Management of Status Epilepticus, Refractory Status Epilepticus, and Super-refractory Status Epilepticus

Abstract

PURPOSE OF REVIEW: Status epilepticus is a serious condition caused by disorders and diseases that affect the central nervous system. In status epilepticus, hypersynchronous epileptic activity lasts longer than the usual duration of isolated self-limited seizures (time t1), which causes neuronal damage or alteration of neuronal networks at a certain time point (time t2), depending on the type of and duration of status epilepticus. The successful management of status epilepticus includes both the early termination of seizure activity and the earliest possible identification of a causative etiology, which may require independent acute treatment. In nonconvulsive status epilepticus, patients present only with subtle clinical signs or even without any visible clinical manifestations. In these cases, EEG allows for the assessment of cerebral function and identification of patterns in need of urgent treatment.RECENT FINDINGS: In 2015, the International League Against Epilepsy proposed a new definition and classification of status epilepticus, encompassing four axes: symptomatology, etiology, EEG, and age. Various validation studies determined the practical usefulness of EEG criteria to identify nonconvulsive status epilepticus. The American Clinical Neurophysiology Society has incorporated these criteria into their most recent critical care EEG terminology in 2021. Etiology, age, symptomatology, and the metabolic demand associated with an increasing duration of status epilepticus are the most important determinants of prognosis. The consequences of status epilepticus can be visualized in vivo by MRI studies. SUMMARY: The current knowledge about status epilepticus allows for a more reliable diagnosis, earlier treatment, and improved cerebral imaging of its consequences. Outcome prediction is a soft tool for estimating the need for intensive care resources. UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE:Drs Trinka and Leitinger discuss the unlabeled/investigational use of antiseizure medications for the treatment of status epilepticus.

Epilepsy in cerebral amyloid angiopathy: an observational retrospective study of a large population

“…), and data on the presence and extension of slow and/or epileptic activity were gathered according to the American Clinical Neurophysiology Society's standardized critical care EEG terminology. 30 Other data collection included use of antiseizure medications (ASMs), presence and type of status epilepticus (SE), 31,32 and refractory epilepsy. 33…”

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

“…Patients were categorized into patients receiving anesthetics as recommended third‐line treatment, 2–4 patients treated with anesthetics earlier than third‐line (i.e., as first‐ or second‐line) treatment, and patients in whom anesthesia was delayed (i.e., as fourth‐ or fifth‐line treatment). Univariable comparisons of these three groups were performed by the Kruskal–Wallis test for continuous variables and by the χ 2 test or the Fisher exact test for categorical variables.…”

“…1 International treatment guidelines recommend antiseizure treatment starting with benzodiazepines as first-line medication, followed by second-line antiseizure medication, such as levetiracetam, valproic acid, or phenytoin. [2][3][4] When SE is refractory to first-and second-line antiseizure drugs, treatment escalation with the induction of an artificial coma by continuously administered intravenous anesthetic drugs is recommended for 24-48 h with the aim of terminating seizures. [2][3][4] Although, at first glance, these recommendations seem justified, high-quality studies regarding the efficacy and tolerability of anesthesia at different stages of SE are scarce 5 and the induction of artificial coma has been associated with adverse effects, [6][7][8][9][10] complications during the course of SE 10,11 and the postictal phase, 12 and unfavorable outcomes in some studies.…”

“…[2][3][4] When SE is refractory to first-and second-line antiseizure drugs, treatment escalation with the induction of an artificial coma by continuously administered intravenous anesthetic drugs is recommended for 24-48 h with the aim of terminating seizures. [2][3][4] Although, at first glance, these recommendations seem justified, high-quality studies regarding the efficacy and tolerability of anesthesia at different stages of SE are scarce 5 and the induction of artificial coma has been associated with adverse effects, [6][7][8][9][10] complications during the course of SE 10,11 and the postictal phase, 12 and unfavorable outcomes in some studies. 10,11,13,14 This comes along with a large proportion of patients with SE in whom neither treatment start (with underdosing of benzodiazepines) nor escalation [15][16][17] adheres to the guidelines.…”

“…Most patients with status epilepticus (SE) are treated in intensive care units (ICUs) due to the high case fatality rate 1 . International treatment guidelines recommend antiseizure treatment starting with benzodiazepines as first‐line medication, followed by second‐line antiseizure medication, such as levetiracetam, valproic acid, or phenytoin 2–4 . When SE is refractory to first‐ and second‐line antiseizure drugs, treatment escalation with the induction of an artificial coma by continuously administered intravenous anesthetic drugs is recommended for 24–48 h with the aim of terminating seizures 2–4 .…”