Causes and outcomes of new onset status epilepticus and predictors of refractoriness to therapy.

We aimed to evaluate the determinants of outcome in new onset refractory status epilepticus (SE). A retrospective analysis of patients with new onset SE admitted between May 2005 and October 2013 was performed. Regression analysis was used to determine factors that affect progression of new onset SE to refractory status epilepticus (RSE) and mortality. Among 114 patients with new onset SE, 52 patients progressed to RSE. Sixty seven (58.7%) were men. New onset RSE patients were younger than new onset SE patients (mean 35.9 ± standard deviation18.2 versus 28.7 ± 20.2 years; p=0.050). Cryptogenic aetiology was the most significant determinant of progression of new onset SE to RSE (Exp [ß]=5.68; p=0.001). The overall mortality in the entire group was 23.7%, significantly higher in new onset RSE group (40.4% versus 9.7%; p<0.0001). New onset RSE patients with symptomatic and cryptogenic etiology did not differ for clinical characteristics and outcome. Acidosis was the strongest predictor of mortality in the entire cohort (Exp [ß]=8.72; p=0.005). Nearly half of the patients with new onset SE progressed to RSE. While cryptogenic aetiology determined progression of new onset SE to RSE, acidosis was associated with mortality. The outcome was similar between symptomatic and cryptogenic new onset RSE.

Pediatric ischemic stroke due to dengue vasculitis.

BACKGROUND: Dengue infection is an important arboviral infection in southeast Asia, especially in India. Neurological manifestations of dengue are increasingly recognized. METHODS: We report an ischemic stroke due to dengue vasculitis in an 8-year-old child. PATIENT: We present a girl with a short febrile illness followed by episodic severe headache, with gradually progressive hemiparesis and visual impairment. Her brain magnetic resonance imaging revealed multiple infarctions in the anterior and posterior circulation. The magnetic resonance angiogram revealed irregular narrowing of bilateral middle cerebral arteries, right anterior cerebral artery, left posterior cerebral, and bilateral vertebral arteries suggestive of vasculitis. Her dengue serology was strongly positive for immunoglobulin M with 68.9 panbio units. The rest of the evaluation for pediatric stroke was unremarkable. She was treated with intravenous followed by oral corticosteroids and recovered totally with resolution of vasculitis on magnetic resonance angiogram over the next 3 months. CONCLUSION: This child illustrates possible immune-mediated vasculitis caused by dengue infection which is rather a rare presentation in a child who subsequently recovered well. One should consider dengue in childhood strokes in endemic regions.

Determinants and predictors of outcome in super refractory status epilepticus--a developing country perspective.

IMPORTANCE: Super refractory status epilepticus (SRSE) is a recent entity. There is limited information about the etiology and outcome of SRSE from developing countries. OBJECTIVE: We evaluated determinants and predictors of outcome in patients with convulsive SRSE in Indian population. METHODS: In this open cohort study, data of patients with convulsive SE admitted in neurointensive care unit (NICU) from 2005 to 2013 was retrospectively analyzed. Regression and survival analysis was done for outcome of patients divided into non refractory SE (NRSE), refractory SE (RSE), and SRSE groups. MAIN OUTCOME MEASURE: The primary outcome for analysis was in hospital mortality. Also functional outcome at 6 months was graded according to the Glasgow outcome scale (GOS), and classified as good (GOS 4 and 5) and poor (GOS 1, 2 and 3) outcome groups. RESULTS: Out of 177 patients with SE, 105 (59.3%) had NRSE; 72 (40.7%) had RSE of which 30 (16.9% of 177) were sub-classified as SRSE. SRSE was frequent (39%) in children (p<0.01), elderly (21.7%; p<0.003), and in incident SE (82.1%, p=0.05). Encephalitis was the commonest etiology in RSE (30.9%, p=0.015), SRSE (66.7%, p<0.001) than NRSE (12.3%). Encephalitis (ß=8.250 (1.8-37.82); p=0.007) was the determinant of the progression of SE to SRSE. Overall mortality was 19.2%, highest in SRSE (40.0%) followed by RSE (35.7%), both significantly (p<0.001) higher than NRSE (6.7%). Mortality was high in patients with encephalitis than other etiologies (39.1% vs. 12.1%; p=0.001). Acidosis predicted mortality in the entire cohort (ß=7.313 (1.6-32.58); p=0.009); however none of the variables predicted mortality in SRSE patients. At 6 months follow up only 33.3% of patients with SRSE were in GOS good outcome group when compared to RSE (33.3% vs. 57.1%; p=0.055), and NRSE (33.3% vs. 79.1%; p<0.0001). CONCLUSIONS AND RELEVANCE: SRSE is common in children, elderly, and incident SE. Encephalitis was the determinant of progression of SE to SRSE. None of the variables predicted mortality in SRSE patients. Sixty percent of patients with SRSE survived and one third had good outcome. Therefore one should continue the care inspite of weeks of SE.

Prognosis and predictors of outcome of refractory generalized convulsive status epilepticus in adults treated in neurointensive care unit.

OBJECTIVE: To evaluate the etiological profile, clinical characteristics and outcome of patients with refractory generalized convulsive status epilepticus treated in Neurological Intensive Care Unit (NICU). METHODS: In this open cohort study, data of 126 patients, aged 18 years and above, with convulsive status epilepticus (SE) admitted in NICU was collected. Status epilepticus was defined as seizures lasting for more than five minutes without regaining consciousness. Refractory SE (RSE) was defined as SE refractory to 2 antiepileptic drugs and requiring anesthetic agents for seizure control. Survival and regression analysis were done to analyze the outcome and factors predicting outcome respectively in the study population. RESULTS: Out of 126 patients, 81 patients had non -refractory status epilepticus (NRSE); 45 (35.7%) had RSE. Acute symptomatic etiology was noted in 58.6% of entire cohort. Significantly higher percentage of patients with RSE had an etiology of CNS infections than NRSE group (44.4% vs. 23.5%; P=0.0171). Amongst the CNS infections, viral encephalitis was significantly higher in RSE than NRSE patients (31% vs. 6.2%; P=0.0004). All the patients with RSE required mechanical ventilation. Overall mortality was 19%. The mortality in RSE was 42% (19 out of 45), significantly higher when compared to NRSE where only 6% (5 out of 81) died. On logistic regression, the only predictor of death was fever with an odds ratio of 8.55 (P=0.024). CONCLUSION: CNS infections, especially viral encephalitis and complications of mechanical ventilation were significantly higher in adult RSE patients. Although mortality is higher in adult patients with RSE, etiology does not contribute to mortality; however fever predicts mortality in these patients. Aggressive management of underlying etiology and prevention of systemic complications may improve outcome in adult RSE patients.

Factors associated with lack of response to valproic acid monotherapy in juvenile myoclonic epilepsy.

PURPOSE: To determine factors associated with lack of response to valproic acid (VPA) in juvenile myoclonic epilepsy (JME). METHOD: Retrospective analysis of clinical and EEG data of 201 patients with JME who had at least 3 years follow up was performed. Psychiatric evaluation was performed using ICD-10 by structured clinical interview. Patients were divided into two groups: VPA responders (seizure free for 2 or more years) and those with lack of response to VPA. Effect size for non-response and correlations for variables significantly different between the groups was performed, the findings were confirmed by ROC curves. RESULTS: The mean duration of follow up was 7.75 (range 3-12) years; 55.2% were males. Focal semiologic features were noted is 16%. EEG was abnormal in 67%; focal EEG abnormalities were noted in 32.8%. Coexisting psychiatric disorders (PDs) were found in 33.3%. Lack of response to VPA was noted in 19%. Diagnosis of PDs and focal EEG abnormalities significantly increased the risk of VPA non-responsiveness by 5.54 (95% CI of 2.60-11.80; p<0.0001) and 3.01 times respectively (95% CI of 1.40-6.47; p<0.008). Diagnosis of PDs showed significant correlation (r=0.332; p<0.0001) and association (AUC 0.700; p<0.0001) with lack of response to VPA. Though focal EEG abnormalities increased the chances, it did not correlate with lack of response to VPA. CONCLUSION: Lack of response to VPA was noted 19% of patients with JME. Coexisting PDs showed significant correlation and association with lack of response to VPA.