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Status Epilepticus

Status epilepticus is defined as a seizure of at least 30 minutes or repeated seizures without intervals of consciousness. It is always considered a medical emergency and brain damage may result.


Presentation

The 2 types of status epilepticus presents with different signs and symptoms. These include:

  • Convulsive status epilepticus is characterized by pattern of contractions accompanied by extraction of arms and the legs. In addition, myoclonus is also evident in comatose patients.
  • Non-convulsive status epilepticus, causes change in the level of consciousness of the affected individual for a longer duration. Such a type of status epilepticus is characterized by 2 states: development of partial seizures or complex partial seizures. Affected individuals suffer from episodes of prolonged duration stupor, periods of unresponsiveness and staring [8].
  • In addition, affected individuals would also experience difficulty in speaking, exhibit an unusual behavior pattern, irregular breathing, clenching of teeth, loss of control over bowel habits, development of muscle spasms and confusion.
Epilepsy
  • BACKGROUND: Focal status epilepticus and catastrophic epilepsy are not rare in infants. Epilepsy surgery can be safely done in selected infants to cure epilepsy.[ncbi.nlm.nih.gov]
  • This may rarely lead to refractory epilepsy and hippocampal sclerosis (HS). CASE DESCRIPTION: We report the first case of epilepsy surgery in a liver-transplanted patient with refractory temporal lobe epilepsy.[ncbi.nlm.nih.gov]
  • Children with epilepsy-related CSE scored higher than norms on all scales and children with non-epilepsy-related CSE scored higher than norms on the Strengths and Difficulties Questionnaire and the Autism Spectrum Screening Questionnaire.[ncbi.nlm.nih.gov]
  • Copyright 2018 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.[ncbi.nlm.nih.gov]
  • In this context, we present here an overview of hemispherectomy and related procedures, including peri-insular disconnective hemispherotomy, and we discuss the efficacy of surgery for challenging hemispheric epilepsies.[ncbi.nlm.nih.gov]
Fever
  • INTERPRETATION: Acute encephalopathy after status epilepticus is more prone to occur in patients with Dravet syndrome who had a high fever. The mortality rate is high in severe cases.[ncbi.nlm.nih.gov]
  • B349, viral infection, would include the fever and vomiting and are therefore not coded separately.[3mhisinsideangle.com]
  • CASE STUDY: We report a 13 years-old girl with negative history for neurological or autoimmune disease that developed at the sixth day of high fever a super-refractory status epilepticus.[ncbi.nlm.nih.gov]
  • In infants and children, the main cause of status epilepticus is an infection with a fever.[columbianeurology.org]
High Fever
  • INTERPRETATION: Acute encephalopathy after status epilepticus is more prone to occur in patients with Dravet syndrome who had a high fever. The mortality rate is high in severe cases.[ncbi.nlm.nih.gov]
  • CASE STUDY: We report a 13 years-old girl with negative history for neurological or autoimmune disease that developed at the sixth day of high fever a super-refractory status epilepticus.[ncbi.nlm.nih.gov]
  • Most cases of SE happen to children under age 15 who have seizures brought on by high fever, and adults over 40 (most often because of strokes).[webmd.com]
  • These include high fever, abnormal levels of sodium or blood sugar, and head injuries. If you have a condition called epilepsy , you may have seizures repeatedly.[columbianeurology.org]
Noncompliance
  • AEM) with which to load patients, as it is no longer a first-line AEM, and argues in favor of using a first-line AEM such as valproate or carbamazepine, or preferably the AEM that previously proved efficacious in a patient with known epilepsy who was noncompliant[ncbi.nlm.nih.gov]
  • Principal causes of GCSE are antiepileptic drug withdrawal or noncompliance, metabolic disturbances, drug toxicity, CNS infections, CNS tumors, refractory epilepsy, and head trauma.[mhmedical.com]
  • The most common precipitating factor in these cases in adults is withdrawal from medication or noncompliance with the regimen. There may, however, be no obvious cause for the episode.[epilepsychicago.org]
  • Noncompliance (Z91.12-, Z91.13-) or complication of care (Y63.6-Y63.9) codes are to be used with an underdosing code to indicate intent, if known.[3mhisinsideangle.com]
  • Patients with a primary seizure disorder are more prone to seize in the setting of: Medical noncompliance (most common cause of recurrent seizure) Sleep deprivation Emotional or physical stress Etiologies of secondary, or reactive, seizures include: Hypoglycemia[saem.org]
Tachypnea
  • Patients in alcohol will have abnormal vital signs including tachycardia, hypertension, hyperthermia and tachypnea. This is predominantly a clinical diagnosis.[saem.org]
Fecal Incontinence
  • In cases where the event was not witnessed, physical exam findings such a bite marks on the tongue or lips, or urinary or fecal incontinence may suggest a recent seizure.[saem.org]
Tachycardia
  • PATIENT PRESENTATION: We describe a 5-month-old girl with Dravet syndrome who presented with paroxysmal supraventricular tachycardia during status epilepticus.[ncbi.nlm.nih.gov]
  • GCSE is obvious when overt convulsions are present, but after 30–45 min of uninterrupted seizures, the signs may become increasingly subtle (mild clonic movements of the fingers; fine, rapid movements of the eyes; or paroxysmal episodes of tachycardia[mhmedical.com]
  • Patients in alcohol will have abnormal vital signs including tachycardia, hypertension, hyperthermia and tachypnea. This is predominantly a clinical diagnosis.[saem.org]
  • Secondary brain injury – e.g. from hyptension, hypoperfusion, hypoxia Excessive intracellular calcium leading to cell toxicity and death Respiratory Hypoxia Aspiration pneumonitis Respiratory acidosis Aspiration pneumonitis Cardiovascular Arrythmias Tachycardia[almostadoctor.co.uk]
Urinary Incontinence
  • incontinence Post-ictal period Injuries Initial investigation of a seizure Glucose Venous blood gas (VBG) Full blood count Urea & electrolytes Magnesium Calcium Further investigation of seizures or status epilepticus Guided by the likely cause but may[oxfordmedicaleducation.com]
Seizure
  • Prior to VNS implantation, 81% (13/16) of patients had  one seizure per month when all seizure types were combined. 75% (12/16) of patients experienced one generalized convulsive seizure per month.[ncbi.nlm.nih.gov]
  • It is of two main types with either prolonged complex partial seizures or absence seizures.[en.wikipedia.org]
  • SE is defined as a continuous seizure lasting more than 30 min, or two or more seizures without full recovery of consciousness between any of them.[ncbi.nlm.nih.gov]
  • seizures in patients treated for NCS or NCSE during their hospitalization.[ncbi.nlm.nih.gov]
  • Status epilepticus is a condition characterized by occurrence of seizures for a period of more than 30 minutes, or several seizures within a 5 minute period.[symptoma.com]
Confusion
  • In the first type of NCSE, patients present with confusion or abnormal behavior, suggesting the diagnosis of absence status epilepticus (ASE) or complex partial status epilepticus (CPSE).[ncbi.nlm.nih.gov]
  • A high level of suspicion of DNASLO in cases of unexplained confusion in adults or elderly subjects taking cephalosporins is essential to prompt an emergency EEG and, in turn, rapidly achieve an appropriate diagnosis and enable optimal treatment.[ncbi.nlm.nih.gov]
  • Symptoms: Symptoms of status epilepticus include onset of muscle spasms, confusion, clenching of teeth, difficulty in breathing, loss of control over bowel movements, unusual behavior and difficulty in speaking.[symptoma.com]
  • Confused, stuporous, or comatose patients may demonstrate rapid, rhythmic epileptiform discharge on the EEG, as shown here.[jaoa.org]
Stroke
  • METHODS: All consecutive patients experiencing post-stroke SE (PSSE) in our center were included (2011-2016). We analyzed SE- and stroke-related factors in relation to the patients' outcome.[ncbi.nlm.nih.gov]
  • Abstract Objective: To evaluate occurrence rate, clinical data, and prognostic factors of status epilepticus (SE) after stroke.[n.neurology.org]
  • In children, it is often infection, whereas in adults, the major causes are stroke, hypoxia, metabolic derangements, and alcohol intoxication or drug withdrawal.[ncbi.nlm.nih.gov]
  • ., 2014), ischemic stroke (Bleck, 2005) and subarachnoid hemorrhage (Bleck, 2005).[ncbi.nlm.nih.gov]
  • The most common causes of RSE were stroke in 5 (14.3%), central nervous system (CNS) infections in 12 (34.3%) and metabolic encephalopathies in 13 (37.1%) patients.[ncbi.nlm.nih.gov]
Aphasia
  • KEYWORDS: Aphasia; Diagnosis; Electroencephalogram; Prognosis; Status[ncbi.nlm.nih.gov]
  • Focal SE of language cortex typically causes aphasia, termed ictal aphasia. Diagnosis is primarily based on clinical findings.[emedicine.com]
Neonatal Seizures
  • For the treatment of neonatal seizures see Newborn Services Clinical Guidelines Management algorithm Definition of Status Epilepticus Recurrent seizures without complete recovery of consciousness between attacks, or continuous seizure activity for more[starship.org.nz]

Workup

At the preliminary level, a thorough physical examination would be carried out taking into consideration a past medical history. In addition, complete information about drugs would also be taken. Following this, an electroencephalogram would be carried out to measure the electrical activity of the brain [9].
Various other tests are also indicated such as lumbar puncture and spinal tap test in order to look for signs of infections. Imaging studies such as CT scan and MRI can also be required to check for any associated brain abnormalities [10].

3 Hz Spikes
  • Some of these instances are characterized by diffuse, slow ( 3 Hz) spike-and-wave activity, albeit with focal predominance. In many instances, interictal recordings demonstrate focal discharges that further implicate a focal process.[emedicine.com]
EEG Seizure Activity
  • Propofol was given to suppress EEG activity Case report Observation of EEG activity Propofol appeared to suppress EEG seizure activity Case report Kuisma M and Roine RO 1995 Finland 8 adult patients in prehospital care with RSE.[bestbets.org]
Hypercapnia
  • Treat complications Resuscitation Attend to ABCS and address life threats Manage airway with recovery position, airway adjuncts and intubation if required Optimise oxygenation and provide ventilatory support as needed (prone to hypercapnia) Early IV or[lifeinthefastlane.com]

Treatment

The primary goal of treatment would be to end the episode of seizure and bring the individual back to normal. Underlying problems also require treatment in order to treat status epilepticus.

If hypoglycemia is the cause of the seizure, then glucose load would be administered. Several anti-seizure drugs such as diazepam, valproate, phenytoin, phenobarbital, lorazepam and fosphenytoin are indicated for treating status epilepticus. Amongst these drugs, diazepam is usually the first choice and preferred for patients suffering from seizures. The drugs are either given through the intravenous route or through injections [11].

Prognosis

The prognosis of the condition is not very favourable. It has been estimated that 10-30% of individuals suffering from status epilepticus do not live longer than 30 days after the onset of first attack. Majority of these individuals are known to be suffering from certain underlying neurological conditions. In addition, other group of individuals with no known underlying disease condition also has significant risk of mortality, if their condition is not quickly stabilized with medications and therapies [7].

Etiology

Individuals with history of epilepsy or those suffering from underlying neurological disorders are prone to develop status epilepticus. Individuals with history of epilepsy suffer from status epilepticus, probably due to change in medications. In addition, other factors or conditions that can trigger a structural damage in the cortical region can also significantly contribute to development of status epilepticus. These include [2]:

Epidemiology

It has been estimated that about 50,000-200,000 individuals suffer from status epilepticus in US every year. It is known to be one of the most common emergencies presented in the neurological department. The estimated mortality rate of status epilepticus is about 20%. Individuals of all age groups are equally susceptible to suffer from this condition [3, 4].

Sex distribution
Age distribution

Pathophysiology

According to the widely accepted definition of status epilepticus, seizures that last for 30 minutes or more are termed as status epilepticus. However, based on the new guidelines, any seizures that continue for 5 minutes or more should be treated as status epilepticus. During an attack of seizure, the body struggles to supply oxygen to the rest of the body parts; failure to do so can cause significant damage to the brain [5].

In addition, other physiologic changes also accompany an attack of convulsive status epilepticus. These changes can be defined by the onset of tachycardia, hyperglycemia and or cardiac arrhythmias. All these occur as a result of catecholamine surge, which accompany every attack of seizure [6].

Prevention

Individuals with past history of epilepsy are advised against changing medications without the doctor’s advice. This is because such a practice can trigger an attack of status epilepticus. Avoiding alcohol and consumption of recreational drugs would also help in preventing the onset of seizures. Keeping blood sugar levels normal can also prevent occurrence of seizures.

Summary

Status epilepticus is a condition characterized by occurrence of seizures for a period of more than 30 minutes, or several seizures within a 5 minute period. In such a kind of condition, the individual does not return to normal state during the several attacks or seizures. It is one of the types of epileptic seizures, which is a life threatening condition. Individuals with certain type of underlying disease conditions or those with history of epilepsy are prone to suffer from status epilepticus. The condition is divided into 2 categories, namely convulsive status epilepticus and non convulsive epilepticus [1]. 

Patient Information

  • Definition: Status epilepticus, is a condition characterized by onset of seizures for more than 5 minutes. In such a type of condition, there is abnormal electrical activity in the brain that severely affects mind and body functioning. It is a medical emergency which can lead to brain damage if not promptly treated. Individuals with history of epilepsy can suffer several attacks of status epilepticus.
  • Cause: Individuals who have already suffered epilepsy in the past are more prone to develop status epilepticus. Underlying neurological disease conditions can also predispose an individual to develop such a type of epilepsy.
  • Symptoms: Symptoms of status epilepticus include onset of muscle spasms, confusion, clenching of teeth, difficulty in breathing, loss of control over bowel movements, unusual behavior and difficulty in speaking. These are some of the common symptoms; individuals with convulsive or non-convulsive form experience different set of symptoms.
  • Diagnosis: A past medical history inclusive of medications, disease profile and alcohol consumption is gathered. Following this, electroencephalogram is conducted to measure the electrical activity of the brain. Imaging studies such as CT scan and MRI of the brain is also indicated in order to diagnose other underlying disease conditions.
  • Treatment: Treatment with anti-seizure medications forms the basis of treatment regime. These include diazepam, phenytoin, valproate, lorazepam, fosphenytoin and Phenobarbital. The drugs are either given intravenously or through injections.

References

Article

  1. Walker M. Status epilepticus: an evidence based guide. BMJ 2005; 331:673.
  2. Aminoff MJ, Simon RP. Status epilepticus. Causes, clinical features and consequences in 98 patients. Am J Med. Nov 1980;69(5):657-66.
  3. Shinnar S, Pellock JM, Moshe SL, et al. In whom does status epilepticus occur: age-related differences in children. Epilepsia. Aug 1997;38(8):907-14.
  4. DeLorenzo RJ, Pellock JM, Towne AR, Boggs JG. Epidemiology of status epilepticus. J Clin Neurophysiol. Jul 1995;12(4):316-25.
  5. Fountain NB, Lothman EW. Pathophysiology of status epilepticus. J Clin Neurophysiol 1995; 12:326.
  6. White PT, Grant P, Mosier J, Craig A. Changes in cerebral dynamics associated with seizures. Neurology. Apr 1961;11(4)Pt 1:354-61.
  7. Wijdicks EF, Parisi JE, Sharbrough FW. Prognostic value of myoclonus status in comatose survivors of cardiac arrest. Ann Neurol 1994; 35:239.
  8. Krumholz A, Sung GY, Fisher RS, Barry E, Bergey GK, Grattan LM. Complex partial status epilepticus accompanied by serious morbidity and mortality. Neurology. Aug 1995;45(8):1499-504.
  9. Treiman DM, Walton NY, Kendrick C. A progressive sequence of electroencephalographic changes during generalized convulsive status epilepticus. Epilepsy Res. Jan-Feb 1990;5(1):49-60.
  10. Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17:3.
  11. Limdi NA, Shimpi AV, Faught E, Gomez CR, Burneo JG. Efficacy of rapid IV administration of valproic acid for status epilepticus. Neurology. Jan 25 2005;64(2):353-5.

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Last updated: 2018-06-22 05:36