Association of Peri-ictal MRI Abnormalities With Mortality, Antiseizure Medication Refractoriness, and Morbidity in Status Epilepticus

Abstract

Background and Objectives:Status epilepticus (SE) is a life-threatening emergency requiring a prompt assessment of patient prognosis to guide management. Magnetic resonance imaging (MRI) allows the identification of peri-ictal MRI abnormalities (PMA) and provides insight into brain structural modifications induced by SE. However, little is known about the significance of PMA in SE prognosis. The aim of this study was to determine whether PMA are associated with an increased mortality in SE, and to establish the association between PMA and refractoriness to antiseizure medications, complications encountered and induced morbidity.Methods:We conducted a retrospective observational cohort study including all eligible consecutive patients over 15 years-old and hospitalized with SE at Bordeaux University Hospital (France), between January 2015 and December 2019. The primary endpoint was in-hospital mortality. Together with a dedicated neuroradiological reassessment, baseline characteristics, in-hospital death, SE characterization, drug refractoriness and following outcome in survivors were assessed by comprehensive medical review.Results:Of 307 patients included, 79 (26%) showed PMA related to SE. Demographic, functional status at baseline and median delay between SE onset and MRI exam were similar in PMA-positive and PMA-negative group. In-hospital death occurred in 15% (45/307) patients, and was significantly higher in the PMA-positive group (27%, 21/79 vs 11%, 24/228; p<0.001). In multivariate analysis, the presence of PMA (odds ratio [OR] 2.86, 95% confidence interval [CI] 1.02-8.18; p=0.045), together with SE duration ([OR] 1.01, 95% CI 1.01-1.02; p=0.007), older age at SE onset ([OR] 1.05, 95% CI 1.01-1.09; p=0.013), preexisting ultimately fatal comorbidity ([OR] 4.01, 95% CI 1.56-10.6; p=0.004) and acute lesional SE etiology ([OR] 3.74, 95% CI 1.45-10.2; p=0.007) were independent predictors associated with in-hospital death. Patients with PMA had a higher risk of refractory SE (71 vs 33%, p<0.001). Among survivors, delayed onset epilepsy (40% vs 21%, p=0.009) occurred more frequently in the PMA-positive group.Discussion:PMA-positive cases had a higher mortality rate in the largest cohort so far to assess the prognosis value of PMA in SE. As a non-invasive and easily available tool, PMA represents a promising structural biomarker for developing a personalized approach to prognostication in SE patients receiving MRI.

Prediction of long‐term unprovoked seizures after status epilepticus

“…In a recent study, a correlation between SE duration and presence of peri-ictal abnormalities on magnetic resonance imaging (MRI) was found, which were further associated with a higher risk of epilepsy development. 27 Unfortunately, not all of our patients underwent MRI studies, and further additional inquiries are warranted to confirm the association with the increased risk of developing epilepsy.…”

Remote seizures and drug‐resistant epilepsy after a first status epilepticus in adults

“…Our results show that the overall risk of seizure recurrence is relatively low, especially in nonlesional etiologies (see Table 1). Future prospective studies are needed to define the risk of post-SE epilepsy development in patients with acute etiologies, eventually considering a more granular classification of SE etiologies as recently proposed by our group [30], as well as other potentially useful tools, such as fluid biomarkers of neurodegeneration/neuroinflammation [31,32] and structural neuroimaging [33][34][35].…”

Magnetic Resonance Imaging in Status Epilepticus: Useful Scrying Board or Expensive Stopwatch?

“…A recent study by Bonduelle et al 5 brings important new insights on the prevalence and clinical implications of PMAs. In this large retrospective series, the authors reviewed the MRI scans performed in 307 patients admitted at their institution with non-anoxic SE over a 5-year period.…”

“…Recent large series found a variable prevalence, between 12% and 46% of these changes in SE, [2][3][4] possibly owing to the nonsystematic use of MRI and to the overlap between PMA and MRI changes attributable to the underlying etiology of SE. A recent study by Bonduelle et al 5 brings important new insights on the prevalence and clinical implications of PMAs. In this large retrospective series, the authors reviewed the MRI scans performed in 307 patients admitted at their institution with non-anoxic SE over a 5-year period.…”