Functional outcome of prolonged refractory status epilepticus

Abstract

IntroductionTo characterize etiology, clinical course and outcomes of patients in prolonged refractory status epilepticus (PRSE) and looking for prognostic factors.MethodsRetrospective study conducted in patients hospitalized from January 1, 2001 to December 31, 2011 in 19 polyvalent intensive care units in French university and general hospitals. Patients were adults with a generalized convulsive refractory status epilepticus that lasted more than seven days, despite treatment including an anesthetic drug and mechanical ventilation. Patients with anoxic encephalopathy were excluded. Follow-up phone call was used to determine functional outcome using modified Rankin Scale (mRS) with mRS 0–3 defining good and mRS 4–6 poor outcome.Results78 patients (35 female) were included. Median age was 57 years. Causes of status epilepticus were various, mainly including prior epilepsy (14.1%), CNS infection (12.8%), and stroke (12.8%). No etiology was found in 27 (34.6%) patients. PRSE was considered controlled in only 53 (67.9%) patients after a median duration of 17 (IQR 12–26) days. The median length of ICU stay was 28 (19–48) days. Forty-one (52.5%) patients died in the ICU, 26 from multiple organ failure, 8 from care withdrawal, 2 from sudden cardiac arrest, 1 from brain death and 4 from unknown causes. PRSE was previously resolved in 20 patients who died in the ICU. At one-year follow-up, there were 12 patients with good outcome and 58 with poor outcome and 8 lost of follow-up. On multivariate analysis, only vasopressor use was a predictor of poor outcome (OR 6.54; 95%CI 1.09-39.29; p = 0.04).ConclusionPoor outcome was observed in about 80% of this population of PRSE. Most patients died from systemic complications linked to their ICU stay. Some patients can recover satisfactorily over time though we did not identify any robust factor of good outcome.

Early-onset status epilepticus in patients with acute encephalitis

“…In the meantime, our findings suggest that early seizure detection and appropriate antiepileptic treatment at the onset of encephalitis may avoid the onset of (super-) refractory SE, a condition associated with very poor outcomes. [11,12,27] …”

“…[3,4] Recently, acute encephalitis was found to be associated with the onset of super-refractory SE, [11] a condition carrying a very poor prognosis. [12] In a previous study of patients undergoing continuous electroencephalographic monitoring, electrographic seizures occurred in 33% of cases and were independently associated with poorer outcomes. [13] Moreover, in a recent study, the presence of seizures and SE at the onset of encephalitis was independently associated with an increased risk of postencephalitic epilepsy in survivors.…”

Long‐term outcomes of status epilepticus: A critical assessment

“…Long‐term mortality data after an episode of SE, including in‐hospital deaths, is 0%‐22% in children5, 6, 17, 26, 27, 28, 29, 33, 34, 35, 37, 38, 45, 53 and 0%‐57% in adults 10, 11, 12, 17, 19, 20, 43, 54…”

“…Especially pentobarbital has been linked to the development of hypotension requiring prolonged duration of mechanical ventilation and vasopressor therapies,76 which have in turn been associated with poor long‐term outcome 54. Continuous infusion of thiopental was also associated with more frequent adverse events and worse outcome at 6 months compared to continuous infusions of midazolam 77.…”

Complication Burden Index—A tool for comprehensive evaluation of the effect of complications on functional outcome after status epilepticus

“…Risk of complications increases as the duration of SE treatment increases, 5,6 and conversely, complications increase the risk of refractoriness 7 and prolong the hospital admittance. 6,[9][10][11] Although complications such as infection, 12 vasopressor use, 9 or mechanical ventilation 13 have been associated singly with poor outcome, only intubation has been included in published outcome scores. 6,[9][10][11] Although complications such as infection, 12 vasopressor use, 9 or mechanical ventilation 13 have been associated singly with poor outcome, only intubation has been included in published outcome scores.…”