Intravenous immunoglobulins for refractory status epilepticus, part I: A scoping systematic review of the adult literature.

PURPOSE: Our goal was to perform a scoping systematic review of the literature on the use of intravenous immunoglobulins (IVIG) for refractory status epilepticus (RSE) in adults. METHOD: Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Healthstar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to May 2016), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers. RESULTS: Twenty-four original articles were identified. A total of 33 adult patients were described as receiving IVIG for RSE. Seizure reduction/control with IVIG occurred in 15 of the 33 patients (45.4%), with 1 (3.0%) and 14 (42.4%) displaying partial and complete responses respectively. No adverse events were recorded. CONCLUSION: Oxford level 4, GRADE D evidence exists to suggest an unclear impact of IVIG therapy in adult RSE. Routine use of IVIG in adult RSE cannot be recommended at this time.

Plasmapheresis for refractory status epilepticus Part II: A scoping systematic review of the pediatric literature.

BACKGROUND: Our goal was to perform a scoping systematic review of the literature on the use of plasmapheresis or plasma exchange (PE) for refractory status epilepticus (RSE) in children. METHODS: Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Healthstar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to May 2016), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers. RESULTS: Twenty-two original articles were identified, with 37 pediatric patients. The mean age of the patients was 8.3 years (age median: 8.5, range: 0.6 years-17 years). Seizure response to PE therapy occurred in 9 of the 37 patients (24.3%) included in the review, with 7 patients (18.9%) displaying resolution of seizures and 2 patients (5.4%) displaying a partial reduction in seizure volume. Twenty-eight of the 37 patients (75.7%) had no response to PE therapy. No adverse events were recorded. CONCLUSIONS: Oxford level 4, GRADE D evidence exists to suggest little to no benefit of PE in pediatric RSE. Routine application of PE for pediatric RSE cannot be recommended at this time.

Plasmapheresis for refractory status epilepticus, part I: A scoping systematic review of the adult literature.

PURPOSE: Our goal was to perform a scoping systematic review of the literature on the use of plasmapheresis or plasma exchange (PE) for refractory status epilepticus (RSE) in adults. METHODS: Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Healthstar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to May 2016), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers. RESULTS: Twenty-two original articles were identified. Twenty-seven adult patients were described in these articles, with a variety of autoimmune conditions leading to RSE. Seizure response with the application of PE therapy occurred in 14 of the 27 patients (51.9%), with 1 (3.7%) and 13 (48.1%) displaying partial and complete responses respectively. Generalized RSE was the most likely seizure subtype to respond to PE therapy. One patient had recorded an adverse events related to PE therapy. CONCLUSIONS: Oxford level 4, GRADE D evidence exists to suggest an uncertain response of adult autoimmune RSE to PE therapy. Thus, the routine application of PE therapy for adult autoimmune RSE cannot be recommended at this time.

Electroconvulsive therapy for refractory status epilepticus: A systematic review.

BACKGROUND: Our goal was to perform an extensive systematic review of the literature on the use of electroconvulsive therapy (ECT) for refractory status epilepticus (RSE). METHODS: Articles from MEDLINE, BIOSIS, EMBASE, Healthstar, Global Health, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to August 2015), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers. RESULTS: We identified 14 original articles with a total of 19 patients receiving ECT for RSE. Of the 19 patients, 15 were adult, and 4 were pediatric. All studies were retrospective in nature. Seizure reduction/control with the application of ECT occurred in 11 of the 19 patients (57.9%), with 4 (21.0%) and 7 (36.8%) displaying partial and complete responses respectively. Seizures control lasted for variable duration, with the most commonly quoted duration ranging from 2 weeks to 3 months. Data on patient functional outcome was available in 13 patients, with 10 patients falling into the categories of dead or severely disabled. All studies were an Oxford level 4, GRADE D level of evidence. CONCLUSIONS: Oxford level 4, GRADE D evidence exists to suggest an improvement in seizure control with ECT application for RSE. Routine use of ECT cannot be recommended at this time. Further prospective study of this therapy is required in order to determine its efficacy in this setting.

Lateral plating of the temporal bone: Hemostatic technique for complex transverse fractures of the petrous temporal bone.

BACKGROUND: Transverse petrous temporal bone fractures are commonly associated with significant intracranial trauma. Diastases of these fractures can lead to issues with hemostasis in the setting of venous sinus or petrous internal carotid artery (ICA) injuries. OBJECTIVE: To describe a rare case of a severe displaced transverse petrous temporal bone fracture with impending intra-operative exsanguination, treated with fracture reduction and lateral plating in order to achieve hemostasis. METHODS: We retrospectively reviewed the records of a patient admitted to the neurosurgical department with a hyperacute epidural hematoma (EDH) secondary to a transverse petrous temporal bone fracture with venous sinus and petrous ICA injuries. RESULTS: A 22 year old male was admitted for a severe traumatic brain injury leading to a left displaced transverse petrous temporal bone fracture and a hyperacute EDH. Given the location of the fractures, injury to the venous sinus (at the area of the transverse-sigmoid junction) and petrous ICA was suspected.Intra-operatively, significant blood loss from both the venous sinus and petrous ICA was encountered. Given the displaced temporal bone fracture, packing of the areas was impaired.We performed a manual reduction of the temporal fracture, followed by lateral plating in order to achieve hemostasis from the petrous ICA and aid with packing of the venous sinus injury. CONCLUSIONS: Reduction and lateral plating of displaced transverse petrous temporal bone fractures can aid significantly with intra-operative hemostasis in the extreme case of venous sinus and/or petrous ICA injuries.

Transcranial Magnetic Stimulation for Status Epilepticus.

Background. Our goal was to perform a systematic review on the use of repetitive transcranial magnetic stimulation (rTMS) in the treatment of status epilepticus (SE) and refractory status epilepticus (RSE). Methods. MEDLINE, BIOSIS, EMBASE, Global Health, Healthstar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to August 2015), and gray literature were searched. The strength of evidence was adjudicated using Oxford and GRADE methodology. Results. We identified 11 original articles. Twenty-one patients were described, with 13 adult and 8 pediatric. All studies were retrospective. Seizure reduction/control with rTMS occurred in 15 of the 21 patients (71.4%), with 5 (23.8%) and 10 (47.6%) displaying partial and complete responses, respectively. Seizures recurred after rTMS in 73.3% of the patients who had initially responded. All studies were an Oxford level 4, GRADE D level of evidence. Conclusions. Oxford level 4, GRADE D evidence exists to suggest a potential impact on seizure control with the use of rTMS for FSE and FRSE, though durability of the therapy is short-lived. Routine use of rTMS in this context cannot be recommended at this time. Further prospective study of this intervention is warranted.

Magnesium sulfate for non-eclamptic status epilepticus.

BACKGROUND: Our goal was to perform a systematic review of the literature on the use of intravenous magnesium sulfate (MgSO4) for non-eclamptic status epilepticus (SE) and refractory status epilepticus (RSE). METHODS: Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library, the International Clinical Trials Registry Platform, clinicaltrials.gov (inception to June 2015), reference lists of relevant articles, and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers. RESULTS: We identified 19 original articles. A total of 28 patients were described in these articles with 11 being adult, 9 being pediatric, and 8 of unknown age. Seizure reduction/control with IV MgSO4 occurred in 14 of the 28 patients (50.0%), with 2 (7.1%) and 12 (42.9%) displaying partial and complete responses respectively. Seizures recurred upon withdrawal of MgSO4 therapy in 50% of the patients whom had reduction/control of their SE/RSE. Three patients had recorded adverse events related to MgSO4 therapy. CONCLUSIONS: Oxford level 4, GRADE D evidence exists to suggest a trend towards improved seizure control with the use of intravenous MgSO4 for non-eclamptic RSE. Routine use of IV MgSO4 in non-eclamptic SE/RSE cannot be recommended at this time. Further prospective study of this drug is required in order to determine its efficacy as an anti-epileptic in this setting.

The Impact of Intravenous Lidocaine on ICP in Neurological Illness: A Systematic Review.

Background. The goal of our study was to perform a systematic review of the literature to determine the effect that intravenous (IV) lidocaine had on ICP in patients with neurological illness. Methods. All articles are from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to March 2015). The strength of evidence was adjudicated using both the Oxford and GRADE methodology. Results. Ten original articles were considered for the final review. There were 189 patients studied. Seven studies focused on prophylactic pretreatment with IV lidocaine to determine if there would be an attenuation of ICP spikes during stimulation, with 4 displaying an attenuation of ICP. Three studies focused on a therapeutic administration of IV lidocaine in order to determine ICP reduction effects. All therapeutic studies displayed a reduction in ICP. Conclusions. We cannot make a strong definitive recommendation on the effectiveness of IV lidocaine on the attenuation of ICP spikes during stimulation. There currently exists both Oxford 2b and GRADE B literature to support and refute the attenuation of ICP spikes with IV lidocaine during stimulation. There currently exists Oxford 2b, GRADE B evidence to support ICP reduction with lidocaine when used as a therapeutic agent.

Lidocaine for status epilepticus in adults.

INTRODUCTION: Our goal was to perform a systematic review of the literature on the use of intravenous lidocaine in adults for status epilepticus (SE) and refractory status epilepticus (RSE) to determine its impact on seizure control. METHODS: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to November 2014), and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology by two independent reviewers. RESULTS: Overall, 13 studies were identified, with 11 manuscripts and 2 meeting abstracts. Seventy-six adult patients were treated for 82 episodes of SE/RSE. Patients had varying numbers of anti-epileptic drugs (AEDs), 1-12, on board prior to lidocaine therapy. During 69 of the 82 (84.1%) episodes of SE/RSE, phenytoin was on board. The dose regimen of lidocaine varied, with some utilizing bolus dosing alone; others utilizing a combination of bolus and infusion therapy. Overall, 70.7% of seizures responded to lidocaine, with complete cessation and greater than 50% reduction seen in 64.1% and 6.1% respectively. Patient outcomes were sparingly reported. CONCLUSIONS: There currently exists level 4, GRADE C evidence to support the consideration of lidocaine for SE and RSE in the adult population. Thus there is currently weak evidence to support the use of lidocaine in this context. Further prospective studies of lidocaine administration in this setting are warranted.