Refractory status epilepticus

Abstract

Refractory status epilepticus is a potentially life-threatening medical emergency. It requires early diagnosis and treatment. There is a lack of consensus upon its semantic definition of whether it is status epilepticus that continues despite treatment with benzodiazepine and one antiepileptic medication (AED), i.e., Lorazepam + phenytoin. Others regard refractory status epilepticus as failure of benzodiazepine and 2 antiepileptic medications, i.e., Lorazepam + phenytoin + phenobarb. Up to 30% patients in SE fail to respond to two antiepileptic drugs (AEDs) and 15% continue to have seizure activity despite use of three drugs. Mechanisms that have made the treatment even more challenging are GABA-R that is internalized during status epilepticus and upregulation of multidrug transporter proteins. All patients of refractory status epilepticus require continuous EEG monitoring. There are three main agents used in the treatment of RSE. These include pentobarbital or thiopental, midazolam and propofol. RSE was shown to result in mortality in 35% cases, 39.13% of patients were left with severe neurological deficits, while another 13% had mild neurological deficits.

Beneficial Outcome of Urethane Treatment Following Status Epilepticus in a Rat Organophosphorus Toxicity Model

“…Status epilepticus (SE) is an unremitting seizure or a series of seizures without intervening regain of consciousness; in ∼30% of patients it is refractory to treatment with anti-epileptic drugs (AEDs) including benzodiazepines ( Claassen et al, 2001 ; Mayer et al, 2002 ; Misra and Singh, 2002 ; Singhi et al, 2002 ; Holtkamp et al, 2005 ; Rossetti et al, 2005 ; Novy et al, 2010 ; Manno, 2011 ; Hunter and Young, 2012 ; Singh et al, 2014 ). Benzodiazepines like diazepam also become less effective as time in SE increases ( Walton and Treiman, 1988 , 1991 ; Kapur and Macdonald, 1997 ; Shih et al, 1999 ; Jones et al, 2002 ; Goodkin and Kapur, 2003 ; Goodkin et al, 2003 ; Löscher, 2007 ).…”

Hemispherotomy for late post-traumatic super-refractory status epilepticus in an adult

“…SE is considered refractory when there is no response to two to three anti-seizure drugs. The mortality rate is three times more in RSE compared to SE [8] . SRSE is defined as status epilepticus that continues or recurs 24 h or more after the initiation of anesthetic therapy, including those cases where status epilepticus recurs on the reduction or withdrawal of anesthesia [9] .…”

Identification of Risk Factors for Refractory Status Epilepticus

“…For example, patients with RSE experience up to a 65% mortality rate, a 39% incidence of severe neurological deficits, and a 13% risk of mild neurological deficits. 2-6…”

“…For example, patients with RSE experience up to a 65% mortality rate, a 39% incidence of severe neurological deficits, and a 13% risk of mild neurological deficits. [2][3][4][5][6] Although there are several definitions for SE, the 2016 American Epilepsy Society Guidelines and the 2012 Neurocritical Care Guidelines for the Evaluation and Management of Status Epilepticus define SE as a seizure that lasts longer than 5 minutes in duration. In addition, the guidelines define RSE as SE that continues despite treatment with adequate doses of a benzodiazepine, defined as the equivalence of lorazepam 4-mg intravenous (IV) injection, and 1 antiepileptic medication.…”