Status Epilepticus In Patients Research Articles

High end-of-life incidence of seizures and status epilepticus in patients with primary and secondary brain tumors

PurposeSeizures pose a significant burden in patients with primary and secondary brain tumors during the end-of-life period. A wide range of 6 to 56% of clinically observed epileptic seizures at the end of life has been reported. We aimed to analyse the incidence of epileptic seizures at the end of life in brain tumor patients more accurately using not only clinical but also electrophysiological findings.MethodsThis retrospective, single center study included brain tumor patients who died during the stay on the ward or within 7 days after discharge between 01/2015 and 08/2020. Clinical observation of seizures derived from the original medical records and EEG findings (within 45 days prior to death) were analyzed to determine the incidence of seizures in that period.ResultsOf the 68 eligible patients, 50 patients (73.5%) suffered from seizures within 45 days prior to death, of which n = 24 had a status epilepticus. The diagnosis of seizures/ status epilepticus was determined either by the presentation of clinical signs in 45 patients and if not, by the detection of a (possible) non-convulsive status epilepticus in the EEG of five patients.ConclusionIn the presence of neurologically trained staff and with the frequent use of routine EEG, we were able to identify seizures and to distinguish status epilepticus from encephalopathy/ hypoactive delirium. We detected a higher incidence of seizures and status epilepticus at the end of life in neurooncological patients than previously reported.

Pharmacist involvement with antiepileptic therapy for status epilepticus in the emergency department

BackgroundDespite there being an estimated 50,000–150,000 emergency department (ED) visits per year related to status epilepticus, there are limited data regarding pharmacist involvement in patient care. The purpose of this study was to evaluate differences in time to antiepileptic drug (AED) administration and appropriate AED use and dose when a pharmacist was present or not. MethodsRetrospective, single-center, observational study of adult status epilepticus patients presenting to the ED between January 2018 through July 2020. The primary outcome was time to AED administration. Secondary outcomes included occurrence of appropriate AED selection and dose, escalation of care, length of stay (LOS), and 30-day mortality. Wilcoxon rank-sum was used for continuous variables and nominal data was analyzed by Chi-square or Fisher's Exact test, as appropriate. ResultsTwenty patients were included; 13 in the pharmacist-present and seven patients in the no-pharmacist-present groups. Median time to first and second AED was 26 min (IQR 17–177) versus 37 min (IQR 21–206), p = 0.58, and 51 min (IQR 30–221) versus 171 min (IQR 99–433), p = 0.07, in the pharmacist-present and no-pharmacist-present groups, respectively. Although there was no difference between groups for appropriate AED selection, those in the pharmacist-present group received a higher median dose of lorazepam equivalents (2.5 mg [IQR 2–4] vs 2 mg [IQR 2–2]; p = 0.04) and were more likely to receive at least 4 mg of lorazepam equivalents (38% vs 0%; p = 0.11). There were no differences in hospital LOS or 30-day mortality. ConclusionPharmacist presence during status epilepticus patient management was associated with a clinically significant reduction in time to administration of AEDs. Medication doses were more guideline adherent and more patients received a lorazepam dose of at least 4 mg compared to when a pharmacist was not present.

Clinico-biological markers for the prognosis of status epilepticus in adults

Prediction of mortality, functional outcome and recovery after status epilepticus (SE) is a challenge. Biological and clinical markers have been proposed to reflect the brain injury or to monitor critical ill patients' severity. The aim of this study was to characterize short-term and long-term prognostic factors for SE patients hospitalized in intensive care unit. Patient's outcome was assessed using the modified Rankin Scale at discharge and after 6-12months. We first assessed the univariate prognosis significance of 51 clinical, demographic or biochemical markers. Next, we built multivariate clinico-biological models by combining most important factors. Statistical models' performances were compared to those of two previous published scales STESS and mSTESS. Eighty-one patients were enrolled. Thirty-five patients showed a steady state while 46 patients clinically worsened at discharge: 14 died, 14 had persistent disability at 6-12months and 18 recovered. Logistic regression analysis revealed that clinical markers (SE refractoriness, SE duration, de novo SE) were significant independent predictors of worsening while lipids markers and progranulin better predicted mortality. The association of clinico-biological variables allowed to accurately predict worsening at discharge (AUC > 0.72), mortality at discharge (AUC 0.83) and recovery at long-term (AUC 0.89). Previous scales provided lower prediction for worsening (AUC 0.63, STESS; 0.53, mSTESS) and mortality (AUC 0.56, STESS; 0.62, mSTESS) (p < 0.001). We proposed new clinico-biological models with a strong discrimination power for prediction of short- and long-term outcome of hospitalized status epilepticus patients. Their implementation in electronic devices may enhance their clinical liability.

Hematologic Indicators and Its Association with Outcomes of Status Epilepticus Patients in Sanglah General Hospital, Denpasar, Bali

Background: Hematologic parameter had been considered as simple prognostic markers for status epilepticus. Hematologic profile might be related to outcomes. This research was aimed to address status epilepticus cases in Sanglah General Hospital and to analyze the relationship between hematologic profiles and the outcomes of status epilepticus patient. Method: This research used cross sectional design. We resumed status epilepticus cases in Sanglah General Hospital, Bali, Indonesia, from 2019 to 2020. With consecutive sampling, we obtained data from medical records. Statistic tests were done with software. Results: One hundred and eight patients with status epilepticus, 58 males and 50 females aged 18 to 95 years old were involved. Fifty-five had focal and 53 general seizures. Fifty-one (47.2%) survived and 57 (52.8%) did not. Intensive care was given to 34 (31.5%) patients. Factors that had relationship with outcome were comorbidity (p&lt;0.01), renal failure (p=0.05), pneumonia (p&lt;0.01), sepsis (P&lt;0.01), intensive care (p=0.01), length of stay (p&lt;0.01), and platelet count (p&lt;0.01). Neutrophil to Lymphocyte Ratio did not have relationship with the outcome (p=3.22). In additional analysis with numeric variable, there were suggestions that Neutrophil to Lymphocyte Ratio and Hemoglobin might have weak correlation with length of stay (p&lt;0.05). Conclusion: Future studies with better designs should be conducted to really address the real relationship between hematologic profile and outcome in status epilepticus patients. Keywords: hematologic profile, status epilepticus, outcome.

Suboptimal Dosing of Benzodiazepines and Levetiracetam in a Cohort of Status Epilepticus Patients and Outcomes Associated with Inadequate Dosing

Background: Status epilepticus (SE) is a neurologic emergency that can result in serious morbidity and mortality. Recent studies have suggested underdosing of both benzodiazepines (BZDs) and antiseizure medications (ASM) which may result in poorer outcomes. Objectives: This study aims to determine the dose of BZDs and levetiracetam given in our emergency department for episodes of SE and determine the outcomes associated with this dosing. Methods: We conducted a retrospective cohort study of all adult patients with SE admitted to our hospital from 2017 to 2020. We collected demographic data, type of SE, dose of BZD and levetiracetam, and outcomes which included mortality and a calculated Glasgow outcome scale (GOS). We compared outcomes of patients with SE who received adequate dosing (according to practice guidelines) to those who did not. Results: 111 adult patients were included of whom 91% were seen initially in our emergency department. 75% had convulsive SE on presentation. Approximately 55% and 68% of patients did not receive an appropriate dose of BZD or levetiracetam, respectively. Inadequate dosing of BZD was associated with worse clinical outcomes based on GOS (43.6% favorable outcome vs 62.5% with adequate dosing P = .046 (95% CI, 1.01–4.60)) and inadequate dosing of both drugs was also associated with a worse GOS outcome (HR, 2.91 (95% CI, 1.05–9.67, P = .02). No difference was found in length of stay or mortality alone. Conclusion: Our study found inadequate dosing of drugs to treat SE in adults was common in our institution and was associated with worse outcomes.

EEG Essentials.

EEG is the best study for evaluating the electrophysiologic function of the brain. The relevance of EEG is based on an accurate interpretation of the recording. Understanding the neuroscientific basis for EEG is essential. The basis for recording and interpreting EEG is both brain site-specific and technique-dependent to detect and represent a complex series of waveforms. Separating normal from abnormal EEG lies at the foundation of essential interpretative skills. Seizures and epilepsy are the primary targets for clinical use of EEG in diagnosis, seizure classification, and management. Interictal epileptiform discharges on EEG support a clinical diagnosis of seizures, but only when an electrographic seizure is recorded is the diagnosis confirmed. New variations of normal waveforms, benign variants, and artifacts can mimic epileptiform patterns and are potential pitfalls for misinterpretation for inexperienced interpreters. A plethora of medical conditions involve nonepileptiform and epileptiform abnormalities on EEG along the continuum of people who appear healthy to those who are critically ill. Emerging trends in long-term EEG monitoring to diagnose, classify, quantify, and characterize patients with seizures have unveiled epilepsy syndromes in patients and expanded medical and surgical options for treatment. Advances in terminology and application of continuous EEG help unify neurologists in the diagnosis of nonconvulsive seizures and status epilepticus in patients with encephalopathy and prognosticate recovery from serious neurologic injury involving the brain. After 100 years, EEG has retained a key role in the neurologist's toolkit as a safe, widely available, versatile, portable test of neurophysiology, and it is likely to remain at the forefront for patients with neurologic diseases. Interpreting EEG is based on qualitative review, and therefore, the accuracy of reporting is based on the interpreter's training, experience, and exposure to many new and older waveforms.

Potential drug–drug interactions when managing status epilepticus patients in intensive care: A cohort study

The risk for drug-drug interactions (DDIs) associated with antiseizure drugs (ASDs) used to manage status epilepticus (SE) patients in the intensive care unit (ICU) has been poorly investigated. We aimed to quantify and describe those potential DDIs and determine SE patient risk profiles. We conducted an observational bi-centric cohort study including all SE patients admitted to the ICU in the period 2016-2020. Overall, 431 SE patients were included and 5504 potential DDIs were identified including 1772 DDIs (33%) between ASDs, 2610 DDIs (47%) between ASDs and previous usual treatments (PUTs), and 1067 DDIs (20%) between ASDs and ICU treatments (ICUTs). DDIs were moderate (n = 4871), major (n = 562) or severe (n = 16). All patients exhibited potential DDIs, which were major-to-severe DDIs in 47% of the cases. DDIs were pharmacokinetic (n = 1972, 36%), mostly involving cytochrome P450 modulators, and pharmacodynamic (n = 3477, 64%), mainly leading to increased sedation. ASD/PUT DDIs were the most frequent and severe. Age, PUT and ASD drug numbers and length of ICU stay were significantly associated with increased DDI number. We identified four SE patient profiles with different DDI risks and outcomes including (1) epileptic or brain trauma patients, (2) withdrawal syndrome patients, (3) older patients with comorbidities and (4) self-poisoned patients with psychiatric disorders and/or past epilepsy. SE patients are subject to potential DDIs between ASDs, ASD/PUT and ASD/ICUT. Major-to-severe DDIs mostly occur between ASDs and PUTs. Physicians should pay attention to SE patient characteristics and history to limit DDI numbers and prevent their consequences.

Characteristics of Patient with Status Epilepticus at the Emergency Department of Sanglah General Hospital

Introduction: Status epilepticus is a neurological condition caused by a failure of body mechanism to terminate the seizures or the onset of abnormal seizure activity resulting in prolonged seizure’s duration for more than five minutes. The available research data on status epilepticus in Indonesia is still limited. The purpose of this study was to determine the profile of patients with status epilepticus at Sanglah General Hospital from 2020 to 2021. Methods: This was a descriptive study with a retrospective approach. The study populations were patients with status epilepticus who were treated at Sanglah General Hospital in 2019-2020 who had no missing data in the medical records. Results: There were 117 patients with status epilepticus, 63 males (53.8%) and 54 females (46.2%). There are 41 patients&gt;60 years (35%), general onset in 63 patients (53.8%), and focal onset in 54 patients (46.2%). Etiology from cerebral was 68 patients (58.1%), followed by metabolic in 28 patients (23.9%). The most common OAE therapy was phenytoin (86.3%) and the longest length of stay status epilepticus patients was 8 days (55.6%). Patients with status epilepticus had leukocytosis (73.5%), increased NLR (66.7%), and decreased mean platelet volume (53.8%). Conclusion: The highest incidence of status epilepticus is in women, above 60 years, general onset type of seizure, and etiology from cerebral. Initial therapy in 117 patients was intravenous diazepam followed by phenytoin for maintenance. NLR increased in most of the patients showing signs of inflammation which further worsened the patient's outcome with a mortality rate of 47%. Keywords: Status epilepticus, seizure duration, anticonvulsant, neutrophil-lymphocyte ratio.

Usefulness of arterial spin labeling perfusion as an initial evaluation of status epilepticus

This study aimed to evaluate the sensitivity and prognostic value of arterial spin labeling (ASL) in a large group of status epilepticus (SE) patients and compare them with those of other magnetic resonance (MR) sequences, including dynamic susceptibility contrast (DSC) perfusion imaging. We retrospectively collected data of patients with SE in a tertiary center between September 2016 and March 2020. MR images were visually assessed, and the sensitivity for the detection of SE and prognostication was compared among multi-delay ASL, DSC, fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI). We included 51 SE patients and 46 patients with self-limiting seizures for comparison. Relevant changes in ASL were observed in 90.2% (46/51) of SE patients, a percentage higher than those for DSC, FLAIR, and DWI. ASL was the most sensitive method for initial differentiation between SE and self-limiting seizures. The sensitivity of ASL for detecting refractory SE (89.5%) or estimating poor outcomes (100%) was higher than those of other MR protocols or electroencephalography and comparable to those of clinical prognostic scores, although the specificity of ASL was very low as 9.4% and 15.6%, respectively. ASL showed a better ability to detect SE and predict the prognosis than other MR sequences, therefore it can be valuable for the initial evaluation of patients with SE.

Prolonged mechanical ventilation in patients with terminated status epilepticus and outcome: An observational cohort study.

Classical clinical characteristics associated with successful or unsuccessful extubation are unreliable in neurocritically ill patients, and attempts to predict successful extubation in this context have failed. We aimed to investigate the frequency of mechanical ventilation (MV) in adult patients in status epilepticus (SE) and its clinical associations, to identify predictors at SE onset of prolonged postictal MV, and to determine the associated outcomes with prolonged MV. From 2012 to 2018, SE patients treated in intensive care units at a Swiss academic care center were included. Multivariable Poisson regression adjusting for potential confounders, such as continuously administered anesthetics, was performed to identify risks for postictal MV for >24h after SE and its association with no return to neurologic function and death. Linear regression was performed to identify correlations between the durations of administered specific anesthetics and postictal MV. Of 262 patients, 42% were ventilated, with 24% being on ventilators for >24h after SE. Patients with prolonged postictal MV were extubated at a median of 7days, with 56% not being extubated on the day of successful weaning from MV because of altered consciousness and/or lack of airway-protective reflexes. After extubation, noninvasive ventilation and reintubation were rarely needed. Prolonged postictal MV was associated with increased risk for death independent of potential confounders, including fatal etiology of SE, age, SE severity, and use of anesthetics (relative risk for every additional day = 2.7, p=.024). At SE onset, decreased consciousness and presumed fatal etiology predicted prolonged postictal MV. Anesthetics were associated with prolonged MV, but linear regression could not identify significant correlations. Our data reveal that prolonged postictal MV is frequent and an independent risk factor for death. Extubation is often delayed for days despite sufficient weaning from the ventilator and altered airway-protective reflexes in only few patients. Studies need to investigate whether more rigorous extubation strategies improve outcome.

EEG Characteristics in COVID-19 Survivors and Non-survivors With Seizures and Encephalopathy.

The objective of this study is to report EEG findings in both COVID-19 survivors and non-survivors who underwent EEG either due to seizure or encephalopathy. Out of total 1468 COVID-19-positive patients, 19 patients underwent EEG. Eight out of 19 patients had a history of seizure disorder and in the remaining 11 with no prior history of seizures, four had a clinical seizure during their hospital stay. Only one had new-onset complex focal status epilepticus on EEG. Amongst the survivors (13/19), the most common EEG findings were normal followed by mild diffuse slowing. Amongst the non-survivors (6/19), the most common EEG finding was moderate to severe slowing in 50% of the patients. It can be deduced that COVID-19 infection does not increase the propensity of epileptiform discharges on EEG. There is perhaps a trend towards increased risk of new-onset status epilepticus in patients with encephalopathy and focal lesions.

Reduction in hypermetabolic state on midazolam stewards anticonvulsive treatment for interictal patterns in severe acute brain injury: A pilot MR perfusion study

Small Cohorts have utilized PET and SPECT scans as complementary markers of metabolic activity in status epilepticus in patients with ictal-interictal EEG patterns (IIC). While some rhythmic/periodic discharges mandate termination, other IIC patterns reflect underlying stable brain lesions with no superimposed cerebral injury. We realize that perfusion mapping is not the greatest surrogate; however, it is more readily available. We suggest severe brain injury patients be treated with aggressive anticonvulsive treatment only when they fulfill all the following criteria: 1) altered mental status, 2) IIC EEG patterns, 3) periodic/rhythmic discharges colocalizing with hypermetabolism detected by loco-regional hyperperfusion and 4) significant decrease in hyperperfusion during a midazolam (MDZ) test.

Genomic analysis of “microphenotypes” in epilepsy

Large international consortia examining the genomic architecture of the epilepsies focus on large diagnostic subgroupings such as "all focal epilepsy" and "all genetic generalized epilepsy". In addition, phenotypic data are generally entered into these large discovery databases in a unidirectional manner at one point in time only. However, there are many smaller phenotypic subgroupings in epilepsy, many of which may have unique genomic risk factors. Such a subgrouping or "microphenotype" may be defined as an uncommon or rare phenotype that is well recognized by epileptologists and the epilepsy community, and which may or may not be formally recognized within the International League Against Epilepsy classification system. Here we examine the genetic structure of a number of such microphenotypes and report in particular on two interesting clinical phenotypes, Jeavons syndrome and pediatric status epilepticus. Although no single gene reached exome-wide statistical significance to be associated with any of the diagnostic categories, we observe enrichment of rare damaging variants in established epilepsy genes among Landau-Kleffner patients (GRIN2A) and pediatric status epilepticus patients (MECP2, SCN1A, SCN2A, SCN8A).

Prognostication and Risk factors of Status Epilepticus in patients treated in Neurointensive Care Units

Background: Status epilepticus (SE) can lead to sequelae or even death. Identifying characteristics associated with poor outcome is crucial in guiding patient treatment, To our information, there is no data illustrating the prevalence and outcome of cases with critical tumor illness with AMS accompanied to non-convulsive seizures (NCS) or NCSE, Aim and objectives: the aim of the study was to evaluate risk factors and prognosing in cases with Status epilepticus (SE) treated in neurointensive care units, Subjects and methods: This was a retrospective cohort investigation, in which 50 cases had SE-episodes were included, We in retrospect analyzed all SE-episodes managed over an interval of 2-yrs (April 2019 to April 2021) in the NICU at the …… hospital. Results: the commonest cause was idiopathic (40%), the commonest trigger factor was poor compliance (38%). 88% of the patients were recurrent SE, Conclusion: many conditions have complicated the image in daily practice so real-life data are vital so as to recognize real cases in the ward. No severe seasonality of SE patients has been found. In our study, the commonest cause of SE was idiopathic, the commonest trigger factor was poor compliance and most of the patients were recurrent SE

Status Epilepticus in Patients with Anti-NMDAR Encephalitis Requiring Intensive Care: A Follow-Up Study.

To date, specialized studies focusing on status epilepticus (SE) in anti-N-methyl D-aspartate receptor (anti-NMDAR) encephalitis are limited, and the association between the occurrence of SE and clinical outcome is controversial. This study aims to investigate the differences between patients with critical anti-NMDAR encephalitis with SE and patients who experienced epileptic seizures without SE and to evaluate the long-term disease outcomes of patients with anti-NMDAR encephalitis with SE who were admitted to the neurological intensive care unit (neuro-ICU). In this retrospective study based on a prospective registry, patients with anti-NMDAR encephalitis with neuro-ICU admission from 2014 to 2019 were analyzed and divided into two groups based on whether they had SE. Their clinical characteristics during the neuro-ICU stay were assessed and compared. The neurological and seizure outcomes were evaluated every 3months. Of 83 patients with anti-NMDAR encephalitis, 24 required intensive care. In the SE group, 38.5% (5 of 13) of patients developed refractory SE (RSE), and 21.3% (3 of 13) of patients developed super RSE. More patients in the SE group presented with seizures as the initial symptoms (53.8% vs. 9.1%, p = 0.033) and had a strong positive NMDAR antibody titer in the cerebrospinal fluid (76.9% vs. 27.3%, p = 0.043). More patients in the non-SE group had a good neurological outcome (modified Rankin Scale (mRS) score < 2) at 3months after disease onset (60.0% vs. 15.4%, p = 0.039), but 83.3% of patients with SE had a mRS score < 2 at 9months after disease onset, which was similar to the rate in the non-SE group. A total of 41.7% of patients with SE had their last seizure within 1month from disease onset, which was significantly lower than the rate in the non-SE group (90%), but all the patients with SE became seizure free after the acute phase of disease. Patients with critical anti-NMDAR encephalitis who present with SE have a high rate of RSE/super RSE and recover more slowly than patients without SE, but most of them will eventually achieve good long-term neurological outcomes and live seizure free after the acute phase.

P-EP002. Status epilepticus during pregnancy: A case report

Introduction. Status epilepticus is a rare but potentially life-threatening complication that women with epilepsy may experience during pregnancy. Poor compliance may contribute to the occurrence of status epilepticus, resulting in the need for substantial increased in anticonvulsant dosing to suppress seizures. This case report aims to report case status epilepticus in patients during pregnancy at Dr. Sardjito Hospital. Results. CASE: A 30-years-old G5P2A2, 25 weeks gestation was admitted to the Emergency Room Sardjito Hospital Indonesia in December 2018, presented with multiple seizure episodes of 3 days duration. She was known epilepsy patient diagnosed about 3 years ago and was on phenytoin but was not on regular medications after she knew that she got pregnant. Physical examination revealed Glasgow Coma Scale (GCS) of E2VTM2 (on midazolam). Patient had normal neurological examination. After aggressive treatments with midazolam and antiepileptic drug, the patient regained full consciousness. Conclusion. Pregnancy sometimes worsens the frequency of seizures in known epileptic women. One of which is that the physiological changes in pregnancy can lead to subtherapeutic serum level of the drugs and discontinuing medications during pregnancy can precipitate status epilepticus.

Prediction of Postictal Delirium Following Status Epilepticus in the ICU: First Insights of an Observational Cohort Study.

To identify early predictors of postictal delirium in adult patients after termination of status epilepticus. Retrospective study. ICUs at a Swiss tertiary academic medical center. Status epilepticus patients treated on the ICUs for longer than 24 hours from 2012 to 2018. None. Primary outcome was postictal delirium during post-status epilepticus treatment defined as an Intensive Care Delirium Screening Checklist greater than or equal to 4. Associations with postictal delirium were secondary outcomes. A time-dependent multivariable Cox proportional hazards model was used to identify risks of postictal delirium. It included variables that differed between patients with and without delirium and established risk factors for delirium (age, sex, number of inserted catheters, illness severity [quantified by the Sequential Organ Failure Assessment and Status Epilepticus Severity Score], neurodegenerative disease, dementia, alcohol/drug consumption, infections, coma during status epilepticus, dose of benzodiazepines, anesthetics, and mechanical ventilation). Among 224 patients, post-status epilepticus Intensive Care Delirium Screening Checklist was increased in 83% with delirium emerging in 55% with a median duration of 2 days (interquartile range 1-3 d). Among all variables, only the history of alcohol and/or drug consumption was associated with increased hazards for delirium in multivariable analyses (hazard ratio = 3.35; 95% CI, 1.53-7.33). Our study provides first exploratory insights into the risks of postictal delirium in adult status epilepticus patients treated in the ICU. Delirium following status epilepticus is frequent, lasting mostly 2-3 days. Our findings that with the exception of a history of alcohol and/or drug consumption, other risk factors of delirium were not found to be associated with a risk of postictal delirium may be related to the limited sample size and the exploratory nature of our study. Further investigations are needed to investigate the role of established risk factors in other status epilepticus cohorts. In the meantime, our results indicate that the risk of delirium should be especially considered in patients with a history of alcohol and/or drug consumption.

Reply to Dravet, C. Different Outcomes of Acute Encephalopathy after Status Epilepticus in Patients with Dravet Syndrome. How to Avoid Them? Comment on "De Liso et al. Fatal Status Epilepticus in Dravet Syndrome. Brain Sci. 2020, 10, 889".

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Status Triphasicus Versus Status Epilepticus?

Generalized periodic patterns with triphasic wave morphology, long referred to as triphasic waves [TWs], had been associated with metabolic encephalopathies, although other neurologic and systemic causes have since been identified. In a recent classification of periodic patterns, TWs were formally grouped with the generalized periodic discharges, which are often associated with ictal activity. The interpretation of generalized periodic patterns with TWs as nonictal can have significant implications in the management of comatose patients in nonconvulsive status epilepticus. Electrographic characteristics that help distinguish nonictal periodic patterns with TWs from generalized periodic discharge ictal patterns include (1) TWs in long runs of periodic bilaterally synchronous and symmetric discharges, maximal in frontocentral or posterior head regions with and without a frontal-to-occipital lag or posterior-to-anterior lag, respectively; (2) recurrent spontaneous and/or low-dose benzodiazepine-induced attenuation and/or suppression of the periodic pattern and replacement with a diffuse slow wave activity throughout a prolonged EEG recording; and (3) stimulation-induced activation and/or increase in frequency and/or organization of TWs. We coined the term of status triphasicus to describe the electrographic periodic pattern of TWs with these three distinct characteristics. In this article, we discuss the advantages and limitations of keeping the status triphasicus pattern as a distinct electrographic entity different from periodic ictal generalized periodic discharge patterns. We discuss the circumstances in which a status triphasicus pattern can be associated with ictal activity and propose a simple pragmatic classification of status triphasicus that encompasses the different clinical scenarios it can be associated with.

Different Outcomes of Acute Encephalopathy after Status Epilepticus in Patients with Dravet Syndrome. How to Avoid Them? Comment on De Liso et al. Fatal Status Epilepticus in Dravet Syndrome. Brain Sci. 2020, 10, 889.

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