Review and Updates on the Treatment of Refractory and Super Refractory Status Epilepticus

Abstract

Refractory and super-refractory status epilepticus (RSE and SRSE) are life-threatening conditions requiring prompt initiation of appropriate treatment to avoid permanent neurological damage and reduce morbidity and mortality. RSE is defined as status epilepticus that persists despite administering at least two appropriately dosed parenteral medications, including a benzodiazepine. SRSE is status epilepticus that persists at least 24 h after adding at least one appropriately dosed continuous anesthetic (i.e., midazolam, propofol, pentobarbital, and ketamine). Other therapeutic interventions include immunotherapy, neuromodulation, ketogenic diet, or even surgical intervention in certain cases. Continuous electroencephalogram is an essential monitoring tool for diagnosis and treatment. In this review, we focus on the diagnosis and treatment of RSE and SRSE.

Modern Treatment of Status Epilepticus in Adults

“…Hypothermia, magnesium infusion, pyridoxine infusion (highly effective in cases of inborn error of pyridoxine metabolism, also found as responsible for SE in rare cases in adults), lidocaine infusion, ketogenic diet, nerve stimulation (vagal, trigeminal, deep brain), resective neurosurgery, electroconvulsive therapy (ECT), cerebrospinal fluid drainage, and many others have been tried and may be beneficial in individual cases. The numerous therapeutic possibilities are summarized in multiple review articles (10,25,(105)(106)(107)(108)(109)(110).…”

“…Ketogenic diet may affect serum concentrations of ASMs (119) and may also influence certain forms of intensive care treatment. Notably, ketogenic diet is contraindicated in patients with hepatic failure, acute pancreatitis, or metabolic acidosis (109). It is also recommended not to combine ketogenic diet with propofol, since it increases the risk for fatal propofol related infusion syndrome (120).…”

Factors associated with mortality in patients with super-refractory status epilepticus

“…If seizures cannot be controlled by IV ASM administration, general anesthesia is subsequently adopted for refractory SE, e.g., by IV infusion of midazolam, propofol, or ketamine 3 , 4 . Anesthetics are continuously infused until the seizure subsides and is maintained for 12–24 h following the last seizure 5 . If SE continues or recurs despite using anesthetics for 24 h or longer, it is defined as super-refractory SE (SRSE) 6 .…”

Predictors of in-hospital mortality among patients with status epilepticus in Lubumbashi, Democratic Republic of the Congo: A retrospective study

“…Status Epilepticus (SE) is a critical condition that requires prompt treatment to minimize the long-term consequences of ongoing seizure activity. In 2015, the International League Against Epilepsy defined SE as "a condition resulting from either failure of mechanisms responsible for seizure arrest or the initiation of mechanisms that lead to abnormally prolonged seizures and may have long-term consequences, including neuronal death, neuronal injury, and alteration of neural networks" [1,2]. Its incidence varies according to the population studied [1].…”

“…In 2015, the International League Against Epilepsy defined SE as "a condition resulting from either failure of mechanisms responsible for seizure arrest or the initiation of mechanisms that lead to abnormally prolonged seizures and may have long-term consequences, including neuronal death, neuronal injury, and alteration of neural networks" [1,2]. Its incidence varies according to the population studied [1]. A variety of etiologies have been described in the literature, including central nervous system infections, brain tumors, stroke, metabolic disorders, etc.…”