Association Between Induced Burst Suppression and Clinical Outcomes in Patients With Refractory Status Epilepticus

Abstract

Objective:To investigate the frequency of induced electroencephalographic (EEG) burst-suppression pattern during continuous intravenous anesthesia (IVAD) and associated outcomes in adult patients treated for refractory status epilepticus (RSE).Methods:Patients with RSE treated with anesthetics at a Swiss academic care center from 2011-2019 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 endpoints.Results: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, and the Status Epilepticus Severity Score (STESS) 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).Conclusions: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.

Case report: Febrile infection-related epilepsy syndrome in a 14-year-old girl with multiple organ failure and lethal outcome

“…Tapering of sedatives and antiepileptic medications resulted in the recurrence of seizure activity in our patient, requiring deep anesthesia with EEG burst suppression. Though prolonged burst suppression reduces cerebral oxygen metabolism in adults ( Liu et al, 2023 ), the long-term outcome seems favorable ( Fisch et al, 2023 ). However, drug-induced burst suppression often resolves seizure activity only temporarily in FIRES ( Fox et al, 2017 ).…”

Ketamine: Pro or antiepileptic agent? A systematic review

“…One concern about using ketamine in a clinical setting is that it does not lead to complete burst suppression, which might imply incomplete termination of seizure activity. A recent study by Fisch et al found that burst suppression (in RSE in general) is clinically infrequent and had little (or even no) benefit in improving outcomes or stopping seizures [ 54 ]. 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.…”

Efficacy and Safety of Eptinezumab in Patients With Chronic Migraine

“…We thank Dr. Sethi for his interest in our study. 1 Current guidelines suggest cessation of electrographic seizures, a burst suppression, or an isoelectric curve as EEG treatment goals for patients with nonanoxic refractory status epilepticus (RSE). One treatment is not preferred over the others.…”

“…I read with interest the study of Fisch et al and the accompanying editorial on association between induced burst suppression (BS) and treatment outcomes in patients with refractory status epilepticus (RSE). 1,2 In the current management of RSE, the goal is to suppress all clinical and electrographic seizures by achieving BS. The study highlights that EEG BS may not be the appropriate treatment target for all patients in RSE.…”