Diagnosis Of Status Epilepticus Research Articles

Telemedicine in follow-up of pediatric status epilepticus: A resounding success story or just a farce?

ObjectivesStatus epilepticus is a life-threatening medical emergency that presents with a continuous seizure lasting for more than five minutes. Telemedicine can potentially play a role in follow-up care of such patients after discharge from the hospital at reduced patient costs. Whether it is efficacious and leads to patient satisfaction is controversial. Therefore, the primary objective of the present study was to compare video consultation with face-to-face consultation in children aged 1–12 years with tonic-clonic status epilepticus after seven days of discharge for any one of the following critical events-any breakthrough seizure, drug compliance, features of raised intracranial pressure and any adverse events. The secondary objective of the study was to compare cost and patient satisfaction of the two modalities. MethodsChildren aged 1–12 years attending Paediatric Emergency of a tertiary care hospital of Northern India with a diagnosis of status epilepticus were enrolled after written informed consent from the parents before completion of their hospital stay. The parents were contacted by the Paediatric Resident on their mobile phone through video calling one day before the scheduled hospital visit. Subsequently, the child was seen directly in hospital on the next day by faculty member/Resident. The information of both interactions was noted on a structured questionnaire. The diagnostic accuracy of telemedicine video consultation for identifying the Critical Clinical Events was estimated using Face-to-Face consultation as the gold standard. ResultsOut of the 108 enrolled patients, two patients were lost to follow up. The diagnostic performance of video consultation in identification of any of the Critical Events compared to Face-to-Face Consultation was as follows: Sensitivity: 42%, Specificity: 100%, PPV: 100%, NPV: 89% with overall Diagnostic Accuracy: 90%. The main discrepancy was seen in identification of the drug compliance. The reason for decreased sensitivity was the presence of different caregivers for video and face to face consultation. The average cost of coming to hospital was 362.73 INR whereas no additional cost was required for video consultation. Also, the average time of visiting the hospital was 4 hour and 26 min, whereas the average time of video consultation was 10 min. 100.0% of the participants agreed that the method of Video Consultation was cost effective and time Saving. Majority (92.5%) of the participants were Satisfied with Video Consultation and 82.1% of the participants were willing for the method of video consultation for further follow up of their children. SignificanceDiagnostic accuracy of video consultation compared to face to face consultation in children aged 1–12 years with tonic clonic status epilepticus after seven days of discharge is 90%. The cost effectiveness time and patient satisfaction seen with telemedicine are encouraging. Ensuring that the primary caregiver is present for both video and face to face consultation by a prior consent can improve the sensitivity and diagnostic accuracy of video consultation. Categories: Medical Education, Neurology, Pediatrics

Treatment of benzodiazepine-refractory status epilepticus: A retrospective, cohort study

IntroductionStatus epilepticus (SE) is a frequent neurological emergency, derived from the failure of mechanisms responsible for seizure termination. The present study aims to compare the efficacy of the most common antiseizure medications (ASMs) employed for the treatment of benzodiazepine-refractory SE. MethodsWe performed a retrospective cohort study of all SE episodes treated in our hospital between January 2016 and December 2020. Inclusion criteria were: age ≥ 18 years; a diagnosis of status epilepticus. Exclusion criteria were: status epilepticus resolved by initial therapy with benzodiazepines; impossibility to retrieve medical records. We considered as effective the ASM that was the last drug introduced or increased in dose before termination of SE and without changes in the co-medication. ResultsA total of 244 episodes in 219 patients were included in the study. The mean age of the final study cohort was 63.6 ± 19.2, with 108 (49%) men. In the total cohort, phenytoin (PHT) showed the highest response rate (57.6%), followed by lacosamide (LCM) (40.7%) and valproate (VPA) (39.8%). The comparative efficacy among the different drugs was significantly different (p < 0.001). In the pairwise comparisons, VPA was superior to levetiracetam (LEV) (response rate: 39.75% vs 24.71%; p = 0.004), but not to LCM. Phenytoin had a significantly higher resolution rate compared to VPA (response rate: 57.63% vs 39.75%; p = 0.02) and LEV (response rate: 57.63% vs 24.71; p < 0.001). The clinical predictors of anaesthetics administration were a disorder of consciousness upon clinical presentation, previous diagnosis of epilepsy, and younger age. ConclusionIn our cohort of SE, PHT showed higher effectiveness in terminating established SE, as well as refractory SE in the subgroup of patients treated with anaesthetics.

Short-Term Prognosis of Patients Hospitalized for Status Epilepticus in Ouagadougou, Burkina Faso

Introduction: Status epilepticus is one of the most common neurological emergency, with high morbidity and mortality and an often poor functional prognosis in survivors. We carried out the present study, to describe the intra-hospital clinical course and to identify the risk factors for intra-hospital death of patients hospitalized for status epilepticus in Ouagadougou, Burkina Faso. Patients and methods: it was a prospective, cross-sectional, multi-center hospital, descriptive and analytical study, which took place from January 1, 2015 to December 31, 2019, involving patients consecutively hospitalized in the university hospitals of Ouagadougou, for status epilepticus. Sociodemographic characteristics, clinical data on admission, biological assessment on admission, EEG characteristics, brain scan and / or brain MRI results ; etiological diagnosis of status epilepticus and intra hospital evolutionary data of the patients, have been analyzed. Univariate analysis between the general characteristics of patients and the intra-hospital mortality, was performed in order to identify the risk factors for the intrahospital mortality. Results: The mean age of the patients was 36.6 years with an M / F sex ratio of 1.4 ; 66 patients (72.5%) had no clinical history of epilepsy, while 25 patients (27.5%) were already known to have epilepsy. The generalized tonic-clonic SE immediately (50.5%) and the focal secondarily generalized convulsive status epilepticus (29.7%) were the most common seizure types. The average duration of an SE episode was 18 hours. status epilepticus were subdivided into status epilepticus symptomatic of acute brain conditions with 61 cases (67%), dominated by central nervous system infections and acute strokes, and status epilepticus of non-acute or sequelae etiologies with 30 cases (33%), dominated by the sequelae of head trauma. Intra-hospital complications were dominated by prolonged post-critical mental confusion, 45 cases (49.4%) and aspiration pneumonia, 30 cases (33%). In-hospital mortality was 12.1% (11 patients). At the end of hospitalization, 49 patients (53.9%) still had moderate to severe disabilities. In univariate analysis, comatose non convulsive status epilepticus (p = 0.003), and altered consciousness on admission (p = 0.026), were the risk factors for in-hospital mortality. Conclusion: Prognosis of status epilepticus in Burkina Faso remains unfavorable with early mortality in more than one in 10 patients and poor functional outcome in more than half of the patients. Altered consciousness on admission and non-convulsive comatose status epilepticus were risk factors for early mortality. The fight against infectious diseases, the prevention of vascular risk factors, the promotion of helmet wearing in cyclists and motorcyclists, early admission of patients sufferinf of status epilepticus, and adequate and standardized management of status epilepticus, will help reduce the frequency and severity of this disease in our African regions.

Prediction of Long-term Survival After Status Epilepticus Using the ACD Score

Early prediction of long-term mortality in status epilepticus is important given the high fatality rate in the years after diagnosis. To improve prognostication of long-term mortality after status epilepticus diagnosis. This retrospective, multicenter, multinational cohort study analyzed adult patients who were diagnosed with and treated for status epilepticus at university hospitals in Odense, Denmark, between January 1, 2008, and December 31, 2017, as well as in Oslo, Norway; Marburg, Germany; and Frankfurt, Germany. They were aged 18 years or older and had first-time, nonanoxic status epilepticus. A new scoring system, called the ACD score, for predicting 2-year (long-term) mortality after hospital discharge for status epilepticus was developed in the Danish cohort and validated in the German and Norwegian cohorts. The ACD score represents age at onset, level of consciousness at admission, and duration of status epilepticus. Data analysis was performed between September 1, 2019, and March 31, 2020. Long-term follow-up using data from national and local civil registries in Denmark, Norway, and Germany. The predefined end point was 2-year survival for all patients and for a subgroup of patients with status epilepticus causes that were not damaging or were less damaging to the brain. Neurological deficits before and after onset, demographic characteristics, etiological categories of status epilepticus, comorbidities, survival, time points, treatments, and prognostic scores for different measures were assessed. A total of 261 patients (mean [SD] age, 67.2 [14.8] years; 132 women [50.6%]) were included, of whom 145 patients (mean [SD] age, 66.3 [15.0] years; 78 women [53.8%]) had status epilepticus causes that were not damaging or were less damaging to the brain. The validation cohort comprised patients from Norway (n = 139) and Germany (n = 906). At hospital discharge, 29.8% of patients (n = 64 of 215) had new moderate to severe neurological deficits compared with baseline. New neurological deficits were a major predictor of 2-year survival after hospital discharge (odds ratio, 5.1; 95% CI, 2.2-11.8); this association was independent of etiological category. Nonconvulsive status epilepticus in coma and duration of status epilepticus were associated with development of new neurological deficits, and a simple 3-factor score (ACD score) combining these 2 risk factors with age at onset was developed to estimate survival after status epilepticus diagnosis. The ACD score had a linear correlation with 2-year survival (Pearson r2 = 0.848), especially in the subset of patients with a low likelihood of brain damage. This study found that age, long duration, and nonconvulsive type of status epilepticus in coma were associated with the development of new neurological deficits, which were predictors of long-term mortality. Accounting for risk factors for new neurological deficits using the ACD score is a reliable method of prediction of long-term outcome in patients with status epilepticus causes that were not damaging or were less damaging to the brain.

Preferential Antiseizure Medications in Pediatric Patients with Convulsive Status Epilepticus: A Systematic Review and Network Meta-Analysis

The optimal choice for first- and second-line antiseizure medications for pediatric patients with convulsive status epilepticus remains ambiguous. The present study aimed to estimate the comparative effect on the efficacy and safety of different antiseizure medications in pediatric patients with status epilepticus and provide evidence for clinical practice. We searched PubMed, EMBASE, and the Cochrane Library for eligible randomized controlled trials. Inclusion criteria included: (1) pediatric patients; (2) diagnosis of status epilepticus; and (3) randomized controlled trials. Exclusion criteria were: (1) mixed population without a pediatric subgroup analysis; (2) not status epilepticus; (3) received the study drug prior to admission; (4) sample size fewer than 30; and (5) not randomized controlled trials. Primary outcome was seizure cessation. Secondary outcomes were seizure recurrence within 24h, respiratory depression, and admission to an intensive care unit. The hierarchy of competing antiseizure medications was presented using the surface under the cumulative ranking curve. Eight first-line antiseizure medication studies involving 1686 participants and eight second-line antiseizure medication studies involving 1711 participants were eligible for analysis. Midazolam, diazepam, lorazepam, and paraldehyde were administered as first-line antiseizure medications. Valproate, phenobarbital, phenytoin, fosphenytoin, and levetiracetam were investigated as second-line antiseizure medications. No significant differences were observed across first- and second-line antiseizure medications. Midazolam ranked the best for primary and secondary outcomes among the first-line antiseizure medications. Phenobarbital ranked the best for seizure cessation and a lower risk of admission to the intensive care unit. Valproate had superiority in preventing recurrence within 24h. Levetiracetam had the lowest probability of developing respiratory depression. This study demonstrated the hierarchy of competing interventions. Midazolam could be a better option for first-line treatment. Phenobarbital, levetiracetam, and valproate had their respective superiority in the second-line intervention. This study may provide useful information for clinical decision making under different circumstances.

Paroxysmal neurological phenomena in patients with familial amyloidotic polyneuropathy - Is there a need to broaden the classification?

In patients with familial amyloid polyneuropathy there is accumulation of transtirretin (TTR) in heart and nerve, but in the post- hepatic transplantation era, the TTR produced by the choroid plexus plays an increasingly important in the etiology of the symptoms of this patients. They ere described has presenting short transitory neurological events, including migraine, seizures like episodes, TIAs and “amyloid spells”. According to the one of the largest series most of them seem to occur on average 14.6 years after disease onset and have usually minuts to hours of duration. A 42 years-old male patient diagnosed with PAF, submitted to liver transplantation presented with a motor aphasia and right hemiparesis. Brain CT was normal. In the day after developed a generalized tonic clonic seizure without recovery of the previous level of consciousness. EEG revealed continuous focal epiletiform activity. The diagnosis of status epilepticus was made and patient started on antiepileptic drug (AED) and 2 days after was seizure free and latter on discharged asymptomatic on AEDs.Transitory neurologic events are being increasing described in PAF patients, and some of these episodes don´t have a clear etiology althought TTR deposits seems do be the main precipitant factor; in some cases there is EEG dysfunction and in others epiletiform activity. In this case, there where clinic an electrographic criterium for status epileticus, which is why one more possible diagnosis to add patients with FAP and paroxysmal neurological changes, and from the authors' knowledge a rare diagnosis of these patients.

S01. Third-line antiepileptic treatment outcomes in refractory status epilepticus

Although there has been multiple studies and several clinical trials (ex ESETT) addressing the use of second-line agents in the treatment of benzodiazepine refractory status epilepticus, there has been little research concerning third-line agents and their effect on outcomes. Our objective for this study was to determine which patient features are predictive of outcomes in those presenting with status epilepticus, compare and contrast those who responded to second-line therapy to those requiring a third-line agent, and evaluate the relationship between the number of third-line agents and respective outcomes. We conducted a retrospective comparative analysis at our level 4 epilepsy center located in San Antonio over a 3 year span from 2013 to 2015. Inclusion criteria included patients 18 years and older with a diagnosis of status epilepticus. Characteristics of age, gender, intubation rate, ventilation time, vasopressor use, history of epilepsy, EEG resolution, seizure type, etiology, length of hospital stay, third-line agent used, and Glasgow outcome score at discharge were compared and evaluated for statistical significance. Factors that correlated with worse outcomes included advanced age, first time seizure, vasopressor use, and prolonged hospital stay. Intubation and vasopressor use were more common in patients who received a third-line agent. Breakthrough seizures correlated with better outcomes while anoxic brain injury correlated with worse outcomes. There were no differences in Glasgow outcome score at discharge between patients that received a third-line agent from those that responded to second-line therapy. However, increasing the number of third-line agents beyond one proportionately led to poorer outcomes. It may be possible to create status epilepticus treatment algorithms tailored to specific subpopulations. Using these results status epilepticus may be anticipated earlier in its course and treated sooner. Information regarding antiepileptic therapy may be used to prevent status epilepticus in the future. It may be possible to design a randomized prospective trial to further evaluate outcomes related to third-line therapy.

B-14. Pathophysiological diagnosis of status epilepticus with complementary use of the periictal MRI (arterial spin labeling perfusion and diffusion-weighted images) and EEG

In the diagnosis of nonconvulsive status epilepticus (NCSE), capture of ongoing ictal EEG findings is the gold standard; however, this is practically difficult without continuous EEG monitoring facilities. MRI, including diffusion-weighted imaging (DWI) and perfusion MRI with arterial spin labeling (ASL), have been applied mainly in emergency situations. Recent reports have described that ictal MRI findings, including ictal hyperperfusion on ASL and cortical hyperintensity of cytotoxic edema on DWI, can be obtained from epileptically activated cortex. We demonstrate the diagnostic value of ictal MRI findings in 15 patients diagnosed as having NCSE (eight had complex partial status epilepticus (SE) and seven subtle SE) who underwent an initial MRI and subsequent routine EEG. In all 10 patients with an epileptogenic lesion, there was a tight topographical relationship between the lesion and the localization of ictal MRI findings. In the other five patients, ictal MRI findings were useful in the diagnosis of NCSE of non-lesional elderly epilepsy, or de novo NCSE of frontal origin as situation-related NCSE. The present study clearly demonstrates that the initial use of ASL and DWI has the ability to diagnose partial NCSE and also allows documentation of the pathophysiological mechanism in each patient.

Electroencephalogram of status epilepticus in children

Electroencephalogram(EEG) is necessary in diagnosis of status epilepticus (SE), particularly in non-convulsive SE with minor or atypical clinical manifestations.SE is a dynamic process, as seizures continue, in which EEG changed and appeared nonepileptic rhythm discharges.Ictal EEG patterns of SE are non-specific and different types of SE have different EEG features.In this paper, the EEG of different type SE will be summarized. Key words: Status epilepticus; Electroencephalogram; Child

Status Epilepticus Diagnosis, Management and Outcome: An Update.

Status Epilepticus Diagnosis, Management and Outcome: An Update.

PP07.6 – 2810: A rare cause of status epilepticus in infant; Alpha lipoic acid intoxication

Objective Alpha lipoic acid (ALA), also known as thiotic acid, is a cofactor found in a number of multienzyme complexes. Lipoic acid is a powerful antioxidant and is widely used as supplementary treatment of diabetic neuropathy. There is no reported dose of safety in children. Methods A 14-month-old previously healthy girl was referred to our hospital with the diagnosis of drug intoxication. She was admitted to the emergency department with lethargy and involuntary movements for several hours after ingesting unknown number of pills of 600 mg ALA belonging to a diabetic parent at home. On admission she was lethargic, bilateral extensor toe sign, and having myoclonic seizures involving all extremities. She had no fever and laboratory examinations were normal except mild methabolic ascidosis (pH: 7.24). The seizures were unresponsive to bolus midazolam injection, fenitoin infusion at 20 mg/kg dose and levetiracetam infusion at 20 mg/kg dose. She was taken to the pediatric intensive care unit with the diagnosis of status epilepticus. Results After failure of the treatment with midazolam infusion (up to 1 mg/kg/hour) she was intubated and thiopental sodium infusion was started. Her myoclonic seizures was controlled with the thiopental sodium infusion (3 mg/kg/hour). After 48 hour intubation and mechanical ventilation the thiopental sodium infusion was gradually reduced and stopped. After withdrawing the thiopental sodium infusion she was seizure free, levetiracetam continued as anticonvulsant drug and she was discharged at the 8. day. Conclusion Alpha lipoic acid and derivatives cause side effects in children like refractory convulsions. As diabetes and the frequency of diabetic neuropathy increase, possibility of ALA usage and intoxication in children living in the same house also rises. When faced with refractory convulsions in children who have had no disease before, intoxication by medicaments with ALA should be taken into consideration.

Status Epilepticus in a Patient with Amyotrophic Lateral Sclerosis

Introduction: Amyotrophic Lateral Sclerosis, the most common and well-known form of motor neuron disease, is characterized by progressive degeneration of upper and lower motor neurons. Respiratory failure and aspiration due to respiratory muscle weakness is the most common causes of mortality in patients with amyotrophic lateral sclerosis. Status epilepticus is the second most frequent neurological emergency with a risk of major morbidity or mortality. Status epilepticus, due to causes such as prolonged seizures, respiratory distress, acidosis, hypoglycemia, and hypotension may lead to mortality. Case Report: A forty-eight year old male patient had been followed for 4 years with a diagnosis of amyotrophic lateral sclerosis and was referred to our clinic with the diagnosis of status epilepticus. The refractory status epilepticus patient was treated with a diagnosis of respiratory failure and the need for mechanical ventilation evolved.Conclusion: We report the development of status epilepticus in a patient with amyotrophic lateral sclerosis, and in addition to the appropriate anti-epileptic medication, ventilator support and intensive care was needed, emphasizing the life-saving procedure

Antiepileptic treatment for anti‐NMDA receptor encephalitis: the need for video‐EEG monitoring

To the Editor, In a recently published clinical commentary (Dericioglu et al., 2013), two patients with anti-NMDAR encephalitis were referred to the neurological ICU with a diagnosis of status epilepticus. Prolonged video-EEG monitoring, however, showed that, for both patients, dyskinesias were not associated with ictal EEG changes. Antiepileptic therapy was not increased and the patients eventually improved with immunotherapy. The authors advised caution in order to avoid mistaking dyskinesias for seizures, and suggested that video-EEG monitoring be used to help differentiate between the two.

Antiepileptic treatment for anti‐NMDA receptor encephalitis: the need for video‐EEG monitoring

Anti-NMDA receptor encephalitis is a severe disorder characterised clinically by seizures, autonomic instability, and severe disturbances of memory, behaviour, and cognition. Due to the severity of symptoms, many patients are admitted to the intensive care unit. For some patients, the presence of various movement disorders and abnormal autonomic signs, as well as a history of seizures, lead to a false impression of status epilepticus, which is reported in 6% of the cases. Here, we present two young female patients, one of whom had ovarian teratoma. Both patients were referred to our neurological intensive care unit with a diagnosis of status epilepticus. However, prolonged video-EEG findings were compatible with encephalopathy. We avoided aggressive treatment with intravenous anaesthetics and both patients recovered after immunotherapy, one of whom received surgery. Physicians should be cautious in interpreting abnormal movements and autonomic signs in such patients and video-EEG monitoring is advised when status epilepticus is suspected. [Published with video sequences].

Parental management of children’s seizures at home

AimParents play an important role in the management of seizures at home. Their attitude has to be fast and efficient enough to avoid complications such as aspiration pneumonia or persistent seizures. The main goals of this study were to analyse the quality of parental management and the predictors of admission after a seizure.MethodA five-year retrospective study of children suffering from seizures at home was conducted. Data were retrieved by medical records and completed by a structured questionnaire.ResultsA total of 114 children were included in the study. Thirty-six percent of the parents turned the child in a lateral security position. Sixty-one percent of the parents did not administer intra-rectal diazepam, when the drug was indicated following the current guidelines. The reasons why diazepam was not administered were the lack of awareness of the procedure, lack of diazepam at home and impossibility to keep calm during the episode. The national emergency numbers were called within a median of 18 min after the seizure started, with a significant correlation between this delay and the total duration of seizures. The predictors of in-hospital admission were drug administration by the mobile unit (SMUR) (OR: a = 25.2; p = 0.001), a diagnosis of status epilepticus (OR: a = 23.6; p < 0.0001) and a pre-existing neurological disease (OR: a=0.19; p = 0.02).ConclusionsOur study finds a significant rate of inappropriate management of paediatric seizures at home. Improving parental education and the use of newer formulations of antiepileptic drugs are necessary to reduce morbidity associated with seizures.

Human Immunodeficiency Virus Infection and Status Epilepticus in United States (2002-2009) (P07.114)

Objective: To determine the association between human immunodeficiency virus (HIV) infection and status epilepticus, and compare the outcomes of patients with status epilepticus with or without underlying HIV infection. Background The direct neurotropic effect of HIV virus has been implicated in such cases. An undetermined proportion of such patients develop status epilepticus. However, it remains unknown whether HIV infection is a risk factor for status epilepticus because of the small sample sizes of most studies and the lack of well-designed case-control studies. Design/Methods: Patients with primary diagnosis of status epilepticus (cases) and status asthmaticus (controls) were identified from the 2002-2009 Nationwide Inpatient Sample (NIS) which is representative of all admissions in the United States. We performed logistic regression analysis adjusting for age, gender, co-morbid conditions including hypertension, diabetes mellitus (DM), renal failure, alcohol use, and opportunistic infections. We compared the in hospital outcomes among patients admitted with status epilepticus in strata defined by underlying HIV infection. Results: The rate of concurrent status epilepticus and HIV has increased over the last 7 years in hospitalized patients with status epilepticus in United States (0.14%-0.27% p Conclusions: Our study suggests that there is a direct association between HIV infection and status epilepticus. The proportion of patients admitted with concurrent status epilepticus and HIV infections is increasing and such patients have higher rates of poor discharge outcomes. Disclosure: Dr. Chaudhry has nothing to disclose. Dr. Rodriguez has nothing to disclose. Dr. Majidi has nothing to disclose. Dr. Bundlie has nothing to disclose. Dr. Patel has nothing to disclose. Dr. Hassan has nothing to disclose. Dr. Suri has nothing to disclose. Dr. Qureshi has nothing to disclose.

Status epilepticus in children: Causes, clinical features and short‐term outcome

We aimed to evaluate the cause, clinical profile, and short-term outcome of status epilepticus cases that were admitted to our pediatric emergency unit between 1 January and 31 December 2008. We studied the clinical features of 59 seizures that occurred in 56 patients aged between 3 months and 15 years with the diagnosis of status epilepticus. We observed the clinical course and outcome of 53 cases for 6 to 18 months. The correlation between the cause of the seizure and the patient's age at the time of status epilepticus was evaluated as well as the correlation between the risk of seizure recurrence and family history of seizure, the neurological status of the patient prior to seizure and the presence of epilepsy. The most common cause of status epilepticus is febrile illness in children younger than 2 years and idiopathic/cryptogenic and remote symptomatic causes in children older than 2 years. The rate of recurrence of seizure was significantly higher in cases with existing neurological abnormalities, prior epilepsy and seizures with remote symptomatic causes. The most common triggering factors of status epilepticus development in cases with epilepsy were noncompliance for anti-epileptic drugs and infectious fever. In our study, the risk factors for seizure recurrence were the presence of prior epilepsy, existence of neurological abnormalities and remote symptomatic causes. We argue that improving the compliance of patients and their families to take medicine appropriately and training them in how to cope with febrile illnesses may decrease the recurrence of seizures.

Epileptological emergencies in Accident and Emergency: a survey at St James’s University Hospital, Leeds

Many patients attending an Accident and Emergency (A&E) department with seizures never come into contact with a neurological service. This survey was designed to find out how many patients with epileptological emergencies come to A&E and how they are managed. Cases were identified using the computerized A&E database. The A&E records of all adult patients attending the casualty department at St James’s University Hospital with emergencies related to epilepsy between 1 April and 30 September 1998 were reviewed retrospectively. Out of a total of 36 024 adults attending A&E, 190 were related to epileptological emergencies. A problem relating to a previously recognized seizure disorder was the commonest reason for attendance. Patient management was highly variable and often suboptimal. Descriptions of seizure semiology and examination findings were frequently deficient. Up to 37.5 mg of diazepam, in up to five boluses, was given. Twenty per cent of patients with a diagnosis of status epilepticus were discharged home after diazepam treatment. Neurologists only became involved in 24.2% of cases. Epileptological emergencies only make up a small proportion of cases seen in adult A&E departments. Treatment and referral guidelines should be agreed between A&E staff and neurologists. The communication between general, specialist and acute services needs to be improved.

Diagnosis and treatment of status epilepticus on a neurological intensive care unit.

Status epilepticus refractory to first-line therapy is associated with a high morbidity and mortality. Correct diagnosis and adequate treatment of this condition require electrographic monitoring and anaesthetic facilities available in specialist intensive care units (ICUs). We carried out an audit of 26 patients admitted to a neurological ICU with a diagnosis of status epilepticus, to identify deficiencies in diagnosis and management prior to transfer to the ICU, and examine the effectiveness of ICU management. Or transfer, only 14 (54%) were in status epilepticus; six were in drug-induced coma or were encephalopathic, and six had pseudostatus epilepticus, of whom four had been intubated. The commonest treatments prior to transfer were benzodiazepines, chlormethiazole and phenytoin; the loading dose of phenytoin was adequate in at least 7/16 cases. All those in status epilepticus on transfer had their seizures successfully controlled, but ten required general anaesthesia with thiopentone, propofol, ketamine or midazolam. Two died--one had a severe encephalitis and the other had had a cardiac arrest prior to treatment. This study highlights deficiencies in the initial diagnosis and management of status epilepticus, the role of specialist neurological intensive care, and the importance of early referral.