The potency of benzodiazepines decreases and of nmda antagonists increases as seizures last longer. The more prolonged status epilepticus becomes, the moreintractable it is to effective treatment. Response to seizure suppressing drugs varies over time. The risk of a seizure becoming refractory to drugs increases with increasing seizure duration. Physiologic mechanisms of inhibition and status epilepticus igor spigelman 22. There are numerous reasons for why one might have a seizure, and of these the majority can by extension of their magnitude become causes of status epilepticus.
Clinical and experimental research indicates that continuous seizure activity for longer than 60. A lifethreatening neurologic condition defined as 5 or more minutes of either continuous seizure activity or repetitive seizures without regaining consciousness. Pathophysiology, causes and treatment of tonicclonic. An estimated 152,000 cases occur per year in the united states, resulting in 42,000. Management of status epilepticus american family physician. Convulsive status epilepticus is not a syndrome in the same sense as febrile convulsions, benign rolandic epilepsy, and infantile polymorphic epilepsy. This is important because partial status epilepticus epilepsia partialis continua can be treated less aggressively.
Correct classification of seizure types will aid in clinical communications and guide correct therapies. Status epilepticus is a common neurological emergency with considerable associated healthcare costs, morbidity, and mortality. Pathophysiology of seizure circuitry in status epilepticus dan c. Pathophysiology, causes and treatment of tonicclonic status. Both human and animal data indicate that the longer a. Pathophysiology of status and brain injury systemic factors hypoxia, hypoglycemia, hypotension. Patients with nonconvulsive status epilepticus fare worse, with a mortality rate approaching 65% within 1 month of the epileptic event treiman 1998.
In this lesson we will learn about status epilepticus pathophysiology and. Convulsive status epilepticus cse is the most common neurological medical emergency and continues to be associated with significant morbidity and mortality. To determine whether clinical features could be used to predict which patients were more likely to. Treatment and prognosis of convulsive status epilepticus is discussed below. A seizure that lasts at least 30 minutes is called status epilepticus, or a prolonged seizure. For the weird causes, there is a good article which lists a massive spectrum of toxins, genetic diseases, rare autoimmune conditions and what have you. Revised definitions of generalized convulsive status epilepticus suggest making this diagnosis with as few as 5 minutes of continuous seizure activity. Report of the guideline committee of the american epilepsy society. Status epilepticus is a medical emergency and can cause permanent brain damage or death. An important concept in the approach to patients in generalized tonicclonic status epilepticus is that treatment should be administered within a predetermined time frame. New guideline for treatment of prolonged seizures in children and adults a treatment algorithm that comprises three phases of treatment. Clinical and experimental research indicates that continuous seizure activity for longer than 60 to 90 minutes may result in irreversible brain damage.
In a clinical trial of adults with inhospital status epilepticus, intravenous lorazepam was superior to intravenous phenytoin. Status epilepticus management information page patient. Nonconvulsive status epilepticus ncse is status epilepticus without obvious tonicclonic activity. The seizure should cause diffuse motor activity and loss of consciousness. The tendency of status epilepticus to become self perpetuating and the fact that it is more than a series of severe seizures were recognised as early as the 19th century. While mortality is less than 3% in children, it can range up to 30% in adults. In addition, a greater understanding of the pathophysiology of status epilepticus has led to a redefinition of status epilepticus 11. Convulsive status epilepticus requires emergency treatment by trained medical personnel in a hospital setting. The understanding of pathophysiological mechanisms underlying deve. Febrile seizures are the most common type of seizure in children, and their management is usually the task of the general pediatrician. Treatment of convulsive status epilepticus in children and adults. During the past two decades, substantial progress has been made in the understanding of the clinical features, classification, pathophysiology, central nervous system consequences, and treatment of status epilepticus. The epilepsy foundations public police institute and teens speak up.
New onset refractory status epilepticus research neurology. Pathophysiology and definitions of seizures and status epilepticus. The neurocritical care society status epilepticus guideline writing committee was established in 2008 to develop evidencebased expert. The status epilepticus severity score stess, consisting of the variables level of consciousness, seizure type, age above or below 65, and history of prior seizure, older age, lower levels of consciousness, generalised convulsivenonconvulsive morphologies, and absence of prior seizures, were all indicative of a worse prognosis. Kothare mdc, a division of epilepsy and clinical neurophysiology, department of neurology, boston childrens hospital, harvard medical school, boston, massachusetts. Status epilepticus literally means a continuous state of seizure. Although the danger of this pattern of seizure activity has been recognized since antiquity, our understanding of the p. Status epilepticus defined as seizure lasting greater than five minutes or repeated seizures without full recovery to normal conscious level between episodes is a neurological emergency. Role of gabaa receptors in status epilepticus robert l. The factors that suggest a poorer outcome in terms of seizures, cognition, and behaviour include the presence of.
This may not be the complete list of references from. Newonset refractory status epilepticus norse is a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurologic disorder, with new onset of refractory status epilepticus rse that does not resolve after 2 or more rescue medications, without a clear acute or active structural, toxic, or metabolic cause. Some forms of status epilepticus are associated with an excellent prognosis, while others can have major morbidity or even mortality. Clark and prout14 described the natural course of status epilepticus in 38 patients unaffected by anticonvulsants. Status epilepticus symptoms, diagnosis and treatment. We then summarise the data on the utility of extended eeg monitoring and emphasise the importance of early termination of status epilepticus.
Status epilepticus is a dangerous situation historically defined as a seizure or a cluster of seizures lasting longer than 30 minutes without improvement in consciousness. Status epilepticus manifests as many different syndromes, each defined by distinctive clinical features and electroencephalography eeg findings. A patient in status epilepticus has continuous or rapidly repeating seizures. This guideline focuses on convulsive status epilepticus because it is both the most common type of status epilepticus and is associated with substantial morbidity and mortality. The clinical features and diagnosis of convulsive status epilepticus in adults are discussed here. Pathophysiology of status epilepticus martin holtkamp summary status epilepticus is refractory to initial intravenous anticonvulsants in every third patient and at least the generalised convulsive form is commonly associated with neuronal longterm consequences. Convulsive status epilepticus is not a syn drome in the same sense as febrile convulsions, benign rolandic epilepsy, and infantile poly morphic epilepsy. An eeg is needed to confirm the diagnosis, but obtaining an eeg on every patient with altered mental state is not practical. Status epilepticus constitutes an emergency situation that can have severe consequences and requires skilled therapy. Status epilepticus is a very serious, although rare seizure condition. Are you surprised from how much you have learned about the pathophysiology of seizures. When seizures do not improve, on their own or with medication, they can cause brain damage or even death. After this point, it becomes less and less likely that doctors will be able to stop the seizure with medication.
Status epilepticus can lead to excitotoxic neuronal death. When seizures do not improve, on their own or with medication, they can cause brain damage or even dea. Population survival studies and laboratory investigations support the idea that brain injury and epileptogenesis result. Status epilepticus, mechanisms and management mit cognet. Adapting treatment to physiologic changes may improve response and outcome. Pathophysiology of convulsive status epilepticus seizure. The full text of this article is available as a pdf 74k. Generalized convulsive status epilepticus emcrit project. Guidelines for the evaluation and management of status. Status epilepticus symptoms, diagnosis and treatment bmj. Feb 22, 2018 pathophysiology of status epilepticus. The management of status epilepticus 20 bassel aboukhalil, m. The pathophysiology of status epilepticus suggests that rapid seizure cessation mitigates neurological and metabolic complications.
Many medical experts become concerned that a seizure is status epilepticus after it lasts 5 to 10 minutes. Status epilepticus defined as continuous seizing for more than 5 minutes or back to back seizing without awakening, it is a medical emergency and something that you must know how to treat. Convulsive status epilepticus represents the most common form of status epilepticus. Pathophysiology of status epilepticus ucl discovery. Status epilepticus affects between 50,000 and 150,000 americans annually. Types, pathophysiology, epidemiology, etiology, and diagnosis author stephan ruegg affiliation.
The operational definition of status epilepticus is an empirical compromise dictated by therapeutic needs, because treatment should not be delayed until patients are in established status epilepticus, when neuronal injury and timedependent development of pharmacoresistance have. The pathophysiology of seizures is multifactorial and incompletely understood. The definition of status epilepticus as a prolonged seizure or a series of seizures with incomplete return to baseline is under reconsideration in an effort to establish a more practical definition to guide management. It occurs due to the failure of mechanisms that terminate seizures. Pdf convulsive status epilepticus cse is the most common neurological medical emergency and continues to be associated with significant morbidity. Status epilepticus is when a seizure lasts longer than 5 minutes or when seizures occur close together and the person doesnt recover between seizures. Status epilepticus is a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the innonconvulsive status epilepticus in adults. Pathophysiology and definitions of seizures and status. Ccsap 2017 book 3 neurocritical caretechnology in the icu 8 status epilepticus alldredge 2001, brophy 2012. Pathophysiology of status epilepticus sciencedirect.
In hospitalized patients with status epilepticus, intravenous lorazepam is the drug of choice for initial emergency therapy. We comment on our preference for drugs with a short elimination halflife and discuss some therapeutic choices. Convulsive status epilepticus includes tonicclonic seizures which are seizures most people are familiar with. Experimental work demonstrates that prolonged, abnormal, and excessive neuronal electrical activity in itself is injurious through several mechanisms independent of systemic acidosis and hypoxia.
The longstanding definition of status epilepticus was a seizure that lasted longer than 30 minutes, but this definition lacks clinical utility10. Clinical presentation and pathophysiology ivan sanchez fernandez mda,b,1, tobias loddenkemper mda,1, jurriaan m. Status epilepticus is a medical and neurologic emergency that requires prompt evaluation and treatment. Aug 01, 2003 status epilepticus is an underrecognized health problem associated with substantial morbidity and mortality.
Of course, the most common causes are failure to take ones own epilepsy tablets. Jan 14, 2015 frequency of refractory status epilepticus in status epilepticus patients 3144% no community based incidence studies in india but is expected to be high because of high prevalence of epilepsy, cns infections and treatment gap. For someone who has seizures, theyre normally similar in length each time they occur and typically stop once that time period has passed. The moreprolonged the status epilepticus, the more likely it is associated withapoorprognosis. Both human and animal data indicate that the longer a seizure lasts, the less likely it is to stop. Pathophysiology of convulsive status epilepticus sciencedirect.
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