESCENT))

BackgroundPaediatric convulsive status epilepticus is the most common neurological emergency presenting to emergency departments. Risks of resultant neurological morbidity and mortality increase with seizure duration. If the seizure fails to stop within defined time-windows, standard care follows an algorithm of stepwise escalation to more intensive treatments, ultimately resorting to induction of general anaesthesia and ventilation. Additionally, ventilatory support may also be required to treat respiratory depression, a common unwanted effect of treatment. There is strong pre-clinical evidence that pH (acid–base balance) is an important determinant of seizure commencement and cessation, with seizures tending to start under alkaline conditions and terminate under acidic conditions. These mechanisms may be particularly important in febrile status epilepticus: prolonged fever-related seizures which predominantly affect very young children. This trial will assess whether imposition of mild respiratory acidosis by manipulation of inhaled medical gas improves response rates to first-line medical treatment.MethodsA double-blind, placebo-controlled trial of pH manipulation as an adjunct to standard medical treatment of convulsive status epilepticus in children. The control arm receives standard medical management whilst inhaling 100% oxygen; the active arm receives standard medical management whilst inhaling a commercially available mixture of 95% oxygen, 5% carbon dioxide known as ‘carbogen’.Due to the urgent need to treat the seizure, deferred consent is used.The primary outcome is success of first-line treatment in seizure cessation. Planned subgroup analyses will be undertaken for febrile and non-febrile seizures. Secondary outcomes include rates of induction of general anaesthesia, admission to intensive care, adverse events, and 30-day mortality.DiscussionIf safe and effective 95% oxygen, 5% carbon dioxide may be an important adjunct in the management of convulsive status epilepticus with potential for pre-hospital use by paramedics, families, and school staff.Trial registrationEudraCT: 2021-005367-49. CTA: 17136/0300/001. ISRCTN: 52731862. Registered on July 2022.

Enteral Ketamine for Status Epilepticus in Children with Epilepsy

BackgroundApproximately 10% to 20% of children with epilepsy experience status epilepticus (SE), and children with seizure clustering are at higher risk. Ketamine is growing in use for SE. This study examines the efficacy and safety of enteral ketamine in the treatment of convulsive status epilepticus (CSE) characterized by refractory seizure clusters and nonconvulsive status epilepticus (NCSE) in children with epilepsy. MethodsPatient charts were reviewed retrospectively. Children with epilepsy aged one to 21 years presenting in SE and treated with enteral ketamine between September 1, 2021 and September 1, 2022 at a pediatric tertiary care center were identified. Resolution or reduction in seizure frequency within 48 hours, clinical presentation, endotracheal intubation, hospitalization duration, side effects, and readmission were assessed. ResultsNine patients aged two to 21 years were identified. Six patients presented in CSE characterized by recurrent seizures, and three patients presented in NCSE. Five patients had genetic epilepsies, including PCDH19- and MECP2-related epilepsy. Seven patients had resolution or reduction in seizures within 48 hours of ketamine initiation. Two patients were intubated. Hospitalization duration ranged from one to 34 days. Three patients reported side effects. Three patient readmissions with early ketamine treatment had equal or shorter hospitalizations. ConclusionsEnteral ketamine may prove an effective, well-tolerated option for treatment of convulsive and nonconvulsive SE in children with epilepsy, including genetic epilepsies, and may prevent intubation and shorten hospitalization time.

Determinants of Outcomes in Convulsive Status Epilepticus: An Observational Study at a Tertiary Care Center in North India

Determinants of Outcomes in Convulsive Status Epilepticus: An Observational Study at a Tertiary Care Center in North India