Does continuous electroencephalography influence therapeutic decisions in neurocritical care?

OBJECTIVES: In the neurocritical care unit (neuro-ICU), the impact of continuous EEG (cEEG) on therapeutic decisions and prognostication, including outcome prediction using the Status Epilepticus Severity Score (STESS), is poorly investigated. We studied to what extent cEEG contributes to treatment decisions, and how this relates to clinical outcome and the use of STESS in neurocritical care. METHODS: We included patients admitted to the neuro-ICU or neurological step-down unit of a tertiary referral hospital between 05/2013 and 06/2015. Inclusion criteria were ≥20 h of cEEG monitoring and age ≥15 years. Exclusion criteria were primary epileptic and post-cardiac arrest encephalopathies. RESULTS: Ninety-eight patients met inclusion criteria, 80 of which had status epilepticus, including 14 with super-refractory status. Median length of cEEG monitoring was 50 h (range 21-374 h). Mean STESS was lower in patients with favorable outcome 1 year after discharge (modified Rankin Scale [mRS] 0-2) compared to patients with unfavorable outcome (mRS 3-6), albeit not statistically significant (mean STESS 2.3 ± 2.1 vs 3.6 ± 1.7, p = 0.09). STESS had a sensitivity of 80%, a specificity of 42%, and a negative predictive value of 93% for outcome. cEEG results changed treatment decisions in 76 patients, including escalation of antiepileptic treatment in 65 and reduction in 11 patients. CONCLUSION: Status Epilepticus Severity Score had a high negative predictive value but low sensitivity, suggesting that STESS should be used cautiously. Of note, cEEG results altered clinical decision-making in three of four patients, irrespective of the presence or absence of status epilepticus, confirming the clinical value of cEEG in neurocritical care.

Relationship between Status Epilepticus Severity Score and etiology in adult NCSE patients.

BACKGROUND AND PURPOSE: Nonconvulsive status epilepticus (NCSE) is a heterogeneous, severe neurological disorder of different etiologies. In this study, the outcomes of NCSE episodes was assessed in a large series of adult patients. Our objective was to evaluate relationship between Status Epilepticus Severity Score (STESS) and etiology and the role of etiological factors on predicting the outcomes. METHODS: In this retrospective study, the medical records of 95 patients over 18 years of age who were diagnosed with NCSE between June 2011 and December 2015 were reviewed. Their treatment and follow-up for NCSE was performed at the Epilepsy Unit in Department of Neurology, Antalya Research and Training Hospital. Etiological factors thought to be responsible for NCSE episodes as well as the prognostic data were retrieved. The etiological factors were classified into three groups as those with a known history of epilepsy (Group 1), primary neurological disorder (Group 2), or systemic/unknown etiology (Group 3). STESS was retrospectively applied to patients. RESULTS: There were 95 participants, 59 of whom were female. Group 1, Group 2, and Group 3 consisted of 11 (7 female), 54 (33 female), and 30 (19 female) patients, respectively. Of the 18 total deaths, 12 occurred in Group 2, and 6 in Group 3. The negative predictive value for a STESS score of ≤ 2 was 93.88% (+LR 2.05 95% CI: 1.44-2.9 and -LR 0.3 95% CI 0.10-0.84 ) in the overall study group. While the corresponding values for Group 1 (patients with epilepsy), Group 2 (patients with primary neurological disorder), and group 3 (patients with systemic or unknown etiology) were 100%, 92.59% (+LR 2.06 95%CI: 1.32-3.21 and -LR 0.28 95% CI 0.08-1.02 ) 83.33% (+LR 1.14 95%CI: 0.59-2.9 and -LR 0.80 95% CI 0.23-2.73). CONCLUSION: This study included the one of the largest patients series ever reported in whom STESS, a clinical scoring system proposed for use in patients with status epilepticus, has been implemented. Although STESS appeared to be quite useful for predicting a favorable outcome in NCSE patients with epilepsy and primary neurological disorders, its predictive value in patients with systemic or unknown etiology was lower. Further prospective studies including larger NCSE samples are warranted.

Outcome prediction in patients with acute repetitive seizures: Application of the Status Epilepticus Severity Score.

Acute repetitive seizures (ARS) pose a risk of hospital admission with status epilepticus and a mortality threat, which underscores the need for the early prediction of a clinical course. Unfortunately, little attention has been given to ARS in this context, even though we possess the appropriate predictive tools for the stages of status epilepticus. Therefore, the main aim of this study was to assess the prognostic value of the Status Epilepticus Severity Score (STESS) in the population of patients with ARS. The study included a population of 200 patients. Almost half of the patients had achieved seizure cessations after diazepam administration, whereas 19.5% progressed to status epilepticus despite antiepileptic drug treatment. Mortality reached 10.5% of the total population. The receiver operating characteristic (ROC) curve for prediction of death by the STESS had an area under the curve (AUC) of 0.901, with an optimal cutoff point for discrimination ≥2 (sensitivity 0.95, specificity 0.71, and Youden index 0.66). Hosmer-Lemeshow indicated good calibration of the STESS (chi-square goodness-of-fit test = 3.24; P = .919). The study shows excellent effectiveness of the STESS in the prognosis of the clinical course in patients with ARS. STESS may be a valuable tool for the proper planning of diagnostic and therapeutic activities in this population.

Prognostic scores in status epilepticus-a critical appraisal.

Currently, there are 4 published scales evaluating status epilepticus (SE) prognosis: the Status Epilepticus Severity Score (STESS), the Epidemiology-based Mortality score in Status Epilepticus (EMSE), the modified STESS (mSTESS), and the Encephalitis Nonconvulsive Status Epilepticus Diazepam Resistence Imaging Tracheal Intubation (END-IT) score. The first prognostic score published for SE, the STESS, is a simple and practical scale that evaluates patient prognosis upon admission and is used widely to predict the outcome and stratify patients. Another scale, which was developed based on large epidemiologic studies, the EMSE, is more easily adapted to different regions around the world when assessing individual risk and stratifying patients in interventional studies. The mSTESS was created by adding the modified Rankin Scale (mRS) to the STESS, which decreases the ceiling effect and increases the mortality prediction capabilities of the STESS. The END-IT is the only prognostic scale assessing functional outcome and is comprehensively simple and satisfyingly accurate. Evaluating the limitations of each of these scales aids in the exploration and advancement of SE prognostic scales, thereby facilitating better clinical interventions and scientific research.

Impact of timing of continuous intravenous anesthetic drug treatment on outcome in refractory status epilepticus.

BACKGROUND: Patients in refractory status epilepticus (RSE) may require treatment with continuous intravenous anesthetic drugs (cIVADs) for seizure control. The use of cIVADs, however, was recently associated with poor outcome in status epilepticus (SE), raising the question of whether cIVAD therapy should be delayed for attempts to halt seizures with repeated non-anesthetic antiepileptic drugs. In this study, we aimed to determine the impact of differences in therapeutic approaches on RSE outcome using timing of cIVAD therapy as a surrogate for treatment aggressiveness. METHODS: This was a retrospective cohort study over 14 years (n = 77) comparing patients with RSE treated with cIVADs within and after 48 h after RSE onset, and functional status at last follow-up was the primary outcome (good = return to premorbid baseline or modified Rankin Scale score of less than 3). Secondary outcomes included discharge functional status, in-hospital mortality, RSE termination, induction of burst suppression, use of thiopental, duration of RSE after initiation of cIVADs, duration of mechanical ventilation, and occurrence of super-refractory SE. Analysis was performed on the total cohort and on subgroups defined by RSE severity according to the Status Epilepticus Severity Score (STESS) and by the variables contained therein. RESULTS: Fifty-three (68.8%) patients received cIVADs within the first 48 h. Early cIVAD treatment was independently associated with good outcome (adjusted risk ratio [aRR] 3.175, 95% confidence interval [CI] 1.273-7.918; P = 0.013) as well as lower chance of both induction of burst suppression (aRR 0.661, 95% CI 0.507-0.861; P = 0.002) and use of thiopental (aRR 0.446, 95% CI 0.205-0.874; P = 0.043). RSE duration after cIVAD initiation was shorter in the early cIVAD cohort (hazard ratio 1.796, 95% CI 1.047-3.081; P = 0.033). Timing of cIVAD use did not impact the remaining secondary outcomes. Subgroup analysis revealed early cIVAD impact on the primary outcome to be driven by patients with STESS of less than 3. CONCLUSIONS: Patients with RSE treated with cIVADs may benefit from early initiation of such therapy.

Diagnostic value of Status Epilepticus Severity Score for survival conditions of patients with status epilepticus: A PRISMA-compliant systematic review and meta-analysis.

OBJECTIVE: In recent years, the Status Epilepticus Severity Score (STESS) has been widely used to predict survival conditions of patients with status epilepticus (SE). However, the diagnostic value of STESS has not yet been evaluated. We therefore performed this meta-analysis to assess the overall diagnostic accuracy of STESS for predicting survival condition of patients with SE. METHODS: Systemic searches for relevant published studies were conducted in EMBASE, PubMed, Web of Science, and Cochrange databases up to July 2, 2017. Quality Assessment of Diagnostic Accuracy Studies (QUADAS) was used to evaluate the quality of included studies. All statistical analyses were performed using Stata12.0 and Meta-DiSc software. RESULTS: A total of 11 studies including 12 observations with 1356 patients were included in this meta-analysis. Summary estimates of the diagnostic value of STESS for survival condition of patients with SE were listed as follows: sensitivity, 0.81 (95% confidence intervals (CI): 0.76-0.85); specificity, 0.53 (95% CI: 0.50-0.56); positive likelihood ratio (PLR), 1.86 (95% CI: 1.57-2.21); negative likelihood ratio (NLR), 0.38 (95% CI: 0.30-0.48); diagnostic odds ratio (DOR), 5.24 (95% CI: 3.49-7.87); and area under the curve (AUC), 0.81. Metaregression analysis showed that ethnicity, study design, publish year, and sample size did not significantly influence the diagnostic performance statistically (all P>0.05). CONCLUSIONS: The STESS is a promising candidate for predicting survival condition of patients with SE. However, the potential tool should be validated in well-designed studies with larger sample sizes.

Prevalence of non-convulsive seizures and electroencephalographic abnormalities in critically ill patients-A retrospective observational study.

OBJECTIVE: Electroencephalographic (EEG) abnormalities especially non-convulsive status epilepticus (NCSE) have been found to be associated with worse outcomes in critically ill patients. We aimed to assess the prevalence of non-convulsive seizures and electroencephalographic abnormalities in critically ill patients. Furthermore, we aimed to investigate any association between the type of EEG abnormality and outcomes including ICU mortality and successful ICU discharge. METHODS: This was a cross-sectional observational study carried out among critically ill patients in a mixed medical-surgical ICU from January 1, 2018 to May 15, 2020. A total of 178 records of 30 min bedside EEG records were found. EEG findings were grouped as normal, non-convulsive seizures (NCS), non-convulsive status epilepticus (NCSE), and other abnormalities. Descriptive analytical tools were used to characterize the case details in terms of the type of EEG abnormalities. Chi square test was used to describe the EEG abnormalities in terms of mortality. The status epilepticus severity scores (STESS) were further calculated for records with NCSE. These data were then analyzed for any association between STESS and mortality for cases with NCSE. RESULTS: The prevalence of EEG abnormality in our cohort of all critically ill patients was found to be 7.3% (170/2234). Among the patients with altered sensorium in whom EEG was done, 42.9% had non-conclusive seizure activity with 25.2% in NCSE. Though the study was not adequately powered, there was a definite trend towards a lower proportion of successful ICU discharge rates seen among patients with higher STESS (>2) with only 33.3% being discharged for patients with a STESS of 6 versus 92.9% for those with STESS 3. SIGNIFICANCE: When combined with a strong clinical suspicion, even a 30-min bedside EEG can result in detection of EEG abnormalities including NCS and NCSE. Hence, EEG should be regularly included in the evaluation of critically ill patients with altered sensorium. PLAIN LANGUAGE SUMMARY: Electroencephalographic (EEG) abnormalities and seizures can have high prevalence in critically ill patients. These abnormalities notably, non-convulsive status epilepticus (NCSE) has been found to be associated with poor patient outcomes. This was a retrospective observational study analyzing 178 EEG records, from a mixed medical-surgical ICU. The indication for obtaining an EEG was based solely on the clinical suspicion of the treating physician. The study found a high prevalence of EEG abnormalities in 96.5% in whom it was obtained with 42.9% having any seizure activity and 28.8% having NCSE. The study was not powered for detection of association of the EEG abnormalities with clinical outcomes. However, a definite trend towards decreased chances of successful discharge from the ICU was seen. This study used strong clinical suspicion in patients with altered sensorium to obtain an EEG. High detection rates of EEG abnormalities were recorded in this study. Hence, combination of clinical judgement and EEG can improve detection of EEG abnormalities and NCSE.

Determinants of Outcomes in Convulsive Status Epilepticus: An Observational Study at a Tertiary Care Center in North India.

Objective Status epilepticus (SE) presents a critical neurological emergency associated with high morbidity and mortality rates worldwide. However, the determinants influencing outcomes in SE within specific regional contexts remain less explored, especially within North India. Understanding the factors influencing the prognosis of SE in this region is crucial for tailored therapeutic approaches and improved patient outcomes.  Materials and methods This observational study was conducted at Jawaharlal Nehru Medical College, Aligarh, India, from December 1, 2020, to November 31, 2022. Patients who presented with convulsive SE lasting more than five minutes or repetitive and discrete seizures with impaired consciousness between the interictal period for at least 30 minutes were included in the study. Their clinical and biochemical variables at presentation were assessed and correlated with the outcome. Results Out of the 110 patients included in the study, males represented 59.1% (n=65), outnumbering females, who comprised 40.9% (n=45). Favourable outcome was observed in 66.36% (n=73) of patients, and unfavourable outcome was observed in 33.63% (n=37). The mean time interval between seizure onset to the patient's arrival at the hospital was 5.30 ± 4.96 hours, and the mean time interval between seizure onset to the point of seizure control was 7.10 ± 6.38 hours. On analysing the factors associated with unfavourable outcome, the type of seizure at onset (p=0.021), Glasgow Coma Scale (GCS) of <=12 at presentation (p<0.001), presence of refractory seizure (p<0.001), presence of abnormal epileptiform discharges on electroencephalography (p=0.001), Status Epilepticus Severity Score (STESS) of >2 (p<0.001), serum lactate levels (p<0.001), duration of hospital stay (p=0.004), time interval between seizure onset to hospital arrival (p<0.001) and time interval between seizure onset to the point of seizure control (p<0.001) showed significant association. However, on analysing the independent risk factors of unfavourable outcome using multivariate logistic regression, only duration of hospital stay (p<0.001, odds ratio (OR): 1.205, 95% confidence interval (CI): 1.046-1.389), and GCS of less than or equal to 12 at presentation (p<0.001, OR: 12.354, 95% CI: 2.974-51.319) showed significant association. Conclusions Our study highlighted key clinical and time-related parameters influencing the outcome of convulsive SE. Understanding these factors is crucial for better treatment and improved patient outcomes. Further research is essential for refining interventions in this complex condition.

Status epilepticus in patients with glioblastoma: Clinical characteristics, risk factors, and epileptological outcome.

PURPOSE: Epilepsy is a common comorbidity in patients with glioblastoma, however, clinical data on status epilepticus (SE) in these patients is sparse. We aimed to investigate the risk factors associated with the occurrence and adverse outcomes of SE in glioblastoma patients. METHODS: We retrospectively analysed electronic medical records of patients with de-novo glioblastoma treated at our institution between 01/2006 and 01/2020 and collected data on patient, tumour, and SE characteristics. RESULTS: In the final cohort, 292/520 (56.2 %) patients developed seizures, with 48 (9.4 % of the entire cohort and 16.4 % of patients with epilepsy, PWE) experiencing SE at some point during the course of their disease. SE was the first symptom of the tumour in 6 cases (1.2 %) and the first manifestation of epilepsy in 18 PWE (6.2 %). Most SE episodes occurred postoperatively (n = 37, 77.1 %). SE occurrence in PWE was associated with postoperative seizures and drug-resistant epilepsy. Adverse outcome (in-house mortality or admission to palliative care, 10/48 patients, 20.8 %), was independently associated with higher status epilepticus severity score (STESS) and Charlson Comorbidity Index (CCI), but not tumour progression. 32/48 SE patients (66.7 %) were successfully treated with first- and second-line agents, while escalation to third-line agents was successful in 6 (12.5 %) cases. CONCLUSION: Our data suggests a link between the occurrence of SE, postoperative seizures, and drug-resistant epilepsy. Despite the dismal oncological prognosis, SE was successfully treated in 79.2 % of the cases. Higher STESS and CCI were associated with adverse SE outcomes.

New-Onset Refractory Status Epilepticus Secondary to COVID-19 Infection in Adults: A Systematic Review.

Background: New-onset refractory status epilepticus (NORSE) has been reported in the scientific literature as a phenomenon associated with the COVID-19 infection. Given the resurgence of the newer variants of COVID-19 added with its multi-system manifestations, this project was conducted to study the clinical picture of NORSE secondary to COVID-19 infection. Methods: Three electronic databases were searched using an extensive search strategy from November 2019 to December 2021. Patients reporting NORSE secondary to COVID-19 were included in this review. The status epilepticus severity score (STESS) was calculated by the study authors for individual patients. Statistical analysis was performed using SPSS version 26 with a p-value <0.05 as statistically significant. Results: After screening, 12 patients were included in this study with a mean age of 61.6 ± 19.0-year olds. The most common type of status epilepticus reported in our study population was non-convulsive status epilepticus (NCSE) (7 out of 12 patients, 58.3%). The linear regression model revealed that STESS scores were significantly influenced by patients' age (p = 0.004) and intra-hospital occurrence (IHO) of status epilepticus (p = 0.026). Overall, 8 patients (66.7%) were discharged without complications. Conclusion: Given the observed association of STESS with the aging population and IHO of status epilepticus, special attention is due to the caretakers of this population, while further studies are needed to further build upon this review.

Clinical findings, etiological factors, and prognosis markers in status epilepticus: a university hospital experience.

OBJECTIVE: To determine the factors affecting mortality and disability in status epilepticus (SE) and to evaluate the prediction ability of the Status Epilepticus Severity Score (STESS) for disability and mortality. MATERIALS AND METHOD: The demographic and clinical characteristics, prognosis and prognosis predictors of 72 patients who were diagnosed with SE between 2013 and 2018 were retrospectively evaluated. The STESS was used to predict prognosis, and the modified Rankin scale (mRS) was used to determine the disability at discharge. RESULTS: The study population had a mean age of 45.4 ± 20.7, and it was found that mortality was 22.2% and acute symptomatic etiology played a 54.1% role in etiology. Advanced age, refractory SE or super-refractory SE, acute symptomatic etiology, and a history of epilepsy were related to mortality, symptomatic etiology (acute, progressive, remote), a history of hospitalization and epilepsy in intensive care or in other departments other than the neurology department were associated with disability. The sensitivity of STESS in predicting mortality was 100%, specificity was 69%, accuracy was 76.4%, positive predictive value (PPV) was 48.5%, and the negative predictive value (NPV) was 100%. The sensitivity of STESS in predicting mobilization during discharge was 55.6% with a 63.9% specificity and 59.7% accuracy, PPV was 60.6%, and NPV was 59%. CONCLUSION: It was observed that STESS strongly predicts a good prognosis; however, it was not found to be useful in predicting motor disability during discharge. Thus, new studies should be conducted to predict and evaluate mobility in SE patients at discharge.

Utility of the END-IT Score to Predict the outcome of Childhood Status Epilepticus: A Retrospective Cohort Study.

INTRODUCTION: Scoring systems to predict outcomes in pediatric status epilepticus (SE) are limited. We sought to assess usefulness of the END-IT score in pediatric SE. METHODOLOGY: We conducted a retrospective study at a tertiary hospital in New Delhi, India. Children aged 1 month-18 years who presented with seizure for ≥5 min/actively convulsing to emergency were enrolled. END-IT score was calculated and correlated with outcome at discharge using Pediatric Overall Performance Category (POPC) scale, in-hospital mortality, and progression to refractory and super-refractory SE (SRSE). RESULTS: We enrolled 140 children (mean age 5.8 years; 67.1% males). Seven children died and 15 had unfavorable outcomes. The predictive accuracy of END-IT at a cutoff of > 2: for unfavorable outcome (POPC score ≥3) was: sensitivity 0.73 (95% CI: 0.45-0.92), specificity 0.94 (95% CI: 0.89-0.98), PPV 0.61 (95% CI: 0.36-0.83), NPV 0.97 (95% CI: 0.92-0.99), positive likelihood ratio (13.09), F1 score (0.666); for death: sensitivity 0.86 (95% CI: 0.42-0.99), specificity 0.91 (95% CI: 0.85-0.95), PPV 0.33 (95% CI: 0.13-0.59), NPV 0.99 (95% CI: 0.96-1.00), F1 score (0.48); for RSE: sensitivity 0.80 (95%CI: 0.28-0.99), specificity 0.90 (95% CI: 0.83-0.94), PPV 0.22 (95% CI: 0.06-0.48) NPV 0.99 (95% CI: 0.96-1.00), F1 score (0.35); for SRSE: sensitivity 0.67 (95% CI: 0.22-0.96) specificity 0.75 (95% CI: 0.66-0.82), PPV 0.22 (95% CI: 0.06-0.48) NPV 0.98 (95% CI: 0.94-0.99), F1 score (0.33). CONCLUSION: We demonstrate utility of the END-IT score to predict short-term outcomes as well as progression to refractory and SRSE for the first time among children with SE.

Status epilepticus severity score as a predictor for the length of stay at hospital for acute-phase treatment in convulsive status epilepticus.

To date, hospital length of stay (LOS) determinants for convulsive status epilepticus's (CSE) acute-phase treatment have not been sufficiently investigated, as opposed to those for status epilepticus's (SE) outcome predictors, such as status epilepticus severity score (STESS). Here, we aimed at assessing the significance of STESS in the LOS in patients with CSE. We retrospectively reviewed consecutive adult patients with CSE who were transported to the emergency department of our urban tertiary care hospital in Tokyo, Japan. The study period was from August 2010 to September 2015. The primary endpoint was the LOS of patients with CSE who were directly discharged after acute-phase treatment, and survival analysis for LOS until discharge was conducted. As a result, among 132 eligible patients with CSE admitted to our hospital, 96 (72.7%) were directly discharged with a median LOS of 10 days (IQR: 4-19 days). CSE patients with severe seizures, represented by higher STESS (≥3), had a significantly longer LOS after adjustments with multiple covariates (p = 0.016, in restricted mean survival time analysis). Additionally, prediction for the binomial longer/shorter LOS achieved better performance when STESS was incorporated into the prediction model. Our findings indicate that STESS can also be used as a rough predictor of longer LOS at index admission of patients with CSE.

Determinants of Outcome in Convulsive Status Epilepticus in Adults: An Ambispective Study from Central India.

BACKGROUND: The determinants of the outcome in adult convulsive status epilepticus(CSE), also the implication of the value of mean arterial blood pressure (MAP), and random blood sugar at admission on the outcome are not clear. OBJECTIVES: The objective of this study is to look for the determinants of unfavorable outcome in CSE. MATERIALS AND METHODS: Ambispectively gathered data from 55 patients, treated consecutively with identical protocol during January 2010-December 2016, were analyzed. The demographic and clinical variables were identified and correlated with outcome in each individual. RESULTS: There were 65.45% males and 34.55% females. Favorable outcome (conscious and discharged) was seen in 63.6%, unfavorable (death 14.5%, absent cortical functions 10.9%, and inability to wean-off anesthetic agents 10.9%). The parameters associated with unfavorable outcome were female gender (odds ratio [OR]: 1.45), MAP ≤80 mmHg (OR: 2.57), time to first medical attention >5 h (OR: 127.8), and time to control clinical seizures >3.5 h (OR: 7.87). Almost 44.2% of patients with SE severity score >2 had unfavorable outcome (sensitivity 75% and specificity 45.7%). New scoring system, the CSE outcome score (CSEOS, developed by combining the predictors associated with higher odds of poor outcome), predicted the poor outcome with the sensitivity and specificity of 90% and 54.29%, respectively. DISCUSSION AND CONCLUSION: Low MAP and delay of >3.5 h in treatment initiation or seizure control are the key determinants of poor outcome in CSE. With the incorporation of CSEOS, we believe that our findings can be helpful in the process of clinical decision-making and prognostication of patients with CSE.

Uric acid is a useful marker to differentiate between responsive and refractory status epilepticus.

OBJECTIVES: Early recognition of refractory status epilepticus (RSE) is essential to select an appropriate treatment strategy and is closely associated with the outcome. Only few studies of RSE biomarkers exist; hence, we investigated the serum levels of uric acid (UA), albumin, and C-reactive protein (CRP) as potential serologic biomarkers for RSE. PATIENTS AND METHODS: Consecutive status epilepticus (SE) patients who had serial conventional blood tests in a referral hospital over a period of 10 years were retrospectively analyzed. Patients with anoxic encephalopathy, renal failure, acute stroke, and myocardial infarction were excluded. RSE was defined as seizure continuing after the first- and second-line treatments. We also assessed SE severity in all included patients using the Status Epilepticus Severity Score (STESS). General demographics and blood test findings were compared between responsive SE and RSE patients. RESULTS: A total of 141 patients (99 responsive and 42 refractory) were recruited from our SE registry. Compared to responsive patients, patients with RSE showed a higher STESS, lower initial albumin levels, lower initial UA levels, lower follow-up UA levels, and greater reduction of UA levels. The RSE group more frequently had acute symptomatic etiology, showed longer hospitalization, and had poorer functional outcomes compared to the responsive-SE group. All evaluated UA level parameters exhibited significant areas under the curve in receiver operating characteristic analyses, predictive of RSE. Initial UA levels, as well as changes therein, were significantly associated with RSE in multivariate logistic regression analysis. CONCLUSION: UA levels at initial and follow-up evaluations, and changes therein differentiated responsive SE and RSE, demonstrating the feasibility of UA serum levels as a biomarker for RSE.

Study of Refractory Status Epilepticus from a Tertiary Care Center.

OBJECTIVES: To determine the proportion of refractory status epilepticus (RSE) and super-RSE (SRSE) among patients with status epilepticus (SE) and to analyze RSE and non-RSE (NRSE) in terms of etiology and predictors for RSE. MATERIALS AND METHODS: Patients were identified from discharge summaries database with keywords of SE and records of the portable electroencephalogram (EEG) machine from January 2011 to March 2016. RESULTS: Two hundred and eighteen events were included in the study with 114 (52.3%) males, bimodal age preponderance age <5 years 30%, and second peak in age 15-65 years 52.8%, preexisting seizures were present in 34.4% (n = 75). Nearly 77.1% had NRSE (n = 168) and 22.9% had RSE (n = 50). This included 17 patients with SRSE (n = 17, 7.8% of all SE). Central nervous system (CNS) infection was a single largest etiological group in SE (69/218, 31.7%). In RSE, autoimmune encephalitis (17/50) and CNS infection (13/50) were the largest groups. De novo seizures (P = 0.007), low sensorium at admission (P = 0.001), low albumin at admission (P = 0.002), and first EEG being abnormal (P = 0.001) were risk factors on bivariate analysis. An unfavorable status epilepticus severity score (STESS) was predictive for RSE (P = 0.001). On multivariate analysis, de novo seizures (P = 0.009) and abnormal EEG at admission (P = 0.03) were predictive for RSE. CONCLUSIONS: Fifty patients had RSE (22.9%), of which 17 went on to become SRSE (7.8%). Unfavorable STESS score was predictive for RSE on bivariate analysis. On multivariate analysis, de novo seizures and abnormal initial EEG were predictors of RSE.

Association of seizure duration and outcome in refractory status epilepticus.

The aim of the study was to identify factors influencing long-term outcome and to evaluate the prognostic power of the Status Epilepticus Severity Score (STESS) in refractory status epilepticus (RSE). We retrospectively extracted data on baseline characteristics, RSE details, and hospital course including complications from all patients treated for RSE in our institution between January 2001 and January 2013. Functional outcome was assessed using the modified Rankin Scale (mRS) and was defined as good when either RSE did not lead to functional decline or when the resulting mRS score was 2 or below. Seventy-one episodes in 65 patients were analyzed. The median follow-up time was 12 weeks (IQR 6-35), two patients were lost to follow-up. Poor functional long-term outcome was observed in 42/69 (60.9%) episodes. In-hospital mortality occurred in 13/71 (18.3%) episodes. Multivariable analysis revealed that STESS ≥ 3, longer RSE duration, and sepsis were independently related to poor functional long-term outcome. Receiver operating characteristics (ROC) curve analyses confirmed the cut-off dichotomization into STESS ≥ 3 and STESS < 3 for optimal discrimination between good and poor outcome (AUC = 0.671, p = 0.002, YI = 0.368, NPV = 0.607, PPV = 0.756) and revealed an RSE duration of 10 days as a significant cut-off point associated with outcome (AUC = 0.712, p = 0.012, YI = 0.310; NPV = 0.545, PPV = 0.750). In conclusion, STESS and RSE duration represent relevant scores and parameters impacting long-term outcome after RSE. A shorter RSE duration is associated with better outcome and, therefore, rapid and adequate treatment for seizure termination should be enforced.