Surgical management of status epilepticus: A systematic review

Abstract

Status Epilepticus (SE), unresponsive to medical management, is associated with high morbidity and mortality. Surgical management is typically considered in these refractory cases. The best surgical approach for affected patients remains unclear; however, given the lack of controlled trials exploring the role of surgery. We performed a systematic review according to PRIMSA guidelines, including case reports and series describing surgical interventions for patients in SE. Cases (157 patients, median age 12.9 years) were followed for a median of 12 months. Patients were in SE for a median of 21 days before undergoing procedures including: focal resection (36.9%), functional hemispherectomy (21%), lobar resection (12.7%), vagus nerve stimulation (VNS) (12.7%), deep brain stimulation (DBS) (6.4%), multiple subpial transection (MST) (3.8%), responsive neurostimulation (RNS) (1.9%), and cortical stimulator placement (1.27%), with 24 patients undergoing multiple procedures. Multiple SE semiologies were identified. 47.8% of patients had focal seizures, and 65% of patients had focal structural abnormalities on MRI. SE persisted for 36.8 ± 47.7 days prior to surgical intervention. SE terminated following surgery in 81.5%, terminated with additional adjuncts in 10.2%, continued in 1.9%, and was not specified in 6.4% of patients. Long‐term seizure outcomes were favorable, with the majority improved and 51% seizure‐free. Eight patients passed away in follow‐up, of which three were in SE. Seizures emerging from one hemisphere were both more likely to immediately terminate (OR 4.7) and lead to long‐term seizure‐free status (OR 3.9) compared to nonunilateral seizures. No other predictors, including seizure focality, SE duration, or choice of surgical procedure, were predictors of SE termination. Surgical treatment of SE can be effective in terminating SE and leading to sustained seizure freedom, with many different procedures showing efficacy if matched appropriately with SE semiology and etiology.Plain Language SummaryPatients with persistent seizures (Status Epilepticus) that do not stop following medications can be treated effectively with surgery. Here, we systematically review the entirety of existing literature on surgery for treating status epilepticus to better identify how and when surgery is used and what patients do after surgery.

Emergent Management of Status Epilepticus

“…Several other approaches have been proposed to treat refractory status epilepticus and super-refractory status epilepticus, including immunotherapy, neuroactive steroids, neuromodulation, magnesium infusion, pyridoxine infusion, hypothermia, ketogenic diet, electroconvulsive therapy, inhaled anesthetics, transcranial direct current stimulation, and surgical intervention if a definitive seizure focus has been clearly recognized ( table 6-10 ). 60,70–77 …”

“…69 Other Interventions to Treat Super-refractory Status Epilepticus Several other approaches have been proposed to treat refractory status epilepticus and super-refractory status epilepticus, including immunotherapy, neuroactive steroids, neuromodulation, magnesium infusion, pyridoxine infusion, hypothermia, ketogenic diet, electroconvulsive therapy, inhaled ◆ Vagus nerve stimulation ◇ Not widely used ◇ A systematic review 72 found that 74% of 38 patients with refractory status epilepticus or super-refractory status epilepticus had seizure cessation after acute VNS implantation ◆ Deep brain stimulation ◆ Limited evidence ◆ Some data suggest that deep brain stimulation can control seizures in patients with epilepsy ◆ Target the anterior thalamic nucleus in super-refractory status epilepticus Pyridoxine (vitamin B 6 ) infusion ◆ Pyridoxine is required for the production of GABA ◆ Up to 80% of patients with established status epilepticus have pyridoxine deficiency 44 ◆ There are no clear dosing data ◆ Might be most beneficial in early status epilepticus (stage 1) Resective neurosurgery 76 ◆ Consider when an epileptogenic zone has been identified ◆ Can include focal, lobar, or multilobar resection; corpus callosotomy; hemispherectomy; or multiple subpial transections, either alone or in combination with focal resection Therapeutic hypothermia ◆ HYBERNATUS multicenter randomized controlled trial 77 failed to show any benefit in functional outcome at 3 months ◆ Antiseizure medication levels should be followed as hypothermia reduces drug clearance Transcranial direct current stimulation ◆ Emerging data for use in super-refractory status epilepticus ◆ Recent pilot study 73 showed that 10 patients with refractory status epilepticus benefited from 2-mA, 20-minute transcranial direct current stimulation sessions (ie, a reduction of 50% of median ictal epileptiform discharge rate per patient per session and a reduction of 25% in the immediate period after the intervention)anesthetics, transcranial direct current stimulation, and surgical intervention if a definitive seizure focus has been clearly recognized (TABLE 6-10) 60,[70][71][72][73][75][76][77]…”