Status epilepticus: review on diagnosis, monitoring and treatment

Abstract

Status epilepticus (SE) is a frequent neurological emergency associated with high morbidity and mortality. According to the new ILAE 2015 definition, SE results either from the failure of the mechanisms responsible for seizure termination or initiation, leading to abnormally prolonged seizures. The definition has different time points for convulsive, focal and absence SE. Time is brain. There are changes in synaptic receptors leading to a more proconvulsant state and increased risk of brain lesion and sequelae with long duration. Management of SE must include three pillars: stop seizures, stabilize patients to avoid secondary lesions and treat underlying causes. Convulsive SE is defined after 5 minutes and is a major emergency. Benzodiazepines are the initial treatment, and should be given fast and an adequate dose. Phenytoin/fosphenytoin, levetiracetam and valproic acid are evidence choices for second line treatment. If SE persists, anesthetic drugs are probably the best option for third line treatment, despite lack of evidence. Midazolam is usually the best initial choice and barbiturates should be considered for refractory cases. Nonconvulsive status epilepticus has a similar initial approach, with benzodiazepines and second line intravenous (IV) agents, but after that, aggressiveness should be balanced considering risk of lesion due to seizures and medical complications caused by aggressive treatment. Usually, the best approach is the use of sequential IV antiepileptic drugs (oral/tube are options if IV options are not available). EEG monitoring is crucial for diagnosis of nonconvulsive SE, after initial control of convulsive SE and treatment control. Institutional protocols are advised to improve care.

Efficacy and Safety of Levetiracetam for Childhood Epilepsies

“…Numerous studies confirmed a significant reduction of seizures in children on polytherapy due to focal, myoclonic, generalized seizures and juvenile myoclonic epilepsy ( 10 ). It has also been shown to be effective treatment for patients in status epilepticus ( 11 , 12 ).…”

Diagnosis and Treatment of Status Epilepticus : An Update Systematic Review

“…This condition can have long-term consequences (after time point T2), including neuronal death, neuronal injury, and alteration of neuronal networks, depending on the type and duration of seizures. 1 The classical definition of convulsive status epilepticus (CSE) is continuous seizure activity for at least 30 minutes, or two or more recurrent convulsive seizures with incomplete recovery of consciousness between seizures. Recently, the definition of CSE was revised in accordance with the various evidences of neuronal injury and changes in clinical settings.…”

“…This is an important conceptual definition, because there are different forms of SE, with different risk and treatment strategies. 1 Before discussing the several factors responsible for the seizures gradually culminating into SE, it is imperative to briefly understand inhibitory and stimulatory neuronal pathways operating at the cellular levels. Primarily, failure of a seizure to stop is due to the imbalance between the inhibitory GABA (gamma-aminobutyric acid) pathway and the excitatory glutamate-mediated pathway.…”