A tiered strategy for investigating status epilepticus

Abstract

In status epilepticus the imperative to start anti-seizure therapy, initially subjugates the need to investigate the cause. Once treatment is initiated this balance shifts in favour of identifying: the causes and consequences of the seizure; the factors that predetermined the occurrence of status epilepticus; and finally the prognosis of this acute episode. Just as there are multiple causes of seizures and epilepsy, there are a vast number of causes of status epilepticus. We discuss the more common and the more important to identify as they may dictate a change in therapy or a certain prognosis.Acknowledging that the burden of epilepsy and status epilepticus is preferentially felt in lower and middle income countries, we have tried to rationalise the investigation of status epilepticus. Basic laboratory studies are necessary in all patients with status epilepticus as systemic complications can occur early and can involve every organ system. Aetiology is important, however the morbidity from treatment does not discriminate when treatment resistant status epilepticus is due to dissociative seizures.Seven percent of epilepsy hospitalisations are for status epilepticus and epilepsy is a prior diagnosis half the time; awareness of prior history is invaluable. EEG is critical for diagnosis in the anaesthetised patient or those in non-convulsive status epilepticus. There is poor correlation of EEG with aetiology except in rare circumstances. Currently quantitative EEG methods should best be viewed as screening tool to reduce EEG reviewing time. MRI is clearly superior for identifying cytotoxic change and the networks that are or were involved in the episode of status epilepticus. Sequential imaging changes may give an estimate of recovery but there is insufficient detail to use MRI as a prognostication tool.We suggest the following model: 1) immediate investigations; 2) investigations targeted by the clinical scenario; 3) investigations targeted following results from bloods, imaging or EEG; 4) investigations targeted for rarer causes and super-refractory status epilepticus. First-line laboratory investigationsBasic laboratory studies are necessary in all SE patients as systemic complications can occur early and can involve every organ system. Laboratory data can aid early treatment strategies [6] and tools that

Valproic acid as adjuvant treatment for convulsive status epilepticus: a randomised clinical trial

“…Maintenance ASM was decided by the local physician, independently of the trial protocol. In both groups, patients received standardised care, including control of secondary brain injuries (temperature, mean blood pressure, blood glucose, sodium levels, PaO 2 and PaCO 2 regulation), aetiological investigations, and neurological monitoring [ 22 ] .…”

“…Not applicable. 22 General Intensive Care Unit, APHP, Raymond Poincaré Hospital, University of Versailles Saint-Quentin en Yvelines, Garches, France. 23 Intensive Care Unit Centre Hospitalier Intercommunal, Poissy/Saint-Germain-en-Laye, France.…”

Valproic Acid as Adjuvant Treatment for Convulsive Status Epilepticus: a Randomised Clinical Trial

“…This clause allowed for the inclusion primarily of de novo established GCSE (Supplementary appendix). In both groups, patients received standardised care, including control of secondary brain injuries (temperature, mean blood pressure, blood glucose, sodium levels, PaO 2 and PaCO 2 regulation), aetiological investigations, and neurological monitoring (21).…”

Status epilepticus special edition

“…While treating status epilepticus, and even once the patient is stabilised, multiple investigations will be initiated. Craig and colleagues explore a strategy that tries to rationalise an approach to the tests that could be considered to determine both the cause and the consequences of prolonged seizure activity [8]. Dividing these investigations into immediate tests for all and then more targeted testing dependent on clinical scenario and evolution allows for an easier handle on the necessary investigations.…”