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Status Epilepticus Status Epilepticus Ednea Simon, MD Swedish Pediatric Neuroscience Center 1 Status Epilepticus • Status epilepticus (SE) is a condition resulting either from failure of the mechanisms responsible for seizure termination or form the initiation of mechanisms which lead to abnormally prolonged seizures. • It can have long-term consequences, including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures • Prolonged seizures lasting over 30 minutes or repeated frequently enough that recover between seizures does not occur. • Important considerations in treatment – T1 when a seizure is likely to be prolonged leading to continuous seizure activity and treatment should be established after 5-minute mark for convulsive seizure and 10 minute mark for focal seizure – T2 marks the time at which neuronal damage or self perpetuating alteration of neuronal networks may begin if seizure is not controlled Trinka E, Cock H, Hesdorffer D at al, Epilepsia 56(10): 1515-23, 2015 Lowenstein et al. Epilepsia 40:120-122, 1999 2 Status Epilepticus • Goal of therapy: rapid cessation of seizure activity before 30-minute mark when seizure-associated neurologic injury can occur • Incidence of up to 10-41 cases per 100,000 per year and overall mortality of 20% – Risk factors • Etiology • Higher incidence in ages less than 12 months and over 60 years • Long duration SE Betjemann JP & Lowenstein DH. Lancet Neurology (6): 615-24, 2015 Kantanen AM et al. Epilepsy Behav, 49 (Aug): 131-4, 2015 Trinka et al., Seizure 44: 65-73, 2017 3 Age-specific incidence of SE Mortality of SE DeLorenzo et al. Epidemiology of Status Epilepticus, J Clin Neurophys; 12(4):316-25, 1995 4 CLASSIFICATION OF STATUS EPILEPTICUS • With prominent motor symptoms – Convulsive type comprises 37-70% of all forms of status – Myoclonic – Focal motor – Tonic – Hyperkinectic • Nonconvulsive status epilepticus: enduring epileptic condition with reduced or altered consciousness, behavioral, and vegetative abnormalities, or merely subjective symptoms without major convulsive movements lasting more than 30 minutes with ictal epileptiform discharges on EEG. – 8-34% of patient with altered mental status in ICU presents NCSE – With associated coma represents a life threatening condition that requires urgent treatment – Without coma • Focal • Generalized Trinka E et al. Epilepsia 53(suppl 4): 127-138, 2012 5 ETIOLOGY OF STATUS EPILEPTICUS • Symptomatic – Acute symptomatic – Remote symptomatic – Progressive symptomatic • Unknown • Most frequent causes – Acute symptomatic 48-63% of cases with stroke present in 14-22% – Preexisting epilepsy -> low level of AED (25% of cases) that has good prognosis with mortality of 4-8.6% – Remote stroke • Approximately 12% of patients with epilepsy have had at least 1 episode of SE in their lifetime • Acute symptomatic etiology may account for 40-50% of cases Trinka E et al. Epilepsia 53(suppl 4): 127-138, 2012 DeLorenzo RJ et al. J Clin Neurophysiol 12:316-25, 1995 Towne AR et at. Epilepsia 35:27-34, 1994 6 ETIOLOGY OF STATUS EPILEPTICUS Trinka E et al. Epilepsia 53(suppl 4): 127-138, 2012 7 ETIOLOGY OF STATUS EPILEPTICUS • Hypoxic ischemic encephalopathy • Cerebrovascular diseases • Withdrawal or low AEDs levels • Metabolic • Intracranial tumors • CNS infections • Neurodegenerative diseases • Cortical dysplasia • Head trauma • Intoxication • Autoimmune • Mitochondrial cytopathy • Genetic • Neurocutaneous syndromes • NORSE – New onset refractory status epilepticus (adults) • FIRES – Febrile infection related epilepsy syndrome Trinka E et al. Epilepsia 56(10): 1515-23, 2015 8 NORSE NEW ONSET REFRACTORY STATUS EPILEPTICUS • Condition characterized by the sudden onset of continuous seizures or a flurry of very frequent seizures that can not be controlled with seizure medications • In many cases there is report of a cold or flu like illness days to weeks prior to the start of seizures • Affects otherwise healthy young adults, although it can affect people of any age. • Super-refractory status epilepticus with patients often treated with IV anesthetics for weeks in an intensive care unit • NORSE is a life-threatening condition, with a death rate of around 30%. Survivors often have lasting brain damage and epilepsy. A minority of people fully recover and return to a normal lifestyle 9 FIRES FEBRILE INFECTION-RELATED EPILEPSY SYNDROME • Rare epilepsy syndrome of unclear etiology in which children, usually of school age, suddenly develop very frequent seizures (up to hundreds per day) within two weeks after a mild febrile illness. • Super-refractory status epilepticus despite use of IV anesthetics that can last months • Immune treatment and the ketogenic diet may help. • Outcome is poor with cognitive disability and refractory epilepsy. 10 TIME IS BRAIN! CLINICAL COURSE Early phase 5-10 Impending SE MIN 10-30 Established SE MIN 30-60 Refractory SE MIN Super >24 H Refractory SE PROGNOSIS OF STATUS EPILEPTICUS WORSENS WITH INCREASING DURATION OF SEIZURE ACTIVITY Trinka et al., Seizure 44: 65-73, 2017 11 Treatment Algorithm of Status Epilepticus • Stabilization phase (0-5 minutes of seizure activity) including standard initial first aid for seizures and initial assessments and monitoring. Maintain airway, respiration, and circulation EARLY TREATMENT SHOULD BE EMPHASIZED SINCE TREATMENT BECOMES LESS EFFECTIVE THE LONGER THE EPISODE OF STATUS EPILEPTICUS LASTS • Initial therapy phase (5-20 minutes) when it is clear the seizure requires medical intervention. • Second therapy phase (20-40 minutes) when response (or lack of response) to the initial therapy should be apparent. • Third therapy phase (+40 minutes) if second therapy fails to stop the seizures, treatment consideration should include repeating second line therapy or IV anesthetic drugs that require continuous video-EEG monitoring. Trinka et al., Seizure 44: 65-73, 2017 12 Treatment Algorithm of Status Epilepticus Stabilization phase • Intubation for airway protection if unconscious • Monitor blood pressure, pulse, cardiac rhythm, and oxygen saturation • Intravenous access • Initial labs: toxic screen, ethanol level, complete blood count, comprehensive metabolic panel, antiepileptic drug levels • Neuroimaging investigation • CSF studies, if indicated • Electroencephalogram 13 TREATMENT OF EARLY PHASE SE FIRST LINE TREATMENT: BENZODIAZEPINE Benzodiazepine is recommended IM or IN midazolam, IV lorazepam, IV diazepam with demonstrated efficacy, safety, and tolerability • Lorazepam IV – 0.07-0.1 mg/kg at rate 2 mg/min • Diazepam IV or rectal – 0.2 mg/kg at rate 5 mg/min – 5-10 mg up to 20 mg • Midazolam IM or IN or buccal – 0.2 mg/kg, dose 10 mg Benzodiazepine increases channel opening frequency of GABA-A receptors with increased chloride conductance and neuronal hyperpolarization, with increased inhibition Trinka et al., Seizure 44: 65-73, 2017 14 TREATMENT OF EARLY PHASE SE FIRST LINE TREATMENT: BENZODIAZEPINE • VA cooperative study using IV lorazepam vs IV phenytoin as first line treatment for SE – 64.9% controlled with IV lorazepam – 43.5 % controlled with IV phenytoin 15 IM Midazolam vs IV Lorazepam as first line for treatment of status epilepticus Double blind study including 893 children and adults treated by paramedics IM Midazolam IV Lorazepam Seizure control 73.4% 63.4% Time administration 1.2 min 4.8 min Clinical seizure cessation 3.3 min 1.6 min RAMPART- rapid anticonvulsant medications prior to arrival trial Silbergleit R et al., N Engl J Med 2012; 366 February (7): 591-600 16 INTRAVENOUS LORAZEPAM VS DIAZEPAM • Meta analysis of 5 randomized controlled trial including 656 patients – 320 treated with LZP – 336 with DZP • No statistically significant differences were found between IV LZP and IV DZP regarding – Clinical seizure cessation – Continuation of SE requiring a different drug – Seizure cessation after a single dose of medication – Ventilatory support – Clinically relevant hypotension Brigo et al., Epilepsy Behav 64 (Oct): 29-36, 2016 17 BENZODIAZEPINES AND ROUTES OF ADMINISTRATION Meta-analysis of 19 studies for efficacy and safety in children and adults using non-intravenous midazolam and rectal or intravenous diazepam. Study included 1,933 seizures in 1,602 patients • For seizure cessation, non-IV midazolam was as effective as IV or rectal diazepam • Time interval between arrival and seizure cessation was shorter with non-IV midazolam • Time from time interval from drug administration to clinical seizure cessation as shorter for diazepam by any route • Non difference in side effects found with midazolam or with any route of diazepam • Non-intravenous midazolam routes represents a practical, rapid, reasonably safe and effective alternative as first-line treatment in out of hospital setting Brigo et al., Epilepsy Behav 2015; 49(August): 325-36; Brigo et al., CNS drugs 2015 A(August) 18 TREATMENT OF ESTABLISHED SE SECOND THERAPY PHASE Approximately 40% of patients with generalized convulsive SE are refractory to benzodiazepine treatment Options: • Fosphenytoin/Phenytoin • Valproic acid • Levetiracetam • Phenobarbital • Lacosamide There is no class I evidence for choosing one AED over the other. Drug choice should take into consideration comorbidities and side effect profile Trinka et al., Seizure 44: 65-73, 2017 19 TREATMENT OF ESTABLISHED SE SECOND THERAPY PHASE • Fosphenytoin/Phenytoin – Fosphenytoin: 20 mg/kg IV at 150 mg PE/min – Phenytoin: 20 mg/kg IV at 50 mg /min – Effect noted within 20 minutes of administration – If seizure persist
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