Status Epilepticus In Patients Research Articles

NORSE seasonality may vary geographically in adults.

The mechanisms causing new onset refractory status epilepticus (NORSE) are often unknown. Recently, a seasonal variation with NORSE peaking during the summer was described in a mixed cohort of adults and children why we here studied the seasonal variation in a Danish status epilepticus (SE) cohort. This retrospective cohort study comprised SE patients aged ≥18 diagnosed and treated 2008-2017 at the Odense University Hospital. Clinical characteristics and seasonality of patients fulfilling the diagnostic criteria for NORSE were compared with patients with refractory SE (RSE) due to other reasons and with the seasonal variation of autoantibodies associated with autoimmune encephalitis in the Danish autoimmune encephalitis register. In this cohort, 26 patients met NORSE criteria. As compared to RSE patients not fulfilling NORSE criteria (n = 152), NORSE patients were more likely to have symptoms of systemic inflammation (C-reactive protein concentrations ≥10 mg/L or fever ≥38°C) at admission; nine fulfilled the criteria for febrile infection related epilepsy syndrome (FIRES). In contrast to the even seasonal distribution of patients with RSE not fulfilling the NORSE criteria, admissions due to NORSE peaked during the winter (46.1%, p = 0.04 as compared to non-NORSE RSE); six out of nine FIRES episodes occurred in the winter season. The seasonal variation was not explained by a seasonal variation of the detection rates of autoantibodies associated with autoimmune encephalitis (incl. NMDAR, LGI1, CASPR2, GABAR, GFAP) in a Danish nationwide register (n = 259). In conclusion, we confirm the seasonality of NORSE in a Danish cohort, however, with a peak during winter suggesting a geographical variation not solely explained by autoimmune encephalitis associated with known autoantibodies. PLAIN LANGUAGE SUMMARY: The study investigated the seasonal patterns of new-onset refractory status epilepticus (NORSE), i.e. severe seizures that occur without an obvious cause and require very intensive treatment. In contrast to the previously observed peak frequency in summer, this Danish study found that NORSE cases peak in winter. Furthermore, the seasonal variation in NORSE cases was not found to be associated with autoimmune encephalitis caused by known autoantibodies. Together with the high rate of patients showing symptoms of systemic inflammation compared to other status epilepticus patients, the data suggest a link between misdirected immune system responses and NORSE. The study can therefore help in the further search for the currently unknown causes of NORSE.

Status epilepticus in patients with brain tumors and metastases: A multicenter cohort study of 208 patients and literature review

ObjectiveBrain tumors and metastases account for approximately 10% of all status epilepticus (SE) cases. This study described the clinical characteristics, treatment, and short- and long-term outcomes of this population.MethodsThis retrospective, multi-center cohort study analyzed all brain tumor patients treated for SE at the university hospitals of Frankfurt and Marburg between 2011 and 2017.ResultsThe 208 patients (mean 61.5 ± 14.7 years of age; 51% male) presented with adult-type diffuse gliomas (55.8%), metastatic entities (25.5%), intracranial extradural tumors (14.4%), or other tumors (4.3%). The radiological criteria for tumor progression were evidenced in 128 (61.5%) patients, while 57 (27.4%) were newly diagnosed with tumor at admission and 113 (54.3%) had refractory SE. The mean hospital length of stay (LOS) was 14.8 days (median 12.0, range 1–57), 171 (82.2%) patients required intensive care (mean LOS 8.9 days, median 5, range 1–46), and 44 (21.2%) were administered mechanical ventilation. All patients exhibited significant functional status decline (modified Rankin Scale) post-SE at discharge (p < 0.001). Mortality at discharge was 17.3% (n = 36), with the greatest occurring in patients with metastatic disease (26.4%, p = 0.031) and those that met the radiological criteria for tumor progression (25%, p < 0.001). Long-term mortality at one year (65.9%) was highest in those diagnosed with adult-type diffuse gliomas (68.1%) and metastatic disease (79.2%). Refractory status epilepticus cases showed lower survival rates than non-refractory SE patients (log-rank p = 0.02) and those with signs of tumor progression (log-rank p = 0.001).ConclusionsSE occurrence contributed to a decline in functional status in all cases, regardless of tumor type, tumor progression status, and SE refractoriness, while long-term mortality was increased in those with malignant tumor entities, tumor progressions, and refractory SE. SE prevention may preserve functional status and improve survival in individuals with brain tumors.

Nonconvulsive status epilepticus in patients with acute subarachnoid hemorrhage is associated with negative arterial spin labeling on peri-ictal magnetic resonance images

PurposeNon-convulsive status epilepticus (NCSE) is characterized by repetitive or continuous seizures without convulsions. Arterial spin labeling (ASL) is useful for assessing hyperperfusion due to neurovascular unit coupling in patients with NCSE; subarachnoid hemorrhage (SAH) impairs the neurovascular unit. We hypothesized that the sensitivity of ASL in detecting NCSE is low in patients with SAH during the acute phase. MethodsBased on ASL findings obtained within 48 h after the clinical suspicion of focal-onset NCSE, we divided 34 patients into ASL-negative (no hyperperfusion; n = 10) and ASL-positive (confirmed hyperperfusion; n = 24) groups. We further divided the two groups according to the NCSE etiology: patients who were diagnosed with NCSE within 14 days after SAH onset (acute SAH, n = 11) and patients with NCSE due to factors other acute SAH (n = 23) and compared their characteristics. ResultsIn 10 of the 34 patients (29.4 %) the ASL findings were normal. The rate of acute SAH was significantly higher in ASL-negative- (n = 8, 80.0 %) than ASL-positive patients (n = 3, 12.5 %). The rate of patients in aphasic status was significantly lower in ASL-negative patients (n = 1, 10 %) than in ASL-positive patients (n = 12, 50.0 %). ConclusionNormal ASL findings alone should not be used to exclude a diagnosis of NCSE particularly in patients in the acute phase of SAH with deterioration or no improvement in consciousness.

Status epilepticus in patients with genetic generalized epilepsy: a case series study

BackgroundGenetic generalized epilepsy (GGE) accounts for nearly one-third of all epilepsies. The feature of status epilepticus (SE) in patients with GGE has been rarely studied. We aimed to determine the electroclinical characteristics of SE in patients with GGE.MethodsIn this retrospective study, nine patients with GGE were enrolled at Xijing Hospital, Xi’an, China from May 2014 to May 2020. SE was confirmed by 24-h video-EEG recording. The demography, clinical manifestation, brain MRI and SE pattern were analyzed.ResultsOf the nine patients in the study, seven were female. The mean age of the patients at the time of inclusion was 16.8 years (range 7–31 years), and the mean age at the onset of epilepsy was 10.9 years (range 6–17 years). The follow-up time ranged from 3 months to 6 years. Myoclonic absence status was identified in four patients showing eyelid myoclonia with absence and one patient showing perioral myoclonia with absences. Myoclonic SE was identified in three patients showing juvenile myoclonic epilepsy. Autonomic SE was found in one patient with eyelid myoclonia with absence. SE was terminated by oral midazolam in four patients. In the other five patients, SE terminated spontaneously.ConclusionsThe seizure type of SE in patients with GGE is often consistent with their major symptoms. Oral midazolam may be an option to terminate SE in patients with GGE.

Impact of Paraclinical Investigations in the Management of CAR T-Cell-Associated Neurotoxicity: Lessons Learned from Real World Experience

Introduction International guidelines regarding the management of immune effector cell-associated neurotoxicity syndrome (ICANS) recommend several paraclinical assessments, including MRI, lumbar puncture (LP) and EEG based on ICANS grade. However, the impact of these paraclinical investigations has not yet been evaluated. Methods Here, we aimed to analyze the role of MRI, LP and EEG in the management of ICANS in a cohort of real-life patients treated with CAR T-cells at the University Hospital of Rennes, France. The primary endpoint was to assess the therapeutic modifications induced by each paraclinical investigation. The secondary endpoints were to assess the specific abnormalities and differential diagnoses founded on MRI, LP and EEG. We also performed subgroup analysis for each ICANS grade. Results Between August 2018 and January 2023, 190 consecutive patients were treated with CAR T-cells. A total of 91 (48%) patients developed an ICANS including 25 grade 1 (13%), 32 grade 2 (17%), 21 grade 3 (11%) and 12 grade 4 (6%). MRI was performed in 71 (78%) patients with ICANS. The most common result was a normal MRI, corresponding to 80 % of MRI. One of the most frequent abnormal result was aspecific hypersignal, which occurred in 4 (6%) patients with ICANS. Notably, there was no oedema depicted on MRI, even in the most severe ICANS grade 4. Overall, 3 MRI (4% of all MRI) generated therapeutic modification (Figure 1). Two MRI which described strokes in patients with ICANS grade 3 led to initiation or increase of APT therapy. One patient with ICANS grade 1 received APT as MRI described a stroke event but reclassified as normal a posteriori. Lumbar puncture was performed in 43 (47%) patients. A high rate of LP was abnormal in our cohort (86%). There were 3 preemptive therapeutic modifications for unconfirmed infection (7%) (Figure 1). Two LP led to probabilistic antivirals introduction (aciclovir) in patient with ICANS grade 1 and 2 because of lymphocytic meningitis. One LP led to probabilistic antifungals introduction (voriconazole) in patient with ICANS grade 3 for a suspected Aspergillus spp. meningitis, which was not confirmed after infectious disease physician's expertise. Systematic EEG performed in 51 (56%) patients requested without clinical signs of epilepsy were analyzed. Only 18% of EEG were normal (Table 1). The most common finding was encephalopathy in 45% of patients. Notably, 6 EEG (12%) reported seizure or status epilepticus in patients with no abnormal movements. Finally, 8 EEG (16%) led to therapeutic modification in the entire cohort (Figure 1). All EEG which found seizure or status epilepticus led to an increase in AE prophylaxis by levetiracetam or introduction of a new AE (mainly phenytoin). Discussion The therapeutic impact varied between paraclinical investigations. On one hand, systematic EEG based on ICANS grade only was often followed by therapeutic modification (16% of cases). On the other hand, systematic LP was never associated with relevant therapeutic modification, even in case of severe ICANS, and this broad LP policy resulted in initiation of antimicrobial agents for unconfirmed infections in three patients (7%). Moreover, the need for systematic MRI assessment is also questionable, as only 4% of MRI led to a therapeutic modification and no MRI found oedema, which is one of the main concerns of treating physicians managing severe ICANS. Our study shows that EEG is the paraclinical assessment with the greatest therapeutic impact while MRI and LP appear to have a limited therapeutic impact. Our results emphasize the role of EEG in the current guidelines, but questions the need for systematic MRI and LP, which might be left to the discretion of the treating physician.

Status epilepticus in patients with glioblastoma: Clinical characteristics, risk factors, and epileptological outcome.

Epilepsy is a common comorbidity in patients with glioblastoma, however, clinical data on status epilepticus (SE) in these patients is sparse. We aimed to investigate the risk factors associated with the occurrence and adverse outcomes of SE in glioblastoma patients. We retrospectively analysed electronic medical records of patients with de-novo glioblastoma treated at our institution between 01/2006 and 01/2020 and collected data on patient, tumour, and SE characteristics. In the final cohort, 292/520 (56.2%) patients developed seizures, with 48 (9.4% of the entire cohort and 16.4% of patients with epilepsy, PWE) experiencing SE at some point during the course of their disease. SE was the first symptom of the tumour in 6 cases (1.2%) and the first manifestation of epilepsy in 18 PWE (6.2%). Most SE episodes occurred postoperatively (n=37, 77.1%). SE occurrence in PWE was associated with postoperative seizures and drug-resistant epilepsy. Adverse outcome (in-house mortality or admission to palliative care, 10/48 patients, 20.8%), was independently associated with higher status epilepticus severity score (STESS) and Charlson Comorbidity Index (CCI), but not tumour progression. 32/48 SE patients (66.7%) were successfully treated with first- and second-line agents, while escalation to third-line agents was successful in 6 (12.5%) cases. Our data suggests a link between the occurrence of SE, postoperative seizures, and drug-resistant epilepsy. Despite the dismal oncological prognosis, SE was successfully treated in 79.2% of the cases. Higher STESS and CCI were associated with adverse SE outcomes.

Lacosamide for the Treatment of Seizures in Neonates and Infants: A Retrospective Assessment of Efficacy and Tolerability

BackgroundA retrospective study was conducted to assess the safety and efficacy of lacosamide in children aged less than 24 months. MethodsPatients were included if they were ≤24 months when they first received lacosamide; patients were excluded if they were enrolled in research studies investigating lacosamide or if there were insufficient data in the chart. Treatment response was assessed by reviewing charts and electroencephalographic reports to determine reduction in seizure burden. ResultsIn this sample, 53 of 86 patients (61.63%) in status epilepticus had good response to lacosamide, defined by ≥50% reduction in seizure burden. In addition, patients’ charts were reviewed until age 24 months to assess for any adverse effects attributed to maintenance lacosamide therapy, with adverse effects noted in three patients (abnormal movements in two patients, worsened seizures in one patient). ConclusionsThis study is among the largest retrospective chart reviews investigating the use of lacosamide in children and the first investigating the efficacy of lacosamide in children aged ≤24 months. Lacosamide was efficacious in reducing seizure burden in status epilepticus, and it was very well-tolerated in this age group. This study should prompt further investigation into the use of lacosamide in this age group.

The Concurrent Use of Phenytoin and Levetiracetam for Seizure Prophylaxis in ICU Patients: The "Arrowhead Rationale".

The administration of multiple antiepileptic drugs (AEDs) is standard practice for neurological intensive care unit (ICU) patients who cannot obtain seizure control with monotherapy. Phenytoin and levetiracetam continue to be highly utilized AEDs for ICU patients due to their efficacy and relatively low cost. However, there is no randomized control trial to date that assesses the efficacy outcomes of the concurrent use of these two medications for ICU patients in convulsive or silent status epilepticus that combats the toxicity with increasing dosages of a single drug by itself. Here, we have analyzed several studies published over the past two decades to better understand whether the concomitant use of these two medications is more efficacious in treating unremitting seizures in ICU patients. Several factors influence which AED is a better fit for ICU patients due to the complexity of their clinical state. Risk for drug interactions, increased incidence of renal and hepatic impairment, and higher need for patient monitoring are daily barriers that determine AED use. After analysis of past research, while the efficacy of concurrent use of levetiracetam and phenytoin is still not fully clear, we offer the "Arrowhead Rationale" for such dual therapy in a subset of patients at our tertiary care trauma and stroke center in Southern California.

P.078 Desynchronization in high-definition transcranial direct current stimulation of refractory status epilepticus

Background: Recently, we showed cathodal high-definition transcranial direct current stimulation (HD-tDCS) inhibits spikes in refractory status epilepticus (RSE) patients. We sought to characterize relative power changes within regional frequency bands to explore connectivity throughout stimulation. Methods: 28 ICU-EEGs from 10 patients were filtered with 1Hz-lower/127Hz-upper/60Hz-notch. Power spectral density was computed for each individual bipolar-longitudinal (excluding midline) electrode chain in delta/theta/alpha/beta/gamma frequency bands. Relative power was extracted throughout recordings by Welch’s method with 2.5-second Hanning window size with 50% overlap every 10 seconds. The average of relative powers from ≤20-minute pre/during/post stimulation windows were calculated per session/chain/band. Absolute maximal relative power change between pre-during and during-post were computed. ANOVA statistically tested for differences. Results: Change in pre-during for delta/theta/alpha/beta/gamma were respectively -0.7%/-3.1%/-2.8%/-2.1%/8.2%, and during-post were 1.3%/2.8%/2.3%/1.7%/-7%. Positive average changes are increases in average relative power where negative changes show decreases. Changes in absolute maximal average relative power between pre-during and during-post stimulation between frequency bands were significant respectively (p=0.0011, p=0.0139). Conclusions: Relative power in all bands drop pre-during and increase during-post except gamma which correlates with desynchronization being a mechanism for HD-tDCS efficacy in RSE. These frequency band power changes may imply brain connectivity changes that need to be further explored.

Epidemiology, real-world treatment and mortality of patients with status epilepticus in Germany: insights from a large healthcare database.

Status epilepticus is a life-threatening emergency, and to date, few studies have reported on its long-term treatment and outcomes. This study aimed to estimate the incidence, the treatment and outcomes, the healthcare resource utilization and the costs of status epilepticus in Germany. Data from 2015 to 2019 were obtained from German claims (AOK PLUS). Patients with ≥1 status epilepticus event and no event in the preceding 12 months (baseline) were included. A subgroup of patients with an epilepsy diagnosis during baseline was also analysed. Of the 2782 status epilepticus patients (mean age = 64.3 years; 52.3% female), 1585 (57.0%) were previously diagnosed with epilepsy. The age- and sex-standardized incidence was 25.5 cases/100 000 persons in 2019. The mortality rate after 12 months was 39.8% overall (19.4% and 28.2% after 30 and 90 days, respectively) and 30.4% in the epilepsy patient subgroup. Factors associated with higher mortality were age, comorbidity status, presence of brain tumours and an acute stroke. An epilepsy-related hospitalization at onset of or 7 days prior to the status epilepticus event as well as prescription of antiseizure medication during baseline was associated with a better survival rate. Overall, 71.6% of patients (85.6% in the epilepsy subgroup) were prescribed with out-patient antiseizure medication and/or rescue medication within 12 months. All patients sustained on average 1.3 status epilepticus-related hospitalizations (20.5% had more than one) during a mean follow-up period of 545.2 days (median 514 days); total direct costs including in-patient and out-patient status epilepticus treatments were 10 826€ and 7701€ per patient-year overall and for the epilepsy patient subgroup, respectively. The majority of status epilepticus patients received an out-patient treatment in line with epilepsy guidelines, and patients previously diagnosed with epilepsy have a higher likelihood to receive it. The mortality in the affected patient population is high; risk factors were older age, higher comorbidity burden, the presence of brain tumours or an acute stroke.

Intramuscular Versus Intravenous Treatment of Status Epilepticus: A Systematic Review.

Status epilepticus is a neurological emergency associated with high morbidity and mortality with fatal outcomes if not treated well. The goal of this study was to compare the intramuscular and intravenous treatment of individuals with status epilepticus. A search was performed on Scopus, PubMed, Embase, and Web of Science databases for articles published in the English language in peer-reviewed publications up to March 1, 2023. Studies were included if the treatment of status epileptics was compared either directly or indirectly between intramuscular and intravenous methods. In addition, relevant papers were manually screened for in the reference lists of the included studies. Non-duplicate articles were identified. Finally, five articles were included in the analysis, of which four were randomized controlled trials and one was a retrospective cohort study. The intramuscular midazolam group's time until the first seizure stopped was significantly shorter than the intravenous diazepam group's time (7.8 versus 11.2 minutes, respectively; p = 0.047). Moreover, the percentage of patients admitted was significantly lower in the intramuscular group than in the intravenous group (p = 0.01), but the lengths of stay in the intensive care unit and the hospital did not differ significantly between the groups. Regarding seizure recurrence, the intramuscular group had fewer incidences of recurrent seizures. Finally, there were no appreciable differences in safety outcomes between the two treatment arms. During the analysis, different outcomes reported after the use of intramuscular and intravenous treatments in managing patients with status epilepticus were categorized. This categorization led to a clear view of the efficacy and safety of intramuscular versus intravenous treatments in managing status epilepticus patients. The information at hand indicates that intramuscular therapy is just as successful as intravenous therapy in treating people with status epilepticus. The availability, adverse effect profile, logistics of administration, cost, and whether it is included in hospital formularies are some of the factors to be taken into consideration when choosing the drug administration technique.

Outcomes In Patients with Traumatic Acute Subdural Hematoma with Non-Convulsive Status Epilepticus (N3.002)

<h3>Objective:</h3> To evaluate the factors contributing to poor outcomes in patients with acute traumatic subdural hematoma (aSDH) who developed nonconvulsive status epilepticus (NCSE). <h3>Background:</h3> NCSE in patients with aSDH is an underdiagnosed yet fatal complication that requires prompt diagnosis and treatment. A high degree of clinical suspicion and evaluation with continuous EEG is required for prompt diagnosis and treatment. <h3>Design/Methods:</h3> This is a single-institution retrospective study approved by the local IRB. Patients with traumatic brain injury (TBI) with aSDH diagnosed with status epilepticus between the years 2016–2020 were included. Demographic, clinical, imaging, treatment, and EEG details were reviewed and collected in a HIPPA-compliant format. Logistic regression analysis was used to evaluate factors contributing to poor outcomes. <h3>Results:</h3> Out of a total of 540 patients, who had presented with traumatic acute intra-cerebral hemorrhage between the years 2016–2022, 28 patients with traumatic aSDH who had presented with status epileptics during the same hospitalization were included in the present study. NCSE was the most common form of status epilepticus (27/28). The mean age was 67 (range 20–92) years and 17(60%) were male. 12(48%) of the patients had an initial presenting GCS of 7 or less. The mean length of stay in the hospital was 16 (5–44) days. Overall mortality was 19(64%). Logistic regression analysis identified the presence of central spikes on EEG (p:0.43, OR:12.72; 95% CI 1.083–149.35) and thickness of aSDH&gt; 1cm (p: 0.025; OR: 16.545; 95%CI: 1.426–191.95) as predictors of mortality in both univariate and multivariate analysis. Good functional outcomes with mRS&lt;2 were seen in rarely 10(35%) of these patients. <h3>Conclusions:</h3> Nonconvulsive status epilepticus (NCSE) is a common form of presentation of status epilepticus in patients with acute traumatic SDH. The presence of epileptiform activity in the central leads in EEG often leads to resistant seizures. NCSE carries a poor prognosis with high mortality. <b>Disclosure:</b> Dr. Mohammed has nothing to disclose. Miss Stebbins has nothing to disclose. The institution of Dr. Shah has received research support from Eisai pharma .

Comparison of three types of Epilepsy Surgery for the treatment of Refractory Status Epilepticus: A Single Center Experience (P9-1.005)

<h3>Objective:</h3> Comparing outcomes for three categories of epilepsy surgery in Refractory Status Epilepticus Patients (RSE). <h3>Background:</h3> Literature comparing morbidity and mortality outcomes between three types of epilepsy surgery for RSE patients is scarce. Previous case series have focused on one type of surgery or does not directly compare outcomes between the modalities. <h3>Design/Methods:</h3> A retrospective analysis for RSE between 2010 and 2021 was done. Sociodemographic data, semiology and etiology were collected. The patients were deidentified using our institute’s software, and comparison data was extracted from the secure system. Data collected included lag time between diagnosis and surgery, number of anti-seizure medications (ASMs) tried, EEG and imaging data, type of surgery performed, level of post-operative care, number of post-operative days admitted, complications and seizure freedom outcomes. <h3>Results:</h3> The mean age was 35.6 ± 23.5 years, with 4/12 patients being female. Seizure types were primarily generalized tonic-clonic or focal seizures with impaired awareness. A plethora of etiologies were included. The mean number of ASMs tried was 2.3 ± 1.4. Every patient had EEG and MRI Brain with ancillary testing such as grid placement. Out of 12, 6 had resection, 5 disconnections and 2 neuromodulations. 11/12 patients required an ICU admission and mean post-operative days admitted was 12 ± 11.2. Minor to no complications occurred in 33 % of all resection patients, and minor complications occurred in 40 % and 50 % patients of the disconnection and modulation patients. 3/4 and 3/5 of patients that had undergone resections and disconnections respectively had Class 1 outcomes in. Patients that received modulation had a Class 4 outcome and 1 patient death. <h3>Conclusions:</h3> Our study reveals that while there is no substantial difference between resection and disconnection, resections have slightly better outcomes and fewer complications. Modulation had poorer seizure freedom and may only be considered as a temporizing measure. <b>Disclosure:</b> Dr. Khan has received personal compensation for serving as an employee of University of Kentucky. Dr. Mirza has nothing to disclose. Dr. Mathias has received research support from My Epilepsy Society Non Profit Organization.

Non-convulsive status epilepticus possibly induced by a rapid correction of severe hyperkalemia: a case report and literature review

BackgroundPatients with chronic kidney disease frequently develop neurological complications including confusion and altered consciousness. Non-convulsive status epilepticus, which is characterized by a change in behavior and/or mental process accompanied by epileptiform discharges on electroencephalogram in the absence of convulsive seizures, is one of the overlooked causes of altered consciousness. The incidence and precise pathophysiological mechanism of non-convulsive status epilepticus in patients with kidney disease, and especially in patients with electrolyte disturbances, remains unknown. We recently treated an older patient with chronic kidney disease and severe hyperkalemia in whom non-convulsive status epilepticus developed following a correction of severe hyperkalemia.Case presentationAn 82-year-old male was admitted to our hospital at midnight because of weakness of all four limbs (Day 1). He underwent urgent hemodialysis for severe hyperkalemia (9.84 mEq/L) and his serum potassium concentration decreased to 4.97 mEq/L. He regained full consciousness and his limb weakness improved on the morning of Day 2, but he became confused in the evening. Electroencephalogram revealed repeated low-voltage ictal discharges in the right occipital region and a diagnosis of non-convulsive status epilepticus was made. Following medication with fosphenytoin and phenytoin, the patient became fully alert and orientated on Day 8.ConclusionWe speculate that a rapid correction of hyperkalemia was the possible cause of non-convulsive status epilepticus development. To our knowledge, this is the first report of non-convulsive status epilepticus from a potassium abnormality. We described a case of this condition in detail and summarized 78 previous case reports of non-convulsive status epilepticus with kidney disease or electrolyte disturbances.

Non-Convulsive Status Epilepticus as A Complication of Electroconvulsive Therapy: A Case Report

IntroductionStatus Epilepticus is defined as a condition that can have long-term outcomes involving neuronal death and injury due to the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms that lead to abnormally prolonged seizures. Electroconvulsive therapy (ECT) is a highly effective treatment option for psychiatric disorders. Although it rarely occurs in the treatment, non-convulsive status epilepticus can be seen as a complication after ECT. Due to its rarity, this complication is not yet well understood, is challenging to diagnose, and information about treatment options is limited.ObjectivesBy sharing this case report, we aim to emphasize the importance of being careful in terms of the risk of status epilepticus in patients receiving electroconvulsive therapy.MethodsHere in we present a 29-year-old patient with no previous neurological disease and who had a history of schizophrenia. Electroconvulsive therapy was planned because the patient was resistant to antipsychotic treatment. EEG was planned for the patient who had urinary incontinence during the ninth session of ECT. Generalized slow wave activity and intermittent rhythmic delta activity were observed in the EEG, therefore it was found suspicious for NCSE, and the patient was planned to perform an EEG again by administering diazepam to confirm the diagnosis. After diazepam, the patient whose EEG tracing was clearly improved was admitted to the neurology intensive care unit. He was followed up for 48 hours with continuous 4 mg/hour/day midazolam and continuous bedside EEG in the neurology intensive care unit. Concomitant lamotrigine was started at 100 mg/day. Significant improvement in EEG, sinusoidal alpha, and beta waves with the eye open was observed at the 48th hour, and the patient was transferred back to the psychiatry service. Lamotrigine treatment was increased up to 200 mg/day and clozapine treatment was adjusted to 350 mg/day in the psychiatry service. In the patient whose EEG was requested again before discharge.ResultsThe diagnosis of NCSE post-ECT can be laborious; the symptoms may not be characteristic and clear, and usually not distinguish from symptoms of confusion, delirium, or psychiatric illness, hence the follow-up psychiatrist should be careful. In suspicious cases, EEG should be taken, especially in patients at risk for seizures. These risky conditions include previous seizure history, and lithium or clozapine use.ConclusionsThe diagnosis of NCSE after ECT is a demanding condition. Particular attention should be paid to factors that will lower the seizure threshold. In cases with ECT treatment with clozapine, intermittent clozapine blood levels can be quantified and medication interactions and smoking can be considered. When the cases are examined, the common aspect of most of them is that the treatments have good results.Disclosure of InterestNone Declared

Epidemiology, clinic and diagnosis of status epilepticus in adults: A review

Status epilepticus is one of the causes of impaired consciousness. Status epilepticus can develop both in patients with epilepsy and in patients without an epileptic history. The most difficult diagnostic task is to identify non-convulsive status epilepticus. The most frequently discussed in the literature issues of the clinical picture, diagnosis of different variants of status epilepticus were analyzed. Particular attention was paid to the peculiarities of status epilepticus in patients of older age groups.

The Increased Interleukin-6 Levels Can Be an Early Diagnostic Marker for New-Onset Refractory Status Epilepticus

New-onset refractory status epilepticus (NORSE) is a condition defined as the occurrence of refractory status epilepticus in patients without active epilepsy and no other acute causes of seizure. Although there is evidence that immune-mediated pathogenesis has a pivotal role in the epileptogenesis of NORSE, the diagnosis of NORSE is usually made on the clinical observation because there is no established biological marker suggesting the diagnosis of NORSE. We recently encountered a NORSE patient who was successfully treated with immunotherapy including tocilizumab, an anti-interleukin-6 (IL-6) receptor monoclonal antibody, and the markedly increased levels of serum and cerebrospinal fluid IL-6 were the only laboratory abnormality during the early treatment of the patient.

Epidemiology and Risk Factors of Convulsive Status Epilepticus Patients Admitted in the Emergency Department of Tertiary Hospital in Mogadishu, Somalia.

Status epilepticus (SE) is one of the most common neurologic emergencies and is associated with significant morbidity and mortality. The underlying cause of SE varies between patients with epilepsy and those presenting without. The aim of this study was to evaluate the epidemiology, risk factors and outcomes of patients presenting with convulsive SE in the emergency department (ED) of a tertiary hospital in Mogadishu. This was a cross-sectional study conducted between July 2021 and June 2022. The study included both patients with epilepsy and those without epilepsy presenting to the ED with SE. Risk factors and underlying etiologies were evaluated in the patients in both the pediatric group (0-18 years) and adult group (18 years and above).Clinical history, neurologic examinations, neuroimaging, electroencephalography findings, and laboratory investigations were all evaluated. The mean age for pediatric patients was 6 (SD±4.7), while the mean age for adult patients was 38 (SD±10.4). About 33 (36%) of the subjects had previous history of epilepsy, while 59 (64%) presented to the ED with their first seizure. About 80 (87%) had generalized seizure while 12 (13%) had focal seizure. Poor antiepileptic compliance was the most common risk factor for SE 20 (21.7%), followed by CNS infections 14 (15%), and prolonged febrile seizures 7 (7.6%). Poor antiepileptic drug compliance, cerebrovascular disorders, electrolyte imbalance, metabolic conditions, and drug abuse were the most common underlying etiologies of SE in patients older than 18 years. Prolonged febrile seizure, meningitis, encephalitis, systemic infections, and structural brain abnormalities were the most common underlying etiologies of SE in patients younger than 18 years. CNS infections, CVDs, metabolic disturbances, electrolyte imbalances, and systemic infections are major etiological risk factors of SE in patients without prior history of epilepsy. Medication adherence was the major etiological risk factor for SE identified in patients with epilepsy.

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.