Antiepileptic and anesthetic drugs in the intensive care unit. Their impact on non-convulsive status epilepticus mortality / Drogas antiepilépticas y anestésicas en la unidad de terapia intensiva. Su impacto en la mortalidad en el estado de mal epiléptico no convulsivo

Abstract Background: Status epilepticus (SE) is a neurological emergency. Non-convulsive status epilepticus (NCSE) can only be diagnosed by electroencephalogram (EEG) because the motor clinical symptoms are usually subtle or absent, with high mortality. The best treatment is still unknown. Objectives: Our aim was to assess anticonvulsive and anesthetic drugs in NCSE and their correlation with Epidemiology-based Mortality Score in Status Epilepticus (EMSE), Status Epilepticus Severity Score (STESS) and mortality. Methods: Retrospective, observational, descriptive, cross-sectional study. Ninety patients in intensive care unit over 18 years-old (57 females [63.3%] and 33 males [36.6%], mean age 63.5 years [SD ± 19]) with NCSE, at the Buenos Aires British Hospital. Data was collected between January 2018 and June 2021. An adjusted mul tivariate statistical analysis was performed. Ninety-five (95%) CI, p<0.05 as statistically significant. EMSE and STESS were used in this study. Results: Total mortality rate was 37.8% (34/90), and in patients ≥ 65 years-old (54/90) it was 40.7% (22/54). Patients with 0-2 STESS (11/90) were discharged, while those with STESS ≥ 3 (79/90) had a 43% death rate (34/79). Patients with EMSE < 34 (27/90) had 7.4% (2/27) death rate, while those with EMSE ≥ 34 (63/90) had 50.8% (32/63). No significant differences were found in survival with regard to the number of antiepileptic drugs administered. Pa tients treated with anesthetics presented a 2.6-fold death risk increase (95% CI 1.001-6.83). Discussion: It could be assumed that mortality rate increases 2.6-fold when patients are treated with anes thetic drugs, regardless of the number of antiepileptic drugs previously administered.

Resumen Introducción: El estado de mal epiléptico (SE) es una emergencia neurológica. El SE no convulsivo (SENC) se diagnostica únicamente por electroencefalograma de bido a la ausencia o sutileza de sintomatología clínica motora, con una mortalidad elevada. No se conoce aún el mejor tratamiento. Objetivos: Evaluar drogas anticonvulsivas y anestési cas en el SENC y su correlación con Epidemiology-based Mortality Score in Status Epilepticus (EMSE), Status Epilep ticus Severity Score (STESS) y el índice de mortalidad. Métodos: Estudio retrospectivo, observacional, de scriptivo, de corte transversal. Noventa pacientes ≥ 18 años (57 mujeres [63.3%] y 33 hombres [36.6%], media de edad 63.5 años [DS ± 19]) con diagnóstico de SENC, en el Hospital Británico. Estudio realizado entre enero 2018 y junio 2021. Análisis estadístico multivariado ajustado. IC 95% p< 0.05 como estadísticamente significativo. Se utilizaron escalas de EMSE y STESS. Resultados: La mortalidad total fue de 37.8% (34/90). Los pacientes ≥ 65 años (54/90) presentaron una mayor tasa de muerte 40.7% (22/54), todos aquellos con STESS de 0-2 (11/90) egresaron, mientras que entre los que presentaron ≥ 3 (79/90) el 43% (34/79) falleció. De los pacientes con EMSE < 34 (27/90) dos fallecieron (7.4%) y de aquellos con EMSE ≥ 34 (63/90) falleció el 50.8% (32/63). No hallamos diferencias significativas entre cantidad de drogas antiepilépticas utiliza das y supervivencia. Pacientes con anestésicos tuvieron un aumento del riesgo de muerte 2.6 veces (IC 95% 1.001-6.83). Discusión: De acuerdo a esto la mortalidad con drogas anestésicas aumenta, independientemente de la cantidad de drogas anticonvulsivas utilizadas previamente.

Simple partial status epilepticus presenting with jargon aphasia and focal hyperperfusion demonstrated by ictal pulsed arterial spin labeling MRI

@#We report a case of 74-year-old lady, presented with recurrent jargon aphasia as simple partial status epilepticus (SPSE) which lasted for a few days to a few weeks, following a brain abscess removal from the left temporo-parieto-occipital region at the age of 71 years. The ictal activity on electroencephalogram was documented at left posterior quadrant, where marked hyperperfusion was clearly visualized by perfusion image acquired with magnetic resonance imaging (MRI) using pulsed arterial spin-labeling (PASL). Jargon aphasia as a primary feature of simple partial status epilepticus is so uncommon that only few cases have been reported. Furthermore, this report suggests that MRI using PASL is a promising method not only to localize the seizure foci but also to follow up the corresponding regional cerebral blood flow changes noninvasively.

Can patients with non-convulsive seizure be identified in the emergency department? / 世界急诊医学杂志（英文）

@#BACKGROUND: Non-convulsive seizure (NCS) is an underdiagnosed, potentially treatable emergency with significant mortality and morbidity. The objective of this study is to examine the characteristics of patients with NCS presenting with altered mental status (AMS) and diagnosed with electroencephalography (EEG), to identify the factors that could increase the pre-test probability of NCS. METHODS: Retrospective study using the data collected prospectively. Inclusion criteria:patients older than 13 years with AMS. Exclusion criteria: (1) immediately correctable AMS (e.g., hypoglycemia, opiod overdose); (2) inability to undergo EEG; (3) hemodynamic instability. Outcomes compared between NCS and non-NCS cases: vital signs, lactate level, gender, witnessed seizure, use of anticonvulsive in the field or in the ED, history of seizure or stroke, head injury, abnormal neurological finding and new abnormal findings on head CT. Data presented as medians and quartiles for categorical and percentages with 95％CI for continuous variables. Univariate analyses were performed with Man-Whitney U and Fisher's Exact tests. A multivariate analysis model was used to test the predictive value of clinical variables in identifying NCS. RESULTS: From 332 patients (median age 66 years, quartiles 50–78), 16 were diagnosed with NCS (5％, 95％CI 3％–8％). Only age was significantly different between the NCS vs. non-NCS groups in both univariate (P=0.032) and multivariate analyses (P=0.016). CONCLUSION: Other than age, no other clinically useful variable could identify patients at high risk of NCS. ED physicians should have a high suspicion for NCS and should order EEG for these patients more liberally.

Quantitative EEG Characteristics of Periodic Lateralized Epileptiform Discharges according to Benzodiazepine Responsiveness

BACKGROUND: Periodic lateralized epileptiform discharges (PLEDs) are associated with altered consciousness in 75% of patients. Major controversy about PLEDs is whether they are ictal or interictal phenomenon. Diagnosis of non-convulsive status epilepticus is often guided by response to benzodiazepine. We conducted a study to evaluate quantitative differences of EEG activity with PLEDs according to their response to acute benzodiazepine trial. METHODS: Nineteen patients with altered consciousness (stupor or coma) for whom the electroencephalography (EEG) recording with acute benzodiazepine trial was undertaken within 24 hours of onset of altered consciousness were retrospectively enrolled. Morphology of PLEDs including amplitude, frequency, and variability of the frequency was analyzed. Quantitative analysis of EEGs includes spectral power, spectral coherence, and graph theory analysis. Results of the analyses were compared between patients whose PLEDs were abolished by benzodiazepine (BDZ-R group) and those whose PLEDs persisted (BDZ-NR group). RESULTS: Morphologic variables were not different between two groups. In BDZ-R group, alpha-1 activity was increased in both frontopolar areas. Beta activity was also increased in both frontal areas while delta activity was reduced. In BDZ-R group, alpha-1 and beta activities were more coherent between bilateral hemispheres in frontal, anterior temporal, and central areas. Coherence line topographic map also revealed more bilaterally symmetric pattern in BDZ-R group. Network characteristics revealed by graph theory analysis did not differ between the two groups. CONCLUSIONS: Greater higher frequency activity (alpha-1 and beta) and lesser lower frequency activity (delta) in frontal areas, and more coherent activity in higher frequency band between hemispheres were associated with benzodiazepine responsiveness.

Clinical analysis of five elderly patients with non-convulsive status epilepticus / 第二军医大学学报

Objective: The non-convulsive status epilepticus (NCSE) is easy misdiagnosed due to its complex etiology, clinical manifestations. It is more difficult to diagnose and treat for elderly patients with multiple basic diseases. The purpose of this study is to investigate the clinical characteristics of elderly patients with NCSE, therapy, diagnosis, and the value of long-range video electroencephalography (LV-EEG). Methods: The clinical and electroencephalography (EEG) data of the five elderly patients with NCSE in my hospital were analyzed retrospectively.Results: Five patients showed episodes of abnormal behavior during seizure (5/5). There were 3 patients with previous history of epilepsy after cerebral infarction (3/5), 1 patient diagnosed intracranial infection because of NCSE episodes to consultation (1/5), and 1 case with previous history of epilepsy (1/5). The V-EEG of the 5 patients showed persistent epileptic form discharges during seizure. Intravenous diazepam had good effect to the 5 patients during seizure. Seizure of the 5 cases was controlled acceptably with different antiepileptic drugs according to different epilepsy forms.Conclusions: The abnormal mind and behavior is still main performance in elderly patients with NCSE. The LV-EEG provides reliable foundation for diagnosis of the disease. The rational use of antiepileptic drugs is effective. Intravenous diazepam slow for elderly patients with NCSE is applied as well.

Non-Convulsive Status Epilepticus as a Manifestation of Hashimoto's Encephalopathy

No abstract available.

Estado epiléptico no convulsivo infantil / Non convulsive status epilepticus in children

Introduction: Status Epilepticus (SE) is a medical emergency with high morbimortality. Non-convulsive Status Epilepticus (NCSE) is defined as electroencephalographic crises in the absence of clinical motor symptoms. Objective: A restrospective study of NCSE in our population. Patients and Methods: Charts of 30 patients in a Child Neurology Clinic seen between December 1999 and June 2008 were reviewed. According to the characteristics of the episode, they were classified as a) Typical absence, b) Atypical absence, c) Partial Complex episode. Results: Of the 30 patients, 15 (50%) were males. Median age was 46 months. Clinically, 63% of the children suffered from complex partial seizures, 30% atypical absences, 7% typical absences. Cryptogenic SE was most frequent (47%), with a mortality of 3%. Discussion: Pediatric patients have a higher risk of NCSE than adults do. Most patients already carried a diagnosis of Epilepsy, cerebral infarcts were the second most frequent cause of NCSE. They should all be monitored through EEGs. Neuroimages are of great value since outcome depends on the etiology. In summary, clinical suspicion, a history of epilepsy supported by an EEG (best if prolonged) allow early diagnosis and treatment.

Introducción: El Estado Epiléptico (EE) es una emergencia médica con alta morbimortalidad. El Estado Epiléptico No Convulsivo (EENC) es definido por la presencia de crisis electroencefalograficas en ausencia de crisis motoras clínicas. Objetivo: Realizar una descripción retrospectiva de los EENC que se presentaron en la población pediátrica atendida en nuestro centro. Pacientes y Método: Se revisaron los registros de 30 pacientes controlados neurología infantil que presentaron EENC entre diciembre de 1999 y junio de 2008. Según el tipo de crisis se clasificó en a) EENC ausencia típica; b) EENC ausencias atípicas y c) EENC parcial complejo. Según etiología se uso la clasificación de Hauser modificada. Resultados: Se analizaron 30 pacientes. Quince (50%) varones. La mediana de edad fue 46 meses. 63% fueron EENC parcial complejo, 30% EENC ausencias atípicas y 7% EENC ausencias típicas. El EE criptogénico fue el más frecuente (47%). La mortalidad fue de 3%. Discusión: Los pacientes pediátricos tienen mayor riesgo de EENC en relación a los adultos. La gran mayoría de los pacientes con EENC ya tenían el diagnóstico de epilepsia. Los infartos cerebrales fueron la segunda causa de EENC, estos deben ser monitorizados con EEG ante la sospecha de EENC. Las neuroimágenes para precisar el diagnóstico son de gran valor dado que el pronóstico de los pacientes con EENC depende de la etiología subyacente. En conclusión, la sospecha clínica, el antecedente de epilepsia y el apoyo con un EEG, especialmente prolongado, permite el diagnóstico oportuno y el tratamiento precoz.

Estado confusional agudo como manifestação de status epilepticus não-convulsivo em criança previamente hígida: relato de caso / Acute confusional state in a child with non-convulsive status epilepticus: case report

INTRODUÇÃO: O estado confusional em crianças pode ter várias causas. Entre elas está o estado de mal não-convulsivo. OBJETIVO: Relatamos o caso de um paciente que se apresentou ao serviço de emergência com confusão mental. Após investigação preliminar, o EEG mostrou tratar-se de estado de mal de ausência. RESULTADO: A administração de Diazepam endovenoso seguiu-se normalização do traçado eletroencefalográfico e melhora clínica do paciente. CONCLUSÃO: O EEG é fundamental para se diagnosticar e tratar quadros de estado de mal epiléptico não-convulsivo.

INTRODUCTION: There are many causes to acute confusional state in children. Non-convulsive status epilepticus is one of them. OBJECTIVE: We report the case of a patient who came to our emergency service with confusion. After preliminary investigation the EEG revealed abnormalities consistent with absence status. RESULTS: After treatment with diazepam intravenously occurred normalization of the EEG and, clinically, the patient was better. CONCLUSION: The EEG is crucial in the evaluation of patients with non-convulsive status epilepticus.

Non-convulsive partial seizure presenting with psychiatric symptoms

A 46-year-old man presented with a six-month history of recurrent episodes of abnormal behaviors characterized by agitation, anxiety, aggression, impulsion, and depression. They were not accompanied by obvious convulsions. Brain MRI demonstrated cerebromalacia from previous traumatic brain injury in both frontal and left anterior temporal lobe. Interictal EEG showed a focal seizure disorder arising from both temporal areas. Following antiepileptic medication, the abnormal behaviors disappeared. These results suggest that non-convulsive status epilepticus or a cluster of seizures could account for prolonged behavioral disturbances.