What Factors Contribute To Occurrence Of Status Epilepticus And Can Trigger It? Neuro Expert Shares Insights

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Status epilepticus (SE) is a common but life-threatening neurologic condition that is characterized by an acute, prolonged epileptic episode. It is defined as a seizure lasting more than 5 minutes or experiencing more than one seizure within 5 minutes without returning to a normal level of consciousness between episodes.

Previously, status epilepticus was defined as a seizure lasting 30 minutes or longer, or a series of seizures in which the patient does not recover normal mental status between seizures.

The diagnosis of convulsive status is clinical and is confirmed by verifying the presence of either an unremitting generalized convulsive seizure lasting longer than five minutes or multiple bilateral seizures without return to the baseline level of consciousness.

Seizures that last 30 minutes or longer are considered dangerous and increase the risk of death. Status epilepticus is extremely rare; the majority of patients with epilepsy will never experience it. This disorder is more prevalent in the elderly and young children.

There are usually 2 types of the status epilepticus.

1. Convulsive status epilepticus: Status epilepticus accompanied by convulsions are more likely to result in long-term harm. Drooling, jerking, grunting noises, and rapid eye movements - can occur during convulsions.

Convulsive SE (CSE) is an emergency because most tonic-clonic seizures last less than two minutes, so after five minutes treatment should be initiated because the chances of spontaneous cessation of these convulsive statuses Epilepticus are low.

2. Nonconvulsive status epilepticus: Individuals with nonconvulsive status epilepticus may seem disoriented, confused, or in a state of daydreaming. They may be unable to communicate and act irrationally. EEG monitoring is crucial for the diagnosis of nonconvulsive SE, also done after initial control of convulsive SE and treatment control.

History of epilepsy is the single most important risk factor for generalized convulsive status epilepticus. In patients with known epilepsy, the cause of SE is a change in medication or skipping medication due to poor compliance.

There are multiple etiologies for status epilepticus. Potential acute processes include-

• Central nervous system infections (CNS) like encephalitis, meningitis, and intracranial abscess,
• Metabolic abnormalities including hypocalcemia, hypoglycemia, hepatic encephalopathy, hyponatremia, and inborn errors of metabolism in
children,
• Cerebrovascular accidents,
• Hypertensive emergency,
• Autoimmune disorders,
• Head trauma (with or without intracranial bleeding),
• Drug toxicity,
• Drug withdrawal syndromes; e.g., alcohol, barbiturates, and benzodiazepines,
• Hypoxia,
• NORSE (New-Onset Refractory Status Epilepticus): It is a clinical presentation in patients who don't have active epilepsy or a relevant history of neurologic illness. These patients also don't present with clear acute or active structural, toxic, or metabolic causes for refractory SE, and
• Febrile infection-related epilepsy syndrome (FIRES) is a subgroup of NORSE that can affect people of all ages. It is associated with a prior fever/febrile infection between 2 weeks and 24 hours before the development of refractory status epilepticus, with or without fever at onset.

Treatment
Treatment of status epilepticus is time-sensitive. Management of SE must include three pillars: stop seizures, stabilize patients, and treat underlying causes.

Benzodiazepines are usually the first line of treatment that is given to people with early status epilepticus. Because they stop seizures quickly, they are the first choice for treating convulsive status epilepticus. Diazepam, lorazepam, and midazolam are the three benzodiazepines that are most often used to treat status epilepticus.

Approximately 60 to 70% of patients with CSE will resolve with benzodiazepines. When the first treatment for generalized convulsive status epilepticus (GCSE) does not work quickly, the majority of patients need to be intubated and placed on mechanical breathing.

As a second line of treatment, phenytoin/fosphenytoin, levetiracetam, and valproic acid are evidence-based options. If SE persists, anesthetic drugs are probably the best option for third-line treatment, IV immunoglobulin, and plasmapheresis are also commonly included as first-line therapies. Corticosteroids are also used in the treatment of autoimmune status Epilepticus. Acute complications of status epilep result from hyperthermia, pulmonary edema, cardiac arrhythmias, and cardiovascular collapse.

Status epilepticus (SE) is associated with high morbidity and mortality, as high as 40% in refractory cases. Mortality rates of status epilepticus are 15% to 20% in adults and 3% to 15% in children. There is substantial evidence of long-term consequences and higher mortality if CSE lasts longer than 30 minutes. Despite initial treatment, about 20% of patients develop refractory status epilepticus and require further therapy.

(This article has been contributed by Dr Santhosh N.S, Consultant - Neurology, Manipal Hospital Whitefield and Manipal Clinic Brookefield, Bengaluru.)

Disclaimer: The information provided in this article is for general informational and educational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or a qualified healthcare provider with any questions you may have regarding a medical condition.