Nonconvulsive Status Epilepticus Research Articles

Hospitalization cost in patients with non-convulsive status epilepticus: is it different from other critical care patients?

Hospitalization cost in patients with non-convulsive status epilepticus: is it different from other critical care patients?

Nonconvulsive status epilepticus (NCSE)

Nonconvulsive seizures (NCS) are seizures that have subtle or no clinical motor phenomena in a patient with impaired consciousness. Nonconvulsive status epilepticus (NCSE), is a subtype of status epilepticus. NCSE denotes an enduring epileptic condition with reduced or altered consciousness ranging from confusion to coma, behavioral and vegetative abnormalities, or merely subjective symptoms like auras, but without major convulsive movements (1) NCS occur in 10–25 % of patients with acute brain injury and are associated with worse outcomes (2). NCSE is also seen a third of patients presenting with altered mental status to the emergency department ( 3.) Indeed, a diagnosis of NCSE is often missed both in the emergency room and in the ICU, because of its pleomorphic presentation, often in the setting of other serious illnesses.

Intravenous methylprednisolone is a potential add on therapy for Ring chromosome 20 syndrome

Ring 20 syndrome is a rare cause of refractory epilepsy and non-convulsive status epilepticus in children. We report a patient with Ring 20 syndrome with refractory focal seizures and non-convulsive status epilepticus who showed good treatment response with intravenous steroids. We wish to highlight that intravenous pulse methylprednisolone is a useful treatment strategy in this setting.

Multicentre observational status-epilepticus registry: protocol for ICTAL

IntroductionStatus epilepticus (SE) is a common life-threatening neurological emergency that can cause long-term impairments. Overall outcomes remain poor. Major efforts are required to clarify the epidemiology of SE and the...

Symptomatic non-convulsive status epilepticus in a patient with acute lymphoblastic leukemia (case report)

Symptomatic non-convulsive status epilepticus develops in intensive care unit patients without a history of epilepsy. It is diagnosed using video electroencephalographic monitoring. Electroencephalographic patterns of status epilepticus are not specific. Epileptiform activity must be recorded. When status epilepticus is prolonged, epileptiform activity changes in frequency, morphology, and localization. Rhythmic non-epileptiform patterns are also recorded on the electroencephalogram. The character of the electroencephalogram is influenced by acute cerebral insufficiency, disruption of the mechanisms of generation of bioelectric activity, and intensive therapy. As an illustration of symptomatic status epilepticus we present the case of a 15-year-old patient with acute lymphoblastic leukemia. This clinical case demonstrates the origin and course of symptomatic status epilepticus according to electroencephalography data. Timely diagnosis and relief of status epilepticus reduce the risk of epilepsy and neurological deficits in cancer patients after recovery from an urgent state.

Toward Evidence-Based Severity Assessment in Mouse Models with Repeated Seizures: (II.) Impact of Surgery and Intrahippocampal Kainate

Introduction: Chronic epilepsy models require neurosurgical procedures including depth electrode implants. The intrahippocampal kainate model is a frequently used chronic paradigm, which is based on chemoconvulsant administration and status epilepticus induction during the surgical procedure. This experimental approach raises the question of the extent to which this approach affects postsurgical recovery. In addition to the short- and long-term impact of the surgical intervention, a potential impact of highly frequent electrographic seizure events needs to be considered in the context of severity assessment. Methods: Various behavioral, biochemical, and telemetric parameters were analyzed in four experimental groups of mice: 1st naive, 2nd with transmitter implants, 3rd with transmitter and electrode implants, and 4th with transmitter implants, electrode implants, and kainate-induced status epilepticus. Results: During the early postsurgical phase, transmitter implants caused a transient impact on Mouse Grimace scores and intragroup increase of fecal corticosterone metabolites. Additional craniotomy was associated with an influence on total heart rate variability and fecal corticosterone metabolites. Heart rate and Irwin score increases as well as a prolonged increase in Mouse Grimace scores pointed to an added burden related to the induction of a nonconvulsive status epilepticus. Data from the chronic phase argued against a relevant influence of frequent electrographic seizures on behavioral patterns, fecal corticosterone metabolites, heart rate, and its variability. However, Irwin scores indicated long-term changes in some animals with increased reactivity, body tone, and Straub tail. Interestingly, selected behavioral and telemetric data from the early post-status epilepticus phase correlated with the frequency of electrographic seizure events in the chronic phase. Conclusion: In conclusion, our findings argue against the pronounced impact of highly frequent electrographic seizures on the well-being of mice. However, an increased level of nervousness in a subgroup of animals should be considered for handling procedures and refinement measures. In the early postsurgical phase, several parameters indicate an influence of the interventions with evidence that the nonconvulsive status epilepticus can negatively affect the recovery. Thus, the development and validation of refinement efforts should focus on this experimental phase. Finally, the datasets suggest that simple readout parameters may predict the long-term consequences of the epileptogenic insult. Respective biomarker candidates require further validation in the follow-up studies in models with subgroups of animals with or without epilepsy development.

EEG changes in intensive care patients diagnosed with COVID-19: a prospective clinical study.

IntroductionCoronavirus disease (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease was declared a pandemic on March 11th, 2020, by the World Health Organization (WHO). There has been a substantial increase in the epileptic seizures and status epilepticus reported in the pandemic period. In this context, it is aimed with this study to identify the electroencephalography (EEG) features of patients admitted to the intensive care unit with the diagnosis of COVID-19 and to look for any specific patterns in these features.Material and methodThe material of this study primarily comprised the neurological evaluations and continuous EEG recordings of 87 intensive care patients who were diagnosed with COVID-19. In addition, demographic and clinical features and comorbid conditions of these patients were also analyzed, and any correlation thereof was investigated.ResultsThe EEG data of 87 patients who were diagnosed with COVID-19 and were followed up in the intensive care unit were recorded and then analyzed. Abnormal EEG findings were detected in 93.1% (n = 81) of the patients, which were found to increase significantly with age (p < 0.001). The mean age of patients with specific epileptiform abnormalities on EEG was found to be significantly higher than those with non-specific abnormalities. Epileptiform discharges were seen in 37.9% (n = 33) of the patients. Nonconvulsive status epilepticus (NCSE) was detected in 5.7% of the patients, and antiepileptic drugs were started in 25 (28.7%) of the patients.DiscussionStatistically significant EEG changes were observed in the continuous EEGs of the patients followed up in the intensive care unit due to COVID-19 infection. However, further studies are needed to associate the EEG changes observed in the COVID-19 patients with the epileptogenesis of COVID-19 infection.

COVID-19 masquerading as a non-convulsive status epilepticus

Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), more and more atypical presentations of COVID-19 are being reported. Here, we present and discuss non-convulsive status epilepticus (NCSE) as presenting symptom of SARS-CoV-2 infection at the Emergency Department.

Associated Factors and Prognostic Implications of Non-convulsive Status Epilepticus in Ischemic Stroke Patients With Impaired Consciousness.

Background and Purpose: Non-convulsive status epilepticus (NCSE) is common in patients with disorders of consciousness and can cause secondary brain injury. Our study aimed to explore the determinants and prognostic significance of NCSE in stroke patients with impaired consciousness.Method: Consecutive ischemic stroke patients with impaired consciousness who were admitted to a neuro intensive care unit were enrolled for this study. Univariate and multivariable logistic regression were used to identify factors associated with NCSE and their correlation with prognosis.Results: Among the 80 patients studied, 20 (25%) died during hospitalization, and 51 (63.75%) had unfavorable outcomes at the 3-month follow-up. A total of 31 patients (38.75%) developed NCSE during 24-h electroencephalogram (EEG) monitoring. Logistic regression revealed that NCSE was significantly associated with an increased risk of death during hospital stay and adverse outcomes at the 3-month follow-up. Patients with stroke involving the cerebral cortex or those who had a severely depressed level of consciousness were more prone to epileptogenesis after stroke.Conclusion: Our results suggest that NCSE is a common complication of ischemic stroke, and is associated with both in-hospital mortality and dependency at the 3-month follow-up. Long-term video EEG monitoring of stroke patients is, therefore required, especially for those with severe consciousness disorders (stupor or coma) or cortical injury.

Nonconvulsive status epilepticus in children with acute encephalopathy: A prospective observational study

Abstract Background: Nonconvulsive status epilepticus (NCSE) in children is underrecognized. Objectives: Assessing the incidence of NCSE in children with acute encephalopathy (AE), clinical description, electroencephalogram (EEG) patterns, and therapeutic response were the objectives. Materials and Methods: Children aged from 6 months to 16 years with AE, Glasgow Coma Scale &lt; 12 were included. Clinical assessment, neurological evaluation, laboratory investigations, cerebrospinal fluid (CSF) analysis, and neuroimaging studies were done. EEG was done for 1 h within 24 h of presentation, repeat EEG on day 3, and continuous EEG monitoring, where needed. Improvement in GCS and EEG determined therapeutic response. Results: Twenty-five (25.51%) of 98 children had NCSE. Altered sensorium (100%), seizures (76.5%), and fever (64.2%) were the common presentation. CSF analysis (61/98) was abnormal in 30 children. There was a significant increase in background slowing (24 to 42, P = 0.001), decrease in sleep markers (42 to 22, P = 0.009), significant decrease in the number of patients with epileptiform discharges (28 to 14, P = 0.036). On day 1, 22 of 25 children had NCSE, 11 had persistence until day 3, three exhibited new appearance on day 3. Generalized discharges (64%) on EEG were common and febrile infection-related epilepsy syndrome (FIRES) (40%) the most common etiology. Signal changes in cortex (n = 7), deep gray matter changes (n = 8), and subcortical and deep white matter changes (n = 10) were the abnormalities on magnetic resonance imaging (MRI). Absence of sleep waves, ictal rhythms on EEG, generalized seizures on day 1 and number of episodes, symmetry, focal seizures, and hyperglycemia on day 3 were significant risk factors for NCSE. Sepsis/systemic inflammatory response syndrome, metabolic causes, trauma, and autoimmune disorders had lower risk of developing NCSE Conclusion: A strong association between clinical seizures and NCSE is demonstrated. The most common etiology for NCSE was FIRES. EEG on day 3 helps in identifying new occurrence of NCSE.

Management of status epilepticus: a narrative review.

Status epilepticus causes prolonged or repetitive seizures that, if left untreated, can lead to neuronal injury, severe disability, coma and death in paediatric and adult populations. While convulsive status epilepticus can be diagnosed using clinical features alone, non-convulsive status epilepticus requires confirmation by electroencephalogram. Early seizure control remains key in preventing the complications of status epilepticus. This is especially true for convulsive status epilepticus, which has stronger evidence supporting the benefit of treatment on outcomes. When status epilepticus becomes refractory, often due to gamma-aminobutyric acid and N-methyl-D-aspartate receptor modulation, anaesthetic drugs are needed to suppress seizure activity, of which there is limited evidence regarding the selection, dose or duration of their use. Seizure monitoring with electroencephalogram is often needed when patients do not return to baseline or during anaesthetic wean; however, it is resource-intensive, costly, only available in highly specialised centres and has not been shown to improve functional outcomes. Thus, the treatment goals and aggressiveness of therapy remain under debate, especially for non-convulsive status epilepticus, where prolonged therapeutic coma can lead to severe complications. This review presents an evidence-based, clinically-oriented and comprehensive review of status epilepticus and its definitions, aetiologies, treatments, outcomes and prognosis at different stages of the patient's journey.

Reflex Seizures with Hot Water and Recurrent Nonconvulsive Status Epilepticus in a Patient with Triple Mosaicism and Ring Formation of Chromosome 20

Reflex Seizures with Hot Water and Recurrent Nonconvulsive Status Epilepticus in a Patient with Triple Mosaicism and Ring Formation of Chromosome 20

Predictors of high functional disability and mortality at 3months in patients with status epilepticus.

PurposeThere are differences in epidemiology, etiology, and outcome in status epilepticus (SE) between developing and developed countries, which limits generalizability. We evaluated factors related to outcome at 3 months in SE patients in a developing country- Ecuador.MethodsRetrospective analysis of a prospectively collected dataset of patients treated for SE at a single hospital over 4 years, recording on 107 patients and 109 episodes, including clinical, demographic, and prognosis assessments.ResultsHospital mortality was 33%, and 38% at 3 months. Glasgow Coma Scale score pretreatment ≤12 (odds ratio = 7.7), Charlson Index of comorbidities ≥3 (odds ratio = 5.6) and brain lesion (odds ratio = 6.4) predicted high disability. History of epilepsy was associated with favorable outcome in general, and showed a positive impact on survival rates (odds ratio = 0.3), while Glasgow Coma Scale scores pretreatment ≤12 (odds ratio = 4.1) and refractory SE (odds ratio = 2.1) were associated with reduced survival rates. Acute symptomatic etiology was the most common cause of SE (58%). Etiologies with structural brain lesion showed a significantly lower survival rate (Log ranks = 0.04 and 0.003) compared to other groups.ConclusionMortality rate at 3 months for SE patients was high. Glasgow Coma Scale, Charlson Index, and brain lesions were associated with unfavorable outcome, including mortality. Overall, the results were similar to those reported in more developed countries, but some differences, including overall higher mortality, prevalence of nonconvulsive SE, and lack of association of age with outcome were evident.

Takotsubo syndrome in status epilepticus –case report

Takotsubo syndrome, also known as stress cardiomyopathy, apical ballooning syndrome or “broken heart syndrome,” is a sudden, transient cardiac condition in which left ventricular dysfunction occurs. Stressors that can induce takotsubo syndrome include both emotional and physical triggers of any kind. The authors present a case of a male patient with nonconvulsive status epilepticus and symptoms suggesting takotsubo syndrome. Echocardiographic examination revealed akinesis of the midsegment and apical segment of the left ventricle, and impaired left ventricle function, but no coronary artery disease was found on cardiac angiography. The clinical symptoms, and echocardiographic and laboratory abnormalities, resolved gradually simultaneously with neurological improvement.

Non-invasive neuromonitoring in intensive care units in Colombia

ResumenEl monitoreo electroencefalográfico no invasivo continuo es una técnica indispensable en los pacientes neurológicos críticos, ya que muestra de forma directa e indirecta su actividad cerebral y permite relacionar los hallazgos con su estado clínico. Es muy sensible, aunque su especificidad es menor, por lo que puede demostrar la alteración del estado de conciencia sin aclarar su etiología.El uso del registro electroencefalográfico continuo en pacientes con alteraciones del estado de conciencia, convulsiones, o estado epiléptico convulsivo y no convulsivo, se ha incrementado en los últimos años porque permite obtener información en tiempo real de la función cerebral y de los cambios en el tiempo; además, facilita la detección de crisis epilépticas subclínicas y electrográficas, estas últimas de gran importancia, ya que no presentan correlación clínica.Los hallazgos del monitoreo permiten modificar el tratamiento farmacológico y anticonvulsivo, y constituyen una gran ventaja para el médico tratante en la toma de decisiones oportunas que redunden en la mejoría del pronóstico del paciente.

Contrast-induced encephalopathy and nonconvulsive status epilepticus after diagnostic cerebral angiography in an end-stage renal disease patient

A 70-year-old man with a history of recurrent ischemic stroke and end-stage renal disease was admitted to the neurology department for a transient ischemic attack. The patient underwent transfemoral cerebral angiography with iopamidol to evaluate the status of carotid stenosis. On the same day, the patient developed drowsy mentality, global aphasia, and fever. Electroencephalography showed continuous regional rhythmic delta activities (0.5 to 1.0 Hz) without definite spatiotemporal evolution, suggestive of focal seizure disorder arising from the left temporal area and ictal-interictal continuum. Computed tomography perfusion images showed hyperperfusion in the left hemisphere. The patient was diagnosed with contrast-induced encephalopathy and associated nonconvulsive status epilepticus. The patient was treated with oral lacosamide, levetiracetam, and daily hemodialysis. The patient’s mental status recovered after 8 days of intensive care unit care.

Novel UBE3A pathogenic variant in a large Georgian family produces non-convulsive status epilepticus responsive to ketogenic diet

PurposeTo report the effect of the ketogenic diet (KD) on non-convulsive status epilepticus (NCSE) due to Angelman syndrome (AS) in two members of a large Georgian family affected by a novel frameshift variant in the UBE3A gene (NM_000462.3). MethodsWe evaluated two members of this family who were affected with clinical and EEG features of AS. Clinical history with special emphasis on development, seizure type, frequency, and treatment was reviewed. Routine and long-term video EEG monitoring were conducted, particularly during NCSE. A non-fasting inpatient KD protocol was implemented using blended food orally with full administration of 4:1 (fat to non-fat) ratio. Urine ketone bodies (KBs), measured with urine ketone acetone strips readings, reached 150 mg/dL in both patients. ResultsPatients had characteristic signs of AS and presented with epilepsy between the age of 2–4 years. As methylation tests were negative, next generation sequencing disclosed a c.2365del variant. For both, NCSE was revealed by cognitive deterioration and did not respond to anti-seizure medication. As recommended, IV pyridoxine, benzodiazepines, and valproic acid were administered, but without success. For both patients, NCSE resolved on the second-third day of KD initiation, before the appearance of ketonuria and resulting in improved communication, mood and sleep. ConclusionKD is safe and effective for the treatment of NCSE due to AS. Resolution before the appearance of ketone bodies points to a possible mechanism of action of KD.

A retrospective study of 92 children with new-onset refractory status epilepticus

Little is known of the etiology, course, and treatment of new-onset refractory status epilepticus (NORSE) in children. Here we identified etiologies, electroencephalography (EEG) characteristics, and neuroimaging findings among pediatric patients with NORSE and among two patient subgroups, febrile infection-related epilepsy syndrome (FIRES) group and non-FIRES group. We also examined treatments and risk factors related to poor prognosis. Ninety-two children with NORSE were identified in Children's Hospital of Chongqing Medical University between January 1, 2010 and September 1, 2020. The end date was chosen to guarantee at least a 6-month follow-up. Our results indicated that patients with FIRES account for 90% of pediatric patients with NORSE. The clinical, EEG, and neuroimaging results and prognosis were not significantly different between the FIRES group and non-FIRES group of individuals. 68.5% of our patients had unknown etiology, and viral etiology was the most common identified cause (26.1%). Electroencephalography might have a certain diagnostic value for NORSE. A gradual increase in seizure burden was obvious from the onset of disease, and continuous or recurrent ictal discharge lasting ≥ 30 min was quite common in our study. The mortality was 22.8% in our study. Among the 71 surviving patients, the outcome at discharge was poor but improved during follow-up, and 68.5% had good or fair outcomes at their last follow-up. A poor outcome was observed in 39 of 92 cases (42%), with 43.9% and 30% of individuals in the FIRES group and non-FIRES group, respectively, having a poor outcome. The presence of super refractory status epilepticus (SRSE), electrographic seizures and nonconvulsive status epilepticus (NCSE), and diffuse cortical edema and multifocal abnormality may be related to a poor prognosis. Our analysis did not indicate that prognosis was directly related to etiology or treatment. Management of NORSE is challenging, and the role of immunotherapy warrants further investigation.

Hippocampal injury and learning deficits following non-convulsive status epilepticus in periadolescent rats

The effects of non-convulsive status epilepticus (NCSE) on the developing brain remain largely elusive. Here we investigated potential hippocampal injury and learning deficits following one or two episodes of NCSE in periadolescent rats. Non-convulsive status epilepticus was induced with subconvulsive doses of intrahippocampal kainic acid (KA) under continuous EEG monitoring in postnatal day 43 (P43) rats. The RKA group (repeated KA) received intrahippocampal KA at P43 and P44, the SKA group (single KA injection) received KA at P43 and an intrahippocampal saline injection at P44. Controls were sham-treated with saline. The modified two-way active avoidance (MAAV) test was conducted between P45 and P52 to assess learning of context-cued and tone-signaled electrical foot-shock avoidance. Histological analyses were performed at P52 to assess hippocampal neuronal densities, as well as potential reactive astrocytosis and synaptic dysfunction with GFAP (glial fibrillary acidic protein) and synaptophysin (Syp) staining, respectively. Kainic acid injections resulted in electroclinical seizures characterized by behavioral arrest, oromotor automatisms and salivation, without tonic-clonic activity. Compared to controls, both the SKA and RKA groups had lower rates of tone-signaled shock avoidance (p < 0.05). In contextual testing, SKA rats were comparable to controls (p > 0.05), but the RKA group had learning deficits (p < 0.05). Hippocampal neuronal densities were comparable in all groups. Compared to controls, both the SKA and RKA groups had higher hippocampal GFAP levels (p < 0.05). The RKA group also had lower hippocampal Syp levels compared to the SKA and control groups (p < 0.05), which were comparable (p > 0.05). We show that hippocampal NCSE in periadolescent rats results in a seizure burden-dependent hippocampal injury accompanied by cognitive deficits. Our data suggest that the diagnosis and treatment of NCSE should be prompt.

Elderly patients with nonconvulsive status epilepticus: Clinical-EEG data, hospital mortality, STESS and EMSE

Purpose To assess the clinical-EEG aspects, characterization of subtypes, relationships with prognostic scales and the occurrence of death in elderly patients in the acute phase of nonconvulsive status epilepticus (NCSE).Methodology Clinical variables, EEG data, Status epilepticus severity score (STESS), and the Epidemiology-based mortality score in status epilepticus (EMSE) were related to the death of 96 patients who were over 60 years old, with NCSE.Results NCSE with coma was observed in 31 patients (19 non-subtle and 12 “subtle” SE) and focal NCSE with impairment of consciousness in 65 cases. There were no significant EEG differences according to the type of NCSE. Higher STESS scores occurred in the comatose NCSE patients when compared to those with focal NCSE and impairment of consciousness (4.8 ± 1.2 vs 3.7 ± 1.2; T-Test; p<0.001). It was observed that 25 (26%) elderly died, with a mean survival time of 19.3 days. Elderly people with a higher risk of death are those diagnosed with NCSE with coma (HR 2.76; 95% CI 1.15–6.65; p = 0.023), with STESS≥3 (HR 16.0; CI 1.77–45.08; p = 0.014), with EMSE≥64 (HR 3.67; CI 1.54–8.72; p = 0.003), and those with no history of recurrent SE (HR 6.80; CI 1.42–32.64; p = 0.017), in Cox regression.Conclusion The ictal EEG patterns did not distinguish the subtypes of NCSE. Thirty-day mortality rate was high in elderly patients with NCSE. The clinical variables are related to prognosis. Mortality in the elderly was associated with comatose NCSE patients, with STESS≥3, with EMSE≥64, and no history of recurrent SE.