Is Favorable Outcome Possible After Prolonged Refractory Status Epilepticus?

Abstract

When status epilepticus (SE) remains refractory to appropriate therapy, it is associated with high mortality and with substantial morbidity in survivors. Many outcome predictors such as age, seizure type, level of consciousness before treatment, and mostly, etiology, are well-established. A longer duration of SE is often associated with worse outcome, but duration may lose its prognostic value after several hours. Several terms and definitions have been used to describe prolonged, refractory SE, including "malignant SE," "prolonged" SE, and more recently, "super refractory" SE, defined as "SE that has continued or recurred despite 24 hours of general anesthesia (or coma-inducing anticonvulsants)." There are few data available regarding the outcome of prolonged refractory SE, and even fewer for SE remaining refractory to anesthetic drugs. This article reviews reports of outcome after prolonged, refractory, and "super refractory" SE. Most information detailing the clinical outcome of patients surviving these severe illnesses, in which seizures can persist for days or weeks (and especially those concerning "super-refractory" SE) come from case reports and retrospective cohort studies. In many series, prolonged, refractory SE has a mortality of 30% to 50%, and several studies indicate that most survivors have a substantial decline in functional status. Nevertheless, several reports demonstrate that good functional outcome is possible even after several days of SE and coma induction. Treatment of refractory SE should not be withdrawn from younger patients without structural brain damage at presentation solely because of the duration of SE.

Treatment of Refractory and Super-refractory Status Epilepticus

“…Possible long-term adverse effects of ketamine are not understood well yet. Unfortunately, under 10% of patients had good outcomes, but ketamine was probably the final of many treatments for prolonged, RSE and thus less likely to rescue the patient [46,168]. This report discusses the possible Bearly use^of ketamine, which is certainly plausible for earlier stages of RSE, but its long-term effects are less well understood, and it is less familiar to most neurologists.…”

“…Mortality from SE is about 5 to 25% overall, depending on the cause and population studied [44,45] but substantially higher for RSE and SRSE [10,13,46]. In one metaanalysis of treatment of RSE with aggressive therapy, the overall mortality was 48% [13].…”

“…In one metaanalysis of treatment of RSE with aggressive therapy, the overall mortality was 48% [13]. SRSE is usually associated with a mortality rate of over 30%, and with over 50% of patients dying or in a vegetative state in cases of Bnew onset refractory status epilepticus^(NORSE) [46]. Considering both mortality and morbidity, under 1/4 of all SRSE and NORSE patients reported so far have had a good outcome; most survivors had significant residual impairment [46].…”

“…SRSE is usually associated with a mortality rate of over 30%, and with over 50% of patients dying or in a vegetative state in cases of Bnew onset refractory status epilepticus^(NORSE) [46]. Considering both mortality and morbidity, under 1/4 of all SRSE and NORSE patients reported so far have had a good outcome; most survivors had significant residual impairment [46]. Nevertheless, good outcome after RSE and SRSE has been reported in several cases.…”

Prolonged status epilepticus: Early recognition and prediction of full recovery in a 12‐year cohort

“…Many patients and their relatives would forgo further intensive treatment if survival were to come at the cost of substantial neurologic impairment. However, there are reports of survival from prolonged SE and favorable outcome in this context . Thus, reliable and timely identification of patients with potential good outcome despite having prolonged SE would be extremely helpful for patients, relatives, and treating physicians alike.…”