Outcomes Of Nonconvulsive Status Epilepticus Research Articles

Prevalence, electroclinical spectrum and effect on the outcome of non-convulsive status epilepticus in critically ill patients; the utility of routine electroencephalogram

ObjectivesTo highlight the importance of routine electroencephalogram (rEEG) in detecting non-convulsive status epilepticus (NCSE), describing the electroclinical spectrum and effect on outcome in critically ill patients with altered mental status (CIPAMS). MethodsThis retrospective study was conducted at King Fahd University Hospital. Clinical data and EEG recordings of CIPAMS to rule out NCSE were reviewed. All patients had at least 30 minutes of EEG recording. The Salzburg Consensus criteria (SCC) were applied to diagnose NCSE. The data analysis was performed using SPSS version 22.0. The chi-squared test was used to compare categorical variables such as etiologies, EEG findings, and functional outcomes. Multivariable analysis was performed to identify the predictors of unfavorable outcomes. ResultsA total of 323 CIPAMS referred to rule out NCSE were enrolled (mean age 57.8 ± 20 years). Nonconvulsive status epilepticus was diagnosed in 54 (16.7%) patients. A significant association was found between subtle clinical features and NCSE (P =< 0.01). Acute ischemic stroke (18.5%), sepsis (18.5%), and hypoxic brain injury (22.2%) were the main etiologies. The previous history of epilepsy was significantly associated with NCSE (P = 0.01). Acute stroke, cardiac arrest, mechanical ventilation, and NCSE were statistically associated with unfavorable outcomes. Nonconvulsive status epilepticus was an independent predictor of unfavorable outcomes (P = 0.02, OR = 2.75, CI = 1.16–6.48) during multivariable analysis. Sepsis was associated with higher mortality (P =< 0.01, OR = 2.4, CI = 1.4–4.0). SignificanceOur study findings suggest that the utility of rEEG in detecting NCSE in CIPAMS should not be underestimated. Important observations further indicate that repeating rEEG is advisable, as this would increase the likelihood of identifying NCSE. Thus, physicians should consider and repeat rEEG when evaluating CIPAMS in order to detect NCSE, which is an independent predictor of unfavorable outcomes. Nonetheless, further studies comparing rEEG and cEEG yields are required to augment the current understanding of the electroclinical spectrum and better describe NCSE in CIPAMS.

Power spectrum analysis and outcomes of non-convulsive status epilepticus: a single-center study.

Diagnosis of non-convulsive status epilepticus (NCSE) is challenging and outcomes during follow-up are not clear. This study aimed to conduct power spectrum analysis in NCSE and measure outcomes of patients. We searched continuous EEG monitoring (cEEG) recordings to identify patients of NCSE. An artifact-free cEEG epoch of continuous 60s was chosen for spectral power analysis. We also collected electronic medical records of the patients for extracting clinical information. Patients recruited were followed up at least every half a year. There were 48 patients with 64 independent NCSE episodes during different course of disease recruited in the study, with a mean age of 40.3 ± 19.1years (range, 12-72years), including 24 males (50%) and 24 females (50%). When the spectral power of 60s equaled to 11.30 μV2 for predicting impairment of consciousness, (sensitivity, specificity) = (0.979, 0.625). When the spectral power of 60s equaled to 52.70 μV2 for predicting myoclonic jerks, (sensitivity, specificity) = (0.783, 0.756). There were 27 patients (56.3%) followed up with a duration over 12months. Nineteen patients (70.4%) continued to have seizures. Eleven (40.7%) resisted to at least two kinds of appropriate anti-seizure medication at maximum tolerated levels. Five patients with prolonged NCSE suffered from loss of brain parenchymal volume on follow-up MRI scans. Spectral power analysis can be used to detect mental status and limb jerks. Early diagnosis and treatment of NCSE are important, which can influence outcomes of the patients during follow-up.

Nonconvulsive Status Epilepticus: Clinical Findings, EEG Features, and Prognosis in a Developing Country, Mexico.

There is a lack of clinical and epidemiological knowledge about nonconvulsive status epilepticus (NCSE) in developing countries including Mexico, which has the highest prevalence of epilepsy in the Americas. Our aim was to describe the clinical findings, EEG features, and outcomes of NCSE in a tertiary center in Mexico. We conducted a retrospective case series study (2010-2020) including patients (≥15 years old) with NCSE according to the modified Salzburg NCSE criteria 2015 with at least 6 months of follow-up. We extracted the clinical data (age, sex, history of epilepsy, antiseizure medications, clinical manifestations, triggers, and etiology), EEG patterns of NCSE, and outcome. Descriptive statistics and multinomial logistic regression were used. One hundred thirty-four patients were analyzed; 74 (54.8%) women, the total mean age was 39.5 (15-85) years, and 71% had a history of epilepsy. Altered state of consciousness was found in 82% (including 27.7% in coma). A generalized NCSE pattern was the most common (32.1%). The NCSE etiology was mainly idiopathic (56%), and previous uncontrolled epilepsy was the trigger in 48% of patients. The clinical outcome was remission with clinical improvement in 54.5%. Multinomial logistic regression showed that the patient's age (P = 0.04), absence of comorbidities (P = 0.04), history of perinatal hypoxia (P = 0.04), absence of clinical manifestations (P = 0.01), and coma (P = 0.03) were negatively correlated with the outcome and only the absence of generalized slowing in the EEG (P = 0.001) had a significant positive effect on the prognosis. Age, history of perinatal hypoxia, coma, and focal ictal EEG pattern influence negatively the prognosis of NCSE.

Nonconvulsive Status Epilepticus in Metabolic Encephalopathy in Indonesia Referral Hospital.

Nonconvulsive status epilepticus (NCSE) is often underdiagnosed in patients with metabolic encephalopathy (ME). The diagnosis of ME should be made specifically to recognize the underlying etiology. Delay in seizure identification and making a diagnosis of NCSE contributed to the poor outcome. This study aimed to find the incidence and outcome of NCSE in patients with ME. This was an observational prospective cross-sectional study in patients with ME in emergency and critical care units in Cipto Mangunkusumo General Hospital. The diagnosis of NCSE was based on EEG using Salzburg Criteria for Nonconvulsive Status Epilepticus (SCNC). The outcome was assessed within 30 days after the NCSE diagnosis has been made. A total of 50 patients with ME were involved in this study. NCSE was confirmed in 32 subjects (64%). The most common etiology of ME was sepsis (58%). The mortality rate in the NCSE and non-NCSE group was 40.6% vs 44.4%. Multiple aetiologies were risk factors to poor outcome in the NCSE group. The incidence of NCSE among patients with ME at our hospital was high. Despite the anti-epileptic treatment of the NCSE group, the underlying cause of ME is still the main factor that affected the outcome. Therefore, aggressive treatment of anti-epileptic drug (AED) should be very carefully considered knowing the possible side-effect that might worsen the outcome of patients with ME.

Clinical features and outcomes of nonconvulsive status epilepticus in a developing country: A 5-year retrospective study

BackgroundThis study aimed to determine the frequency of electrographically confirmed nonconvulsive status epilepticus (NCSE) in a cohort suspected with this condition and to determine the demographic/clinical profile, treatment, and outcomes of these patients in the context of a developing country, the Philippines. MethodsWe conducted a retrospective study among patients with suspected with NCSE admitted in the Philippine General Hospital from 2014 to 2019. Using the Salzberg 2013 criteria to diagnose NCSE, three electroencephalographers independently reviewed the electroencephalogram (EEG) tracings of suspected patients and were blinded from the clinical information. Then, we obtained pertinent clinical data from the medical records of EEG-confirmed NCSE cases. ResultsOut of 89 patients suspected with NCSE and with available EEG tracings, information from a total of 14 patients (15.7%) with electrographically confirmed cases were included in the analysis. Median age was 52 ranging from 22 to 77 and female-to-male ratio was 1.3:1. The following conditions were associated with NCSE: intracranial tumor (n = 4), metabolic encephalopathy (n = 4), autoimmune encephalitis (n = 3), intracranial hemorrhage (n = 3), sepsis (n = 3), cardiac arrest (n = 2), hypoxic-ischemic injury (n = 2), antiepileptic withdrawal (n = 1), intracranial abscess (n = 1), head trauma (n = 1), and meningitis (n = 1). Three patients (21.4%) had relatively good clinical outcomes (mRS 0–2) while 6 patients (42.8%) had poor outcomes (mRS 3–5) at discharge. Five patients (35.7%) died due to medical/neurological complications. Our review of the literature showed that the profile of NCSE cases identified in our resource-limited institution strengthens the findings in other populations. ConclusionOur data showed that approximately 1 in 6 patients who are suspected with NCSE may have electrographic evidence of NCSE in our setting. The most common etiologies associated with NCSE were intracranial tumors and metabolic conditions. Further studies may entail a prospective collection of data to validate the estimates of our study.

Nonconvulsive status epilepticus after convulsive status epilepticus: Clinical features, outcomes, and prognostic factors

ObjectivesTo investigate clinical characteristics and outcomes of nonconvulsive status epilepticus (NCSE) after convulsive status epilepticus (CSE) and determine risk factors for unfavorable outcomes. MethodsWe reviewed consecutive patients with NCSE after CSE over eight years in the neurological intensive care unit. Clinical presentations and the Salzburg EEG criteria for NCSE were used to identify patients with NCSE after CSE. Demographics, clinical features, and anti-epileptic treatment responses were collected and analyzed. Modified Rankin Scale (mRS) was used to evaluate three-month outcomes. A multivariate logistic regression model was used to determine independent prognostic factors. ResultsAmong 145 consecutive patients with convulsive SE, 48 (33.1%) patents eventually evolved into NCSE. Two patients with cerebral anoxia were exclude. At three-month follow-up, 23 patients (50.0%) had mRS ≥ 3, and 16 (34.8%) died. Thirty-two patients (69.6%) were given continuous intravenous anesthetic drugs (CIVADs). Fourteen patients (30.4%) had CIVAD at the rate >50% proposed maximal dose (PMD). There was a single predictor factor found significant after multivariate logistic regression analysis: the recurrence of EEG seizures within two hours of initiation of CIVAD at a dose of greater than half the proposed maximal dose (OR, 9.63; 95%CI, 1.08–86.18; p = 0.043). The use of CIVAD, even with a high dose (>50% PMD), was not independently associated with unfavorable outcomes. ConclusionsThe recurrence of EEG seizures within two hours of initiation of CIVAD at a dose of greater than half the proposed maximal dose predicts unfavorable outcomes in NCSE after CSE. The refractoriness of the seizures might be a significantly greater risk for poor outcome in NCSE after CSE than treatment with CIVADs.

The electroclinical spectrum, etiologies, treatment and outcome of nonconvulsive status epilepticus in the elderly

BackgroundNonconvulsive status epilepticus (NCSE) in the elderly is particularly difficult to diagnose, mainly due to subtle clinical manifestations and associated comorbidities. The recently validated electroencephalography (EEG) diagnostic criteria for NCSE and the proposed operational classification of status epilepticus provide tools that can allow an earlier diagnosis and better management of NCSE in this age group, possibly contributing to reduce its high mortality. Material and methodswe used these tools to identify and characterize a cohort of elderly (>60year-old) patients admitted at our institution in a 3-year period; the video-EEG and clinical files of the patients fulfilling EEG diagnostic criteria for NCSE were reviewed, being in this study described their electroclinical spectrum, etiologies, treatment, inhospital mortality, and status epilepticus severity score (STESS). ResultsFourty patients (23 women; mean age 76.6years) were identified. Although dyscognitive NCSE associated with >2.5Hz of epileptiform discharges (ED) was the most frequent electroclinical phenotype, this was quite heterogeneous, ranging from patients with aura continua to patients in coma, associated with frequent ED or rhythmic slow activities. Acute symptomatic (45%) and multifactorial (27.5%) etiologies were the most common, and associated with the worst prognosis. There was a trend to use newer antiepileptic drugs in the early steps of NCSE treatment. The inhospital mortality was high (22.5%) and predicted by STESS scores ≥3. ConclusionIn the elderly, NCSE has heterogeneous electroclinical phenotypes and etiologies. In spite of the treatment limitations conditioned by the comorbidities, more aggressive treatments could be justified to reduce mortality in patients with high STESS scores.

Clinical presentation, epidemiology, neurophysiological findings, treatment and outcome of nonconvulsive status epilepticus: a 3-year prospective, hospital-based study

Objective: This study reports the prevalence of Nonconvulsive Status Epilepticus (NCSE) in patients with altered mental status (AMS), and describes the clinical presentation, etiology, neurophysiological findings, neuroimaging, treatment, and outcome of NCSE in Qatar. Recording duration of continuous EEG monitoring was also discussed.Methods: This was a 3-year, prospective, hospital-based study involving patients with AMS and continuous EEG monitoring admitted to the Emergency and ICUs of Hamad Hospital, Qatar. Patients with confirmed diagnosis of NCSE were compared to the patients who did not show EEG and clinical features compatible with NCSE. Descriptive statistics in terms of mean with standard deviation, as well as frequency and percentages for categorical variables, were calculated; Student’s t test as well as Chi-square tests or Fisher’s exact tests were applied. Logistic regressions NSCE was performed using significance level 0.05 for independent variables at univariate analysis.Results: Number of patients with AMS and continuous EEG monitoring was 250. Number of patients with EEG compatible with NCSE: 65 (age range, 12–79 ys; m, 37; f, 28). Number of controls (defined as patients with EEG not compatible with NCSE): 185 (age range, 12–80 ys; m, 101; f, 84). Rate of occurrence of NCSE in patients with AMS: 26%. NCSE group was younger than controls (p < .001). Twenty patients with NCSE (31%) and 35 patients in the control group (19%) died. Death was more frequent in comatose NCSE compared to controls (p < .0007). NCSE proper and comatose NCSE had longer hospital stays than controls (p < .02 and p < .03, respectively). Complete recovery occurred in 26 NCSE patients (40%) and in 98 controls (53%) (p < .08). Twenty-one patients (31%) presented with refractory NCSE: 12 patients survived, 9 died.Conclusion: This was the first prospective study reporting a high number of NCSE in Qatar, a small country in the MENA region. This prevalence (26%) was in the middle range. NCSE patients did not perform better than controls, outcome being worse with comatose NCSE. NCSE is an emergent condition warranting expedited diagnosis and management. Three days of continuous EEG monitoring were able to diagnose most cases of NCSE.

Clinical presentation, epidemiology, treatment and outcome of nonconvulsive status epilepticus: a 3- year prospective, hospital based study

Clinical presentation, epidemiology, treatment and outcome of nonconvulsive status epilepticus: a 3- year prospective, hospital based study

Intravenous anesthesia in treatment of nonconvulsive status epilepticus: Characteristics and outcomes

ObjectiveTo determine factors associated with continuous anesthetic drug (IVAD) use in nonconvulsive status epilepticus (NCSE). MethodsRetrospective cohort study of patients who met clinical and EEG criteria of NCSE from 2009 to 2014 at a tertiary academic medical center. Patients were categorized according to IVAD use. Outcome variables were response to treatment and in-hospital death. We used descriptive analyses for baseline characteristics and outcome variable differences among patients who did and did not receive IVAD. ResultsForty-three patients had a total of 45 NCSE episodes. IVAD was used in 69% of the episodes. Patients treated with IVAD were younger (53.1±14.1 vs 64.1±13.3, p=0.019). The episodes treated with IVAD occurred more frequently in patients with an acute neurologic pathology (58% vs 21%, p=0.024) and those presenting in a coma (39% vs 7%, p=0.030). NCSE resolved in 74% of the patients who received IVAD. Duration of NCSE did not differ significantly by treatment group. There were total 13 in-hospital deaths: ten in IVAD users vs three in the no-IVAD group (p>0.05). Only one in-hospital death appeared to be a direct consequence of IVAD use. Mortality was more common among episodes that were not treated according to the published status epilepticus treatment guidelines compared to the episodes where guidelines were followed. ConclusionOur findings showed that factors such as younger age, acute neurologic pathology and coma at presentation were associated with IVAD use in patients with NCSE. These factors should be controlled in the future outcome and effectiveness studies to determine the effect of IVAD use on outcome of NCSE.

Adult nonconvulsive status epilepticus in a clinical setting: Semiology, aetiology, treatment and outcome

PurposeOur objective was to study the semiology, aetiology, treatment and outcome of nonconvulsive status epilepticus (NCSE) in adults. MethodsAll NCSE episodes in an unselected hospital cohort in the period 2004–2009 were identified, and the files reviewed. STESS (Status Epilepticus Severity Scale) was conducted retrospectively and correlated to outcome. Follow-up was undertaken after >2 years. Results48 NCSEs in 39 patients, 22 men and 17 women, were found. Mean age was 63 years. 23/39 (59%) patients had established epilepsy. The underlying cause of NCSE was cerebrovascular disease in 17/39 (44%). 37/48 (77%) NCSEs were complex focal status epilepticus. 3/48 NCSEs (6.3%) lead to death, whereas 8.5% lead to severe sequelae. Cognitive sequelae were found after 14.9% of NCSEs. The outcome was worst in the group with no prior epilepsy (p=0.013). STESS had a negative predictive value of 96% (cut-off value of 3) for severe sequelae and death combined (p<0.002). ConclusionsNCSE has a potential for severe sequelae and represents an emergency in need of intensive treatment. The major determinant of outcome is the underlying cause. The outcome was worse in patients without epilepsy than in patients with epilepsy. STESS is of value in predicting outcome. Cognitive sequelae following NCSE can occur, but need further investigation with prospective, systematic studies.

Spectrum of Nonconvulsive Status Epilepticus in Patients With Cancer

Determine incidence, clinical presentation, electrographic correlates, and outcome of nonconvulsive status epilepticus (NCSE) in cancer patients on whom an EEG was performed. Retrospective review of 947 EEG reports on 658 patients in whom any type of EEG was performed at Memorial Sloan-Kettering Cancer Center (July 2006 to March 2008). Using the Epilepsy Research Foundation criteria, patients were classified as definite or probable NCSE. Medical records were reviewed for diagnosis, causes of NCSE, response to treatment, and outcome. Mortality was determined for patients with NCSE. Twenty-six episodes of NCSE were identified in 25 patients (25/658, 4%). Eleven patients had primary brain tumor, 12 patients systemic cancer, and two had both. At diagnostic EEG, 18 were awake, 3 were lethargic, and 5 patients were comatose. EEG revealed a seizure in 62% of the patients, periodic lateralized epileptiform discharges in 42%, and periodic epileptiform discharges in 7.7%. Neuroimaging revealed new intracranial pathology in 54% of the patients. Seventy-seven percent of the patients achieved control; 65% required ≥3 antiepileptic drugs, and 33% required intubation. Three patients died from NCSE. In our cohort, awake NCSE was more common than comatose NCSE. Treatment was successful in patients with heterogeneous central nervous system disease. EEG evaluation should be considered in patients with cancer because NCSE is treatable despite a high prevalence of structural brain disease. Nonconvulsive status epilepticus control did not always require intubation and burst suppression, but frequently required three or more antiepileptic drugs.

Non-convulsive status epilepticus in adults - an overview

Status epilepticus (SE) is the most frequent neurological emergency requiring admission on the intensive care unit (ICU). The classification of status epilepticus may be dichotomised into the and the form. Whereas the diagnosis of generalised convulsive status epilepticus (GCSE) is easily made in view of the evident manifestation, the diagnosis of non-convulsive status epilepticus (NCSE) may become very difficult according to its non-spectacular and protean presentation. Non-convulsive status epilepticus is a common cause of altered mental status and delirium; and a substantial number of comatose patients in the intensive care unit may suffer from NCSE. The most important part of making a diagnosis of NCSE is to think of it at all. The definite diagnosis of NCSE is dependent on electroencephalographic (EEG) confirmation. Repetitive or, optimally, continuous EEG recording may help to closely monitor seizure activity and to guide the therapy in order to protect the patient from under- and/or over-treatment. The interpretation of EEG recordings of NCSE may become challenging because of numerous artifacts caused by the patient, caregivers and devices, and because of trace elements of ambiguous significance and of waveforms mimicking epileptic activity. Non-convulsive status epilepticus was historically subdivided into the groups of complex-partial status epilepticus (focal; CPSE) and absence status (generalised; AS). Most recently, a classification proposed by the International League Against Epilepsy (ILAE) has subdivided focal NCSE into aura continua (non-convulsive simple partial with maintained consciousness) and into dys-cognitive (with impaired consciousness) of mesial temporal or neocortical origin. Several patients with focal NCSE or AS were known for pre-existing epilepsy. In addition, other types of NCSE have been reported, like subtle where convulsions in patients with GCSE clinically stop, but the continuous epileptic activity electroencephalographically still persists. Another variant belongs to those patients with critical illness where the serious disorder and/or medications may trigger an acute, prolonged and all too often very-hard-to-treat epileptic condition (critical illness SE [CISE]). The majority of these patients will never have had seizures before. Of note, none of the currently proposed classifications has gained broad acceptance and official approval. Since the need for immediate and intensive treatment of GCSE is beyond debate, the insidiously calm presentation of NCSE may mislead to a much less aggressive therapeutic approach. However, experimental and clinical data suggest that continuous epileptic activity in the brain during NCSE associated with consecutive (glutamatergic) hyperexcitation triggers neurotoxicity and proapoptotic mechanisms which eventually may lead to irreversible brain damage and the onset of a chronic epileptic disorder or to an irreversible neurological deficit. Thus, recent national and international guidelines and reviews recommend immediate and intensive treatment for NCSE as well as for GCSE. With a few exceptions, the first drug is an intravenous benzodiazepine, mainly lorazepam; intravenous phenytoin or valproate should be started without delay. Persistence of NCSE after administration of these two classes of drugs heralds refractory (RSE) where single or combinations of drugs in anaesthetic dosages requiring intubation and enteral antiepileptics may be added except for the cases of AS or an underlying terminal disease. The outcome of NCSE is mainly determined by the type, duration, cause and the severity of concomitant diseases.

NONCONVULSIVE STATUS EPILEPTICUS IN OLDER PEOPLE: A DIAGNOSTIC CHALLENGE AND A TREATABLE CONDITION

To the Editor: Lacking the typical phenotypic features of seizures and the adverse systemic consequences of prolonged convulsions, nonconvulsive status epilepticus (NCSE) was incorrectly assumed not to cause neuronal injury.1 Unfortunately, NCSE is associated with morbidity and mortality due to neuronal damage from abnormal electrical activity and its association with the acute neurological disorders that may precipitate it.2,3 This becomes more apparent in the geriatric population, in which impaired baseline mental status hampers diagnosis even further, and the brain parenchyma is more sensitive to prolonged abnormal electrical activity. To determine the prevalence, clinical features, and course of NCSE in the elderly population, an observational prospective study was conducted of all consecutive patients with acute unexplained change in mental,cognitive, or behavioral status or confusion that was the cause of hospitalization or had occurred during hospitalization in the Department of Geriatrics, Shaare Zedek Medical Center, over a 24-month period. Typical electroencephalogram (EEG) changes were required to establish the diagnosis of NCSE.4 Clinical improvement was defined as resumption of the previous (baseline) mental status and disappearance of epileptic activity on EEG. Within a 2-year period seven of 307 hospitalized patients, aged 73 and older, were diagnosed with NCSE (Table 1). Of the seven patients (4 women and 3 men, aged 73–90, mean age 82.7), only one had a previous history of epilepsy; three had renal insufficiency. All patients presented with acute altered mental state: confusion, stupor or coma, without concomitant clinical convulsive activity. In three patients, the presenting symptom was refusal to eat. Time until diagnosis ranged from 1 to 5 days (mean 3 days). All seven patients had generalized NCSE on EEG that disappeared with intravenous diazepam injection (5–8 mg) in the five patients to whom it was given and in all patients on follow-up. None of the patients had focal status epilepticus on EEG. Patients were treated with an intravenous loading dose of phenytoin (800–1,000 mg) or valproic acid (20 mg/kg) followed by a maintenance dose. In six patients, clinical improvement was achieved within 1 to 4 days (mean 2.2 days). None of the medications that the patients were taking are known to cause seizures. In the patients with renal failure, the clinical and encephalographic improvement was chronologically related to the antiepileptic treatment and not to renal function improvement. One patient died of sepsis 19 days after the diagnosis of NCSE. All other six patients were discharged from the hospital after they regained their previous mental and neurological status. We describe seven elderly patients with generalized NCSE. Although the diagnosis was delayed in all, they improved after diagnosis and appropriate treatment. Several features characterize the present series: old age (6 of 7 patients aged ≥80), high incidence (2.3%) of NCSE,5,6 only one patient with a previous history of epilepsy (unlike in other series in which up to 50% of patients were known to suffer from a convulsive disorder),2,3,7 and a benign outcome. Impairment of baseline cognitive abilities and confusion was the presenting symptom in five of seven patients. The fact that NCSE in most of the patients occurred under medical conditions that can cause acute mental status change highlights the diagnostic difficulty and the important role of EEG (sometimes at least as important as imaging) in the evaluation of abrupt mental or behavioral changes in the elderly population. Although the outcome of NCSE is variable, mortality has been reported to reach 50% in critically ill patients,6,8 and in the geriatric age group, NCSE might cause permanent neurological damage.9 Whether the good outcome in our series can be attributed, in part, to the fact that, in all these patients, epileptic activity was generalized and not focal, remains speculative. In addition, because a systemic, metabolic, or infectious condition (renal insufficiency, sepsis, or hypothermia) could have triggered the NCSE in five of seven, the reversibility of these causes may account, in part, for the relatively benign outcome. Although intravenous treatment of seizures is considered to be associated with morbidity and mortality in older people because of hypotensive, cardiac depressant and sedative effects of antiepileptic drugs,10 our experience suggests that, with the appropriate indications and when taking the proper precautions, such therapy is well tolerated in elderly patients with NCSE.