Status Epilepticus Severity Score Research Articles

Status epilepticus in Auckland, New Zealand: Treatment patterns and determinants of outcome in a prospective population-based cohort.

Determination of the real-world performance of a health care system in the treatment of status epilepticus (SE). Prospective, multicenter population-based study of SE in Auckland, New Zealand (NZ) over 1 year, with data recorded in the EpiNet database. Focus on treatment patterns and determinants of SE duration and 30-day mortality. The incidence, etiology, ethnic discrepancies, and seizure characteristics of this cohort have been published previously. A total of 365 patients were included in this treatment cohort; 326 patients (89.3%) were brought to hospital because of SE, whereas 39 patients (10.7%) developed SE during a hospital admission for another reason. Overall, 190 (52.1%) had a known history of epilepsy and 254 (70.0%) presented with SE with prominent motor activity. The mean Status Epilepticus Severity Score (STESS) was 2.15 and the mean SE duration of all patients was 44 min. SE self-terminated without any treatment in 84 patients (22.7%). Earlier administration of appropriately dosed benzodiazepine in the pre-hospital setting was a major determinant of SE duration. Univariate analysis demonstrated that mortality was significantly higher in older patients, patients with longer durations of SE, higher STESS, and patients who developed SE in hospital, but these did not maintain significance with multivariate analysis. There was no difference in the performance of the health care system in the treatment of SE across ethnic groups. When SE was defined as 10 continuous minutes of seizure, overall mortality was lower than expected and many patients had self-limited presentations for which no treatment was required. Although there were disparities in the incidence of SE across ethnic groups there was no difference in treatment or outcome. The finding highlights the benefit of a health care system designed to deliver universal health care.

Evaluation of prognostic scores for status epilepticus in the neurology ICU: A retrospective study

ObjectiveStatus epilepticus (SE) in the neurology intensive care unit (ICU) is associated with significant morbidity. We aimed to evaluate the utility of existing prognostic scores, namely the Status Epilepticus Severity Score (STESS), Epidemiology Based Mortality Score in Status Epilepticus (EMSE)-EACE and Encephalitis-Nonconvulsive Status Epilepticus-Diazepam Resistance-Image Abnormalities-Tracheal Intubation (END-IT), among SE patients in the neurology ICU. MethodsNeurology ICU patients with SE requiring continuous electroencephalography (cEEG) monitoring over a 10 year period were included. The STESS, EMSE-EACE and END-IT scores were applied retrospectively. Receiver operating characteristic (ROC) analysis was performed to assess the discriminatory value of the scores for inpatient mortality and functional decline, as measured by increase in the modified Rankin Scale (mRS) on discharge. ResultsEighty-five patients were included in the study, of which 71 (83.5%) had refractory SE. Inpatient mortality was 36.5%. Sixty – seven (78.8%) of patients suffered functional decline, with a median mRS of 5 upon hospital discharge.The AUCs of the STESS, EMSE-EACE and END-IT scores associated with inpatient mortality were 0.723 (95% CI 0.613–0.833), 0.722 (95% CI 0.609–0.834) and 0.560 (95% CI 0.436–0.684) respectively. The AUCs of the STESS, EMSE-EACE and END-IT scores associated with functional decline were 0.604 (95% CI 0.468–0.741), 0.596 (95% CI 0.439–0.754) and 0.477 (95% CI 0.331–0.623). SignificanceSE was associated with high mortality and morbidity in this cohort of neurology ICU patients requiring cEEG monitoring. The STESS and EMSE-EACE scores had acceptable AUCs for prediction of inpatient mortality. However, the STESS, EMSE-EACE and END-IT were poorly-correlated with discharge functional outcomes. Further refinements of the scores may be necessary among neurology ICU patients for predicting discharge functional outcomes.

Correlation between inflammatory markers over time and disease severity in status epilepticus: a preliminary study.

Convulsive status epilepticus (CSE) is a major subtype of status epilepticus that is known to be closely associated with systemic inflammation. Some important inflammatory biomarkers of this disorder include the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), systemic immune inflammation index (SII), and pan-immune inflammation value (PIV). This study aimed to determine the NLR, PLR, MLR, SII, and PIV levels before and after treatment in adult patients with CSE and investigated the relationship of these parameters with disease severity. This retrospective study analyzed data from 103 adult patients with CSE and 103 healthy controls. The neutrophil, monocyte, platelet, and lymphocyte counts, as well as the NLR, PLR, MLR, SII, and PIV, were compared in adult patients with CSE during acute seizures (within 2 h of admission) and after treatment relief (1-2 weeks of complete seizure control). Furthermore, multivariate linear regression analysis investigated the relationship between NLR, PLR, MLR, SII, and PIV with the Status Epilepticus Severity Score (STESS). The data revealed significant differences (p < 0.05) in neutrophils, monocytes, lymphocytes, NLR, PLR, MLR, SII, and PIV between adult patients with CSE during acute seizures and after treatment relief. The average neutrophil count was high during acute seizures in the patient group and decreased after remission. In contrast, the average lymphocyte count was lower after remission (p < 0.05). Furthermore, significant differences (p < 0.05) were observed in monocytes, lymphocytes, platelets, NLR, PLR, MLR, and PIV levels between adult patients with CSE after remission and the healthy control group. Multivariate linear regression analysis showed no significant correlation between NLR, PLR, MLR, SII, and PIV with STESS. The results of this study indicated that adult patients with CSE experienced a transient systemic inflammatory response during acute seizures, which gradually returned to baseline levels after remission. However, there was a lack of robust clinical evidence correlating the severity of adult CSE and systemic inflammatory response.

Correlation between serum galanin and neuron-specific enolase levels with EEG abnormalities in pediatric convulsive status epilepticus and the efficacy of triple drug therapy.

This study aimed to investigate the association between serum galanin (GAL) and neuron-specific enolase (NSE) levels in children with convulsive status epilepticus (CSE) and their relationship with abnormal electroencephalogram (EEG) patterns. Additionally, the study assessed the effectiveness of a combination therapy involving midazolam, diazepam, and phenobarbital in treating CSE. The research involved 100 children diagnosed with CSE and included a control group of 50 healthy children. Serum GAL and NSE levels were measured, and EEGs were analyzed for abnormalities in the CSE group. Comparisons were made between the healthy control group and the CSE group, particularly within the first 24 hours after persistent seizures. The severity of EEG abnormalities was correlated with GAL and NSE levels. The treatment consisted of an observation group that received the triple therapy of midazolam, diazepam, and phenobarbital, while a control group received diazepam and phenobarbital. Clinical efficacy, symptom improvement, Status Epilepticus Severity Score (STESS), and adverse reactions were evaluated. The results indicated elevated levels of GAL and NSE in the CSE group, with higher levels noted within 24 hours after persistent seizures. Furthermore, a positive correlation was observed between the severity of EEG abnormalities and GAL and NSE levels. The group receiving the triple therapy demonstrated superior efficacy, faster resolution of seizures and fever, reduced STESS scores, and fewer adverse reactions than the control group. In conclusion, this study highlights the positive correlation between serum GAL and NSE levels and the severity of EEG abnormalities in pediatric CSE. The triple therapy approach is effective in treating CSE, leading to improved clinical symptoms, reduced brain damage, and enhanced safety. The study concludes that serum GAL and NSE levels in children with convulsive status epilepticus are positively correlated with the degree of EEG abnormalities. The combination therapy involving midazolam, diazepam, and phenobarbital is effective in treating children with convulsive status epilepticus, significantly improving clinical symptoms, reducing brain damage, and ensuring safety.

Impact of frailty, biomarkers and basic biochemical parameters on outcomes of comatose patients in status epilepticus: a single-center prospective pilot study

BackgroundStatus epilepticus (SE) is a severe acute condition in neurocritical care with high mortality. Searching for risk factors affecting the prognosis in SE remains a significant issue. The primary study’s aim was to test the predictive values of the Clinical Frailty Scale (CFS) and the Modified 11-item Frailty Index (mFI-11), the biomarkers and basic biochemical parameters collected at ICU on the Glasgow Outcome Scale (GOS) assessed at hospital discharge (hosp), and three months later (3 M), in comatose patients with SE. The secondary aim was to focus on the association between the patient’s state at admission and the duration of mechanical ventilation, the ICU, and hospital stay.MethodsIn two years single-centre prospective pilot study enrolling 30 adult neurocritical care patients with SE classified as Convulsive SE, A.1 category according to the International League Against Epilepsy (ILAE) Task Force without an-/hypoxic encephalopathy, we evaluated predictive powers of CFS, mFI-11, admission Status Epilepticus Severity Score (STESS), serum protein S100, serum Troponin T and basic biochemical parameters on prognosticating GOS using univariate linear regression, logistic regression and Receiver Operating Characteristic (ROC) analysis.ResultsOur study included 60% males, with a mean age of 57 ± 16 years (44–68) and a mean BMI of 27 ± 5.6. We found CFS, mFI-11, STESS, and age statistically associated with GOS at hospital discharge and three months later. Among the biomarkers, serum troponin T level affected GOS hosp (p = 0.027). Serum C-reactive protein significance in prognosticating GOS was found by logistic regression (hosp p = 0.008; 3 M p = 0.004), and serum calcium by linear regression (hosp p = 0.028; 3 M p = 0.015). In relation to secondary outcomes, we found associations between the length of hospital stay and each of the following: age (p = 0.03), STESS (p = 0.009), and serum troponin T (p = 0.029) parameters.ConclusionsThis pilot study found promising predictive powers of two frailty scores, namely CFS and mFI-11, which were comparable to age and STESS predictors regarding the GOS at hospital discharge and three months later in ICU patients with SE. Among biomarkers and biochemical parameters, only serum troponin T level affected GOS at hospital discharge.

Assessing the Role of Status Epilepticus Severity Score in Predicting Outcome in Patients with Convulsive Status Epilepticus: A Cross-sectional Study

Introduction: Status Epilepticus (SE) is a neurological emergency that necessitates prompt intervention and treatment. The Status Epilepticus Severity Score (STESS) is a clinical tool developed to assess the mortality rate among patients diagnosed with Convulsive Status Epilepticus (CSE). Aim: To assess the accuracy of STESS in predicting the outcome of CSE. Materials and Methods: This cross-sectional study was conducted at Jawaharlal Nehru Medical College, Aligarh, Uttar Pradesh, India from December 2020 to November 2022, involving 110 patients aged more than 15 years presenting with CSE lasting more than five minutes. Age, gender, seizure type, history of epilepsy, Glasgow Coma Scale (GCS), and STESS at presentation were assessed and associated with the outcome. Results: Among the 110 patients included in the study, there was a higher number of male patients compared to female patients. The mean age of the patients was 35.77±17.9 years. The most prevalent type of seizure observed was generalised tonic-clonic seizures, accounting for 65.45% of the cases, 9.09% of the patients expired, 89% of the patients had a STESS below 2. The Receiver-Operating Characteristic (ROC) curve for STESS at presentation to predict in-hospital mortality had an area under the curve of 0.859, 95% Confidence Interval (CI) from 0.780 to 0.918, and p-value&lt;0.0001. It had a sensitivity of 70%, specificity of 95%, Positive Predictive Value (PPV) of 58.3%, Negative Predictive Value (NPV) of 96.9%, and diagnostic accuracy of 92.73%. Conclusion: Assessment of in-hospital mortality at the onset of SE was reliably determined by STESS and is an useful clinical score. To fully comprehend the reasons for the high overall mortality rate following SE and potential prognostic factors, more research is required.

External validation of newly modified status epilepticus severity score for predicting mortality in patients with status epilepticus in a regional hospital in Taiwan

PurposeTo evaluate and compare the performance of the status epilepticus severity score (STESS), modified STESS (mSTESS), and the newly modified STESS (nSTESS) in predicting mortality in patients with status epilepticus (SE) at a regional hospital in Taiwan. MethodsData were collected from 81 patients with SE, aged over 18 years at a regional medical hospital in Tainan from January 2012 to December 2022. SE were treated following the standard treatment protocol. Exclusion criteria included missing data, lack of adherence to the treatment protocol, and transfer to tertiary medical centers. Outcome measures included differences in characteristics between survivor and non-survivor groups, the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of STESS, nSTESS, mSTESS. Receiver operating characteristic (ROC) curve and area under curve (AUC) of scales were generated. Calibration with Hosmer–Lemeshow test was built as well. ResultsThe study found significant differences in seizure types (p = 0.015) and undergoing intubation (p = 0.017) between survivor and non-survivor groups. No significant differences were observed in age, gender, underlying diseases, or the category of antiseizure medications (ASMs) usage. The ROC curve for STESS, nSTESS and mSTESS showed similar predictive values of around 0.75, indicating moderate performance of prediction. The Hosmer-Lemeshow test showed no significant difference between real-world predictions and these three clinical scales. In the aspect of accuracy, sensitivity and specificity, nSTESS has similar overall accuracy as in STESS and mSTESS. ConclusionThis external validation study demonstrates the moderate performance of nSTESS in predicting mortality in SE patients at a regional hospital in Taiwan. These outcomes underscore the practical utility of these scales in clinical practice, with nSTESS demonstrating accuracy on par with the others. Further validation in larger, multicenter cohorts and other healthcare settings is necessary to fully confirm its predictive value.

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.

Comparison of the status epilepticus severity score and the epidemiology-based mortality score in predicting 30-day mortality and status epilepticus cessation

ObjectiveTo evaluate the role of the Status Epilepticus Severity Score (STESS) and the Epidemiology-based Mortality score (EMSE) in predicting 30-day mortality and SE (Status epilepticus) cessation, and their prognostic performance in subgroups of patients with specific characteristics. MethodsWe reviewed consecutive episodes of SE occurring in patients aged ≥14 years at Baggiovara Civil Hospital (Modena, Italy) from 2013 to 2021. We evaluated the predictive accuracy of EMSE and STESS for 30-day mortality and SE cessation through stepwise regression binary logistic models adjusted for possible univariate clinical confounders. ResultsSeven hundred and eleven patients were enrolled. The mean value of STESS was 3.2 (SD 1.7) and of EMSE was 80.1 (SD 52.6). Within 30 days of the onset of SE, 28.4% of patients (202/711) died. EMSE had higher discriminatory ability for 30-day mortality compared with STESS (AUROC: 0.799; 95% CI: 0.765–0.832 versus 0.727; 95% CI: 0.686–0.766, respectively; p = 0.014). SE cessation within 1 h for convulsive SE and within 12 h for nonconvulsive SE was achieved in 35.3% (251/711) of patients. No significant difference was found between EMSE and STESS in discriminatory ability for SE cessation (AUROC: 0.516; 95% CI: 0.488–0.561 and 0.518; 95% CI: 0.473–0.563, respectively; p = 0.929). EMSE was superior to STESS in predicting 30-day mortality in patients with specific characteristics. No difference between the two scores was found in predicting SE cessation in subgroups of patients with specific characteristics. ConclusionsEMSE seems superior to STESS in predicting 30-day mortality, particularly in specific patient categories. Conversely, there is no difference in the ability of these scores in predicting SE cessation, which is overall rather low.

Nonconvulsive status epilepticus in neurocritical care: A critical reappraisal of outcome prediction scores.

Nonconvulsive status epilepticus (NCSE) is a frequent condition in the neurocritical care unit (NCCU) patient population, with high morbidity and mortality. We aimed to assess the validity of available outcome prediction scores for prognostication in an NCCU patient population in relation to their admission reason (NCSE vs. non-NCSE related). All 196 consecutive patients diagnosed with NCSE during the NCCU stay between January 2010 and December 2020 were included. Demographics, Simplified Acute Physiology Score II (SAPS II), NCSE characteristics, and in-hospital and 3-month outcome were extracted from the electronic charts. Status Epilepticus Severity Score (STESS), Epidemiology-Based Mortality Score in Status Epilepticus (EMSE), and encephalitis, NCSE, diazepam resistance, imaging features, and tracheal intubation score (END-IT) were evaluated as previously described. Univariable and multivariable analysis and comparison of sensitivity/specificity/positive and negative predictive values/accuracy were performed. A total of 30.1% died during the hospital stay, and 63.5% of survivors did not achieve favorable outcome at 3 months after onset of NCSE. Patients admitted primarily due to NCSE had longer NCSE duration and were more likely to be intubated at diagnosis. The receiver operating characteristic (ROC) for SAPS II, EMSE, and STESS when predicting mortality was between .683 and .762. The ROC for SAPS II, EMSE, STESS, and END-IT when predicting 3-month outcome was between .649 and .710. The accuracy in predicting mortality/outcome was low, when considering both proposed cutoffs and optimized cutoffs (estimated using the Youden Index) as well as when adjusting for admission reason. The scores EMSE, STESS, and END-IT perform poorly when predicting outcome of patients with NCSE in an NCCU environment. They should be interpreted cautiously and only in conjunction with other clinical data in this particular patient group.

Clonazepam Loading Dose in Status Epilepticus: Is More Always Better?

Benzodiazepines are the first treatment line in status epilepticus (SE). Despite their well-established benefit, benzodiazepines are frequently underdosed with potential detrimental consequences. In some European countries, clonazepam (CLZ) is commonly used as the first line treatment. The aim of this study was to explore the correlation between CLZ loading doses and SE outcome. This study included a retrospective analysis of a prospective registry in Lausanne, Switzerland (CHUV Lausanne University Hospital), including all SE episodes treated between February 2016 and February 2021. Only adults (>16 years old) were included with CLZ used as the first treatment line. Post-anoxic SE were excluded because of significant differences in physiopathology and prognosis. Patient characteristics, SE features, the validated SE severity score (STESS), and treatment characteristics were prospectively recorded. We considered loading doses of 0.015 mg/kg or higher (following commonly recommended loading doses)as high doses. We analyzed outcome in terms of number of treatment lines after the CLZ, proportion of refractory episodes, intubation for airways protection, intubation for SE treatment, and mortality. We performed univariable analyses to investigate the association between loading doses and clinical response. A multivariable stepwise backward binary logistic regression was applied for adjusting for potential confounders. Multivariable linear regression was similarly used to analyze CLZ dose as a continuous variable. We collected 251 SE episodes in 225 adult patients. Median CLZ loading dose was 0.010 mg/kg. CLZ high doses were used in 21.9% of SE episodes (in 43.8% for >80% of the high dose). Thirteen percent of patients with SE were intubated for airways control, while intubation was needed in12.7% for SE treatment. High CLZ loading doses were independently associated with younger age (median 62 versus 68 years old, p = 0.002), lesser weight (65kg versus 75kg, p = 0.001) and more frequent intubation for airways protection (23% vs 11%, p = 0.013), but differing CLZ dose was not associated with any outcome parameter. CLZ high doses were more frequently used for SE treatment in younger patients with healthy weight and were more often associated with intubation for airways protection, probably as an adverse event. Varying CLZ dose did not alter outcome in SE, raising the possibility that commonly recommended doses are above what is needed, at least in some patients. Our results suggest that CLZ doses in SE may be individualized depending on the clinical setting.

Early timing of anesthesia in status epilepticus is associated with complete recovery: A 7-year retrospective two-center study.

This study was undertaken to investigate the efficacy, tolerability, and outcome of different timing of anesthesia in adult patients with status epilepticus (SE). Patients with anesthesia for SE from 2015 to 2021 at two Swiss academic medical centers were categorized as anesthetized as recommended third-line treatment, earlier (as first- or second-line treatment), and delayed (later as third-line treatment). Associations between timing of anesthesia and in-hospital outcomes were estimated by logistic regression. Of 762 patients, 246 received anesthesia; 21% were anesthetized as recommended, 55% earlier, and 24% delayed. Propofol was preferably used for earlier (86% vs. 55.5% for recommended/delayed anesthesia) and midazolam for later anesthesia (17.2% vs. 15.9% for earlier anesthesia). Earlier anesthesia was statistically significantly associated with fewer infections (17% vs. 32.7%), shorter median SE duration (.5 vs. 1.5 days), and more returns to premorbid neurologic function (52.9% vs. 35.5%). Multivariable analyses revealed decreasing odds for return to premorbid function with every additional nonanesthetic antiseizure medication given prior to anesthesia (odds ratio [OR] = .71, 95% confidence interval [CI] = .53-.94) independent of confounders. Subgroup analyses revealed decreased odds for return to premorbid function with increasing delay of anesthesia independent of the Status Epilepticus Severity Score (STESS; STESS = 1-2: OR = .45, 95% CI = .27-.74; STESS > 2: OR = .53, 95% CI = .34-.85), especially in patients without potentially fatal etiology (OR = .5, 95% CI = .35-.73) and in patients experiencing motor symptoms (OR = .67, 95% CI = .48-.93). In this SE cohort, anesthetics were administered as recommended third-line therapy in only every fifth patient and earlier in every second. Increasing delay of anesthesia was associated with decreased odds for return to premorbid function, especially in patients with motor symptoms and no potentially fatal etiology.

Association Between Induced Burst Suppression and Clinical Outcomes in Patients With Refractory Status Epilepticus: A 9-Year Cohort Study.

To investigate the frequency of induced EEG burst suppression pattern during continuous IV anesthesia (IVAD) and associated outcomes in adult patients treated for refractory status epilepticus (RSE). Patients with RSE treated with anesthetics at a Swiss academic care center from 2011 to 2019 were included. Clinical data and semiquantitative EEG analyses were assessed. Burst suppression was categorized as incomplete burst suppression (with ≥20% and <50% suppression proportion) or complete burst suppression (with ≥50% suppression proportion). The frequency of induced burst suppression and association of burst suppression with outcomes (persistent seizure termination, in-hospital survival, and return to premorbid neurologic function) were the endpoints. We identified 147 patients with RSE treated with IVAD. Among 102 patients without cerebral anoxia, incomplete burst suppression was achieved in 14 (14%) with a median of 23 hours (interquartile range [IQR] 1-29) and complete burst suppression was achieved in 21 (21%) with a median of 51 hours (IQR 16-104). Age, Charlson comorbidity index, RSE with motor symptoms, the Status Epilepticus Severity Score and arterial hypotension requiring vasopressors were identified as potential confounders in univariable comparisons between patients with and without any burst suppression. Multivariable analyses revealed no associations between any burst suppression and the predefined endpoints. However, among 45 patients with cerebral anoxia, induced burst suppression was associated with persistent seizure termination (72% without vs 29% with burst suppression, p = 0.004) and survival (50% vs 14% p = 0.005). In adult patients with RSE treated with IVAD, burst suppression with ≥50% suppression proportion was achieved in every fifth patient and not associated with persistent seizure termination, in-hospital survival, or return to premorbid neurologic function.

Post-Stroke Status Epilepticus: Time of Occurrence May Be the Difference?

(1) Background: Stroke is one of the most frequent causes of status epilepticus (SE) in adults. Patients with stroke and SE have poorer prognosis than those with stroke alone. We described characteristics and prognosis of early- and late-onset post-stroke SE (PSSE). (2) Methods: We retrospectively analyzed consecutive stroke patients who experienced a first SE between August 2012 and April 2021, comparing clinical characteristics, stroke, and SE features between early- versus late-onset SE in relation to patients' outcome. (3) Results: Forty stroke patients experienced PSSE. Fourteen developed an early-onset SE (35%) and twenty-six a late-onset SE (65%). Early-onset SE patients had a slightly higher NIHSS score at admission (6.9 vs. 6.0; p = 0.05). Early-onset SE was more severe than late-onset, according to STESS (Status Epilepticus Severity Score) (3.5 vs. 2.8; p = 0.05) and EMSE (Epidemiology-based Mortality score in Status Epilepticus) score (97.0 vs. 69.5; p = 0.04); furthermore, it had a significant impact on disability at 3-month and 1-year follow-up (p = 0.03 and p = 0.02). SE recurrence and seizures relapse were observed mainly in cases of late-onset SE. (4) Conclusions: Early-onset SE seems to be associated with higher disability in short- and long-term follow-up as possible expression of severe acute brain damage.

Severity scores for status epilepticus in the ICU: systemic illness also matters

BackgroundCurrent prognostic scores for status epilepticus (SE) may not be adequate for patients in ICU who usually have more severe systemic conditions or more refractory episodes of SE. We aimed to compare the prognostic performance of two SE scores, Status Epilepticus Severity Score (STESS) and Epidemiology-Based Mortality Score in Status Epilepticus (EMSE) score, with four systemic severity scores, Acute Physiology and Chronic Health Evaluation 2 (APACHE-2), Simplified Acute Physiology Score 2 (SAPS-2), Sequential Organ Failure Assessment (SOFA) score, and Inflammation, Nutrition, Consciousness, Neurologic function and Systemic condition (INCNS) score in critically ill patients with SE.MethodsThis retrospective observational study of a prospectively identified SE cohort was conducted in the ICU at a tertiary-care center. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value, negative predictive value, accuracy, and associations with outcomes of STESS, EMSE, INCNS, APACHE-2, SAPS-2, and SOFA score for the prediction of in-hospital mortality and no return to baseline condition were assessed.ResultsBetween January 2015 and December 2020, 166 patients with SE in ICU were included in the study. In predicting in-hospital death, APACHE-2 (0.72), SAPS-2 (0.73), and SOFA score (0.71) had higher AUCs than STESS (0.58) and EMSE (0.69). In predicting no return to baseline condition, the AUC of APACHE-2 (0.75) was the highest, and the AUC of INCNS (0.55) was the lowest. When the specificity approached 90%, the sensitivity values of these scores were not quite acceptable (< 40%). Neither SE scores nor systemic severity scores had desirable prognostic power. In the multivariate logistic regression analyses, the best combinations of scores always included at least one or more systemic severity scores.ConclusionsSTESS and EMSE were insufficient in outcome prediction for SE patients in ICU, and EMSE was marginally better than STESS. Systemic illness matters in ICU patients with SE, and SE scores should be modified to achieve better accuracy in this severely ill population. This study mostly refers to severely ill patients in the ICU.Graphical abstract

Long-term outcome of convulsive status epilepticus: a 10-year follow-up

This study aimed to determine the mortality, causes of death and factors affecting the outcome of convulsive status epilepticus (CSE) at 10 years. This retrospective study consisted of 62 consecutive adult patients diagnosed with CSE at the Helsinki University Hospital (HUS) emergency department during 2002-2003. Patients were followed for up to 10 years or up to the time of death. Data on patient demographics, CSE characteristics, treatment, complications, and outcome from the time of CSE were collected. The Official Statistics of Finland provided the information on mortality and causes of death. Survival analysis was conducted using Cox proportional hazards regression analysis. In-hospital mortality was 8.1%, and mortality was 25.8% at one year, 51.6% at five years and 64.5% at 10 years. Estimated standardized mortality ratio (SMR) was 5.3 and the deceased patients lost 20.9 potential years of life, on average. The leading causes of death were disorders of the brain or the circulatory system, epilepsy-related conditions or intracranial tumours. The univariable survival analysis demonstrated that age ≥65 (HR=2.8, p=0.001), Charlson Comorbidity Index (CCI)>0 (CCI=1-3: HR=3.0, p=0.009; CCI>3: HR=8.4, p<0.001), Status Epilepticus Severity Score (STESS)>4 (HR=5.3, p<0.001) and Epidemiology-Based Mortality Score (EMSE-EAC)>15 (HR=2.2, p=0.036) were risk factors and a Glasgow outcome scale (GOS) of 5 at discharge (HR=0.14, p=0.025) was a protective factor for survival. The multivariable analysis established STESS>4 (HR=5.0, p=0.002) and CCI>0 (CCI=1-3: HR=2.9, p=0.015;CCI>3: HR=6.3, p=0.006) as independent risk factors and GOS>3 (time-dependent) (GOS=4: HR=0.33, p=0.048;GOS=5: HR=0.13, p=0.019) as a protective factor for survival. The rate of long-term mortality and number of potential years of life lost were high. Factors demonstrative of the overall situation of the patients, such as comorbidities, functional state after CSE and age, were significant predictors for long-term outcome.

Prognostic scores in status epilepticus: A systematic review and meta-analysis.

The performance of prognostic scores of status epilepticus (SE) has been reported in very heterogeneous cohorts. We aimed to provide a summary of the available evidence on their respective performance. PubMed and EMBASE were searched for relevant articles. Studies were reviewed for eligibility for meta-analysis of the area under the receiver-operating characteristic curve (AUC) and for meta-analysis of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in predicting in-hospital mortality with scores in which at least two external evaluations had been published. This study was registered with PROSPERO (international prospective register of systematic reviews) (CRD42022325766). Study quality was assessed using Prediction model Risk Of Bias ASsessment Tool (PROBAST). In the meta-analysis of AUC, 21 studies were pooled for STESS (Status Epilepticus Severity Score), five for EMSE-EAC (Epidemiology-based Mortality Score in Status Epilepticus - Etiology, Age, level of Consciousness), five for EMSE-EACE (EMSE - Etiology, Age, level of Consciousness, EEG), and two for ENDIT (Encephalitis, nonconvulsive status epilepticus, Diazepam resistance, Imaging abnormalities, Tracheal intubation). The pooled AUC of STESS, EMSE-EAC, EMSE-EACE, and ENDIT was 0.74 (95% CI: 0.71-0.78), 0.68 (95% CI 0.63-0.72), 0.77 (95% CI: 0.72-0.81), and 0.78 (95% CI: 0.70-0.87), respectively. The pooled sensitivity of STESS-3, STESS-4, EMSE-EACE-64, and ENDIT-4 was 0.83 (95% CI: 0.80-0.86), 0.60 (95% CI: 0.55-0.65), 0.76 (95% CI: 0.67-0.83), and 0.70 (95% CI: 0.55-0.82), respectively. Their pooled specificity was 0.50 (95% CI: 0.48-0.52), 0.74 (95% CI: 0.72-0.76), 0.63 (95% CI: 0.59-0.67), and 0.65 (95% CI: 0.61-0.70), respectively. Their pooled PPV was 0.27 (95% CI: 0.24-0.30), 0.35 (95% CI: 0.29-0.41), 0.33 (95% CI: 0.24-0.43), and 0.20 (95% CI: 0.13-0.27). Their pooled NPV was 0.94 (95% CI: 0.93-0.96), 0.90 (95% CI: 0.89-0.92), 0.89 (95% CI: 0.80-0.98), and 0.95 (95% CI: 0.92-0.98). Variations in performance were observed in patients' subgroups, such as critically ill patients and refractory cases. Investigated scores only have acceptable AUC, sensitivity, and specificity for predicting in-hospital mortality, with the EMSE-EAC having a lower discriminative power. STESS-3 has the highest sensitivity, and STESS-4 the highest specificity, but neither combines acceptable sensitivity and specificity. All these scores had high NPV but very low PPV. Caution should be exercised in their clinical use. Further studies are required to develop more accurate scores.

Retrospective External Validation of the Status Epilepticus Severity Score (STESS) to Predict In-hospital Mortality in Adults with Nonhypoxic Status Epilepticus: A Machine Learning Analysis.

The objective of this study was to validate the value of the Status Epilepticus Severity Score (STESS) in the prediction of the risk of in-hospital mortality in patients with nonhypoxic status epilepticus (SE) using a machine learning analysis. We included consecutive patients with nonhypoxic SE (aged ≥ 16years) admitted from 2013 to 2021 at the Modena Academic Hospital. A decision tree analysis was performed using in-hospital mortality as a dependent variable and the STESS predictors as input variables. We evaluated the accuracy of STESS in predicting in-hospital mortality using the area under the receiver operating characteristic curve (AUROC) with 95% confidence interval (CI). Among 629 patients with SE, the in-hospital mortality rate was 23.4% (147 of 629). The median STESS in the entire cohort was 2.9 (SD 1.6); it was lower in surviving compared with deceased patients (2.7, SD 1.5 versus 3.9, SD 1.6; p < 0.001). Of deceased patients, 82.3% (121 of 147) had scores of 3-6, whereas 17.7% (26 of 147) had scores of 0-2 (p < 0.001). STESS was accurate in predicting mortality, with an AUROC of 0.688 (95% CI 0.641-0.734) only slightly reduced after bootstrap resampling. The most significant predictor was the seizure type, followed by age and level of consciousness at SE onset. Nonconvulsive SE in coma and age ≥ 65years predicted a higher risk of mortality, whereas generalized convulsive SE and age < 65years were associated with a lower risk of death. The decision tree analysis using STESS variables correctly classified 90% of survivors and 34% of nonsurvivors after the SE, with an overall risk of error of 23.1%. This validation study using a machine learning system showed that STESS is a valuable prognostic tool. The score appears particularly accurate and effective in identifying patients who are alive at discharge (high negative predictive value), whereas it has a lower predictive value for in-hospital mortality.

Pediatric Status Epilepticus Severity Score (STEPSS): Predictive Performance of Functional Outcomes: A Prospective Single-Center Study.

Objective: To prospectively investigate the predictive value of the modified Status Epilepticus Severity Score (STESS) for pediatric use (STEPSS) regarding unfavorable outcomes in the short term. Methods: Patients diagnosed as status epilepticus in the emergency department between January 2019 and June 2021 at a tertiary center of the University of Health Sciences, Dr. Behcet Uz Children's Hospital, were included in the study. The patients were followed up in the emergency department, neurology clinic, and pediatric intensive care unit until discharge. Demographic and clinical characteristics, STEPSS, and Pediatric Overall Performance Category Scale (POPC) scores were calculated. We defined a Pediatric Overall Performance Category Scale score ≥3 as an unfavorable outcome. We compared the effect of STEPSS on unfavorable outcomes and mortality. Results: 124 children were included. The median age was 33 months (interquartile range 16.2-84.7). Seventy-two (58.1%) patients had acute symptomatic etiology. We found that the STEPSS score with the receiver operating characteristic curve (area under the curve = 0.917, P < .001) could predict unfavorable outcomes (Pediatric Overall Performance Category Scale score ≥3) in children with status epilepticus. The Youden index (0.76) showed that a STEPSS score >2 was the optimal cutoff point for an unfavorable outcome. We found STEPSS useful in predicting mortality (area under the curve = 0.853, P < .001). The Youden index (0.58) indicated that a STEPSS >2 was the optimal cutoff for mortality: sensitivity 0.90 (95% confidence interval [CI] 0.58-0.99), specificity 0.67 (95% CI 0.57-0.77), positive predictive value 0.21, negative predictive value 0.98, positive likelihood ratio 2.7, negative likelihood ratio 0.14. Conclusion: We determined that STEPSS can be predicted unfavorable outcomes and mortality. We think that STEPSS can be used as a useful clinical score with further studies and external validations.

Management of Refractory Status Epilepticus: An International Cohort Study (MORSE CODe) Analysis of Patients Managed in the ICU.

Status epilepticus that continues after the initial benzodiazepine and a second anticonvulsant medication is known as refractory status epilepticus (RSE). Management is highly variable because adequately powered clinical trials are missing. We aimed to determine whether propofol and midazolam were equally effective in controlling RSE in the intensive care unit, focusing on management in resource-limited settings. Patients with RSE treated with midazolam or propofol between January 2015 and December 2018 were retrospectively identified among 9 centers across 4 continents from upper-middle-income economies in Latin America and high-income economies in North America, Europe, and Asia. Demographics, Status Epilepticus Severity Score, etiology, treatment details, and discharge modified Rankin Scale (mRS) were collected. The primary outcome measure was good functional outcome defined as a mRS score of 0-2 at hospital discharge. Three hundred eighty-seven episodes of RSE (386 patients) were included, with 162 (42%) from upper-middle-income and 225 (58%) from high-income economies. Three hundred six (79%) had acute and 79 (21%) remote etiologies. Initial RSE management included midazolam in 266 (69%) and propofol in 121 episodes (31%). Seventy episodes (26%) that were initially treated with midazolam and 42 (35%) with propofol required the addition of a second anesthetic to treat RSE. Baseline characteristics and outcomes of patients treated with midazolam or propofol were similar. Breakthrough (odds ratio [OR] 1.6, 95% CI 1.3-2.0) and withdrawal seizures (OR 2.0, 95% CI 1.7-2.5) were associated with an increased number of days requiring continuous intravenous anticonvulsant medications (cIV-ACMs). Prolonged EEG monitoring was associated with fewer days of cIV-ACMs (1-24 hours OR 0.5, 95% CI 0.2-0.9, and &gt;24 hours OR 0.7, 95% CI 0.5-1.0; reference EEG &lt;1 hour). This association was seen in both, high-income and upper-middle-income economies, but was particularly prominent in high-income countries. One hundred ten patients (28%) were dead, and 80 (21%) had good functional outcomes at hospital discharge. Outcomes of patients with RSE managed in the intensive care unit with propofol or midazolam infusions are comparable. Prolonged EEG monitoring may allow physicians to decrease the duration of anesthetic infusions safely, but this will depend on the implementation of RSE management protocols. Goal-directed management approaches including EEG targets may hold promise for patients with RSE. This study provides Class III data that propofol and midazolam are equivalently efficacious for RSE.