Status Epilepticus signs and symptoms
Content
Status epilepticus (SE) is a common, life-threatening neurologic disorder that is essentially an acute, prolonged epileptic crisis. SE can represent an exacerbation of a preexisting seizure disorder, the initial manifestation of a seizure disorder, or an insult other than a seizure disorder. In patients with nown epilepsy, the most common cause is a change in medication. !ost seizures terminate spontaneously.
Essential update: Ketamine treatment in refractory status epilepticus
In a retrospecti"e re"iew of patients with status epilepticus refractory to typical antiepileptic drugs, etamine was found to be effecti"e and safe as an ad#uncti"e treatment in all the patients. $%& 'etamine was the final antiepileptic drug used before seizure cessation in ( of %% patients) % additional antiepileptic drug was added after initiation of etamine infusion in * patients.$%& !ean time from initiation of etamine infusion to seizure cessation was +., days) ( patients achie"ed resolution within % wee of initiation. !oreo"er, - of ( patients who had re.uired "asopressors during therapy were successfully weaned during etamine treatment. /o patients experienced acute ad"erse effects.$%& 0
Signs and symptoms
1y clinical history, nonmotor simple partial status epilepticus in"ol"es sub#ecti"e sensory disturbances, including the following2
• • • • •
3ocal or unilateral paresthesias or numbness 3ocal "isual changes, usually characterized by flashing lights 3ocal "isual obscuration or focal colorful hallucinations 4lfactory or gustatory hallucinations 5typical rising abdominal sensations
Epilepsy partialis continua, or focal status epilepticus of the motor cortex, may occur in "arious contexts, with some authors subdi"iding it into type I (nonprogressi"e) and type II (progressi"e). 6ype I epilepsy partialis continua features include the following2
• • •
Intermittent, semi-rhythmic, in"oluntary twitching in"ol"ing a discrete subset of muscles !ost commonly affects the face and ipsilateral distal hand musculature !yoclonus of this "ariety may e"ol"e into partial or generalized con"ulsion
6ype II epilepsy partialis continua features include the following2
• • •
7sually lin ed with 8asmussen encephalitis 9radual loss of unilateral function, with parallel focal or unilateral hemispheric atrophy Impaired intellectual s ills to "arious degrees
•
:ossible effect on language s ills
6ype I complex partial status epilepticus refers to recurrent, recognizable complex partial seizures without reco"ery between seizures. 6ype II represents continuous, ongoing complex partial seizure acti"ity. 6he se.uence of constellation of features in complex partial status epilepticus is as follows2 %. Serious medical, surgical, or neurologic illness 0. 5 brief con"ulsi"e seizure ;. :rotracted stupor with fluctuating neurologic findings, subtle nystagmus, or focal twitching In addition, complex partial status epilepticus may ha"e the following characteristics2
• • • • •
<istory of recurrent or prolonged simple partial seizures or may follow or precede a generalized con"ulsi"e seizure =onfused and "ariable responsi"eness) fluctuating or bizarre beha"ior Impaired memory of the e"ent =linical automatisms (eg, repetiti"e lip-smac ing, fumbling, swallowing mo"ements) Subtle nystagmus
See =linical :resentation for more detail.
Diagnosis
Examination for status epilepticus includes the following2
• • • • •
9eneralized con"ulsi"e status epilepticus2 6ypical rhythmic tonic-clonic acti"ity, impaired consciousness) rarely, may present as persistent tonic seizure Status epilepticus due to the use of illicit, or street, drugs2 needle-trac mar s Status epilepticus due to possible mass lesion or brain infection2 :apilledema, lateralized neurologic features Subtle or transformed status epilepticus2 5ny patient without impro"ing le"el of consciousness within 0>-;> minutes of cessation of generalized seizure acti"ity 5ssociated in#uries in patients with seizures2 !ay include tongue lacerations (typically lateral), shoulder dislocations, head trauma, facial trauma
Classification 6he ?uders and 8ona semiologic classification consists of ; axes, as follows$0& 2
• • •
6he type of brain function predominantly compromised 6he body part in"ol"ed 6he e"olution o"er time
6he 6reiman classification is as follows2
• • • •
9eneralized con"ulsi"e status epilepticus Subtle status epilepticus /oncon"ulsi"e status epilepticus (eg, absence, complex partial) Simple partial status epilepticus
Testing 6he wor up for potential status epilepticus is similar to that for any self-limited seizure but is done more expeditiously to confirm the diagnosis and to abort or limit the seizures. Stat laboratory studies that should be obtained include the following2
• • • • •
9lucose and electrolyte le"els (including calcium, magnesium) =omplete blood count 8enal and li"er function tests 6oxicologic screening and anticon"ulsant drug le"els 5rterial blood gas results
4ther tests that may be appropriate depending on the clinical setting include the following2
• • •
Electroencephalography2 =riterion standard for diagnosing status epilepticus$;, *& ) howe"er, neurologic consultation is usually re.uired 1lood cultures 7rinalysis and@or cerebrospinal fluid analysis
Imaging studies Imaging modalities used to e"aluate status epilepticus may include the following2
• •
=6 scanning and@or !8I of the brain =hest radiography
Procedures
If a central ner"ous system infection is suspected, consider performing a lumbar puncture (after neuroimaging to rule out potential cerebral herniation). See Aor up for more detail.
Management
5ggressi"e treatment is necessary for status epileptics. =linicians should not wait for blood le"el results before administering a loading dose of phenytoin, regardless of whether the patient is already ta ing phenytoin. Pharmacotherapy !ost patients with status epilepticus who are treated aggressi"ely with a benzodiazepine, fosphenytoin, and@or phenobarbital experience complete cessation of their seizures. If status epilepticus does not stop, general anesthesia is indicated. !edications used in the treatment of status epilepticus include the following2
• • • •
1enzodiazepines (eg, lorazepam, diazepam, midazolam)2 3irst-line agents 5nticon"ulsant agents (eg, phenytoin, fosphenytoin) 1arbiturates (eg, phenobarbital, pentobarbital) 5nesthetics (eg, propofol)
Supportive therapy Supporti"e care in patients with status epilepticus includes the following2
• • • •
!aintenance of "ital signs 5irway, breathing, circulation (eg, hemodynamic@cardiac monitoring) 8espiratory support, with intubation and@or mechanical "entilation if necessary :eriodic neurologic assessments
Surgery Surgical inter"ention for status epilepticus is a last resort and rarely performed.$B, -, (, ,& 4perati"e procedures depend on the etiology of this condition and may consist of ablating a structural abnormality, hemispherectomy, subpial resection, or placement of a "agus ner"e stimulator.
Essential update: Ketamine treatment in refractory status epilepticus
In a retrospecti"e re"iew of patients with status epilepticus refractory to typical antiepileptic drugs, etamine was found to be effecti"e and safe as an ad#uncti"e treatment in all the patients. $%& 'etamine was the final antiepileptic drug used before seizure cessation in ( of %% patients) % additional antiepileptic drug was added after initiation of etamine infusion in * patients.$%& !ean time from initiation of etamine infusion to seizure cessation was +., days) ( patients achie"ed resolution within % wee of initiation. !oreo"er, - of ( patients who had re.uired "asopressors during therapy were successfully weaned during etamine treatment. /o patients experienced acute ad"erse effects.$%& 0
Signs and symptoms
1y clinical history, nonmotor simple partial status epilepticus in"ol"es sub#ecti"e sensory disturbances, including the following2
• • • • •
3ocal or unilateral paresthesias or numbness 3ocal "isual changes, usually characterized by flashing lights 3ocal "isual obscuration or focal colorful hallucinations 4lfactory or gustatory hallucinations 5typical rising abdominal sensations
Epilepsy partialis continua, or focal status epilepticus of the motor cortex, may occur in "arious contexts, with some authors subdi"iding it into type I (nonprogressi"e) and type II (progressi"e). 6ype I epilepsy partialis continua features include the following2
• • •
Intermittent, semi-rhythmic, in"oluntary twitching in"ol"ing a discrete subset of muscles !ost commonly affects the face and ipsilateral distal hand musculature !yoclonus of this "ariety may e"ol"e into partial or generalized con"ulsion
6ype II epilepsy partialis continua features include the following2
• • •
7sually lin ed with 8asmussen encephalitis 9radual loss of unilateral function, with parallel focal or unilateral hemispheric atrophy Impaired intellectual s ills to "arious degrees
•
:ossible effect on language s ills
6ype I complex partial status epilepticus refers to recurrent, recognizable complex partial seizures without reco"ery between seizures. 6ype II represents continuous, ongoing complex partial seizure acti"ity. 6he se.uence of constellation of features in complex partial status epilepticus is as follows2 %. Serious medical, surgical, or neurologic illness 0. 5 brief con"ulsi"e seizure ;. :rotracted stupor with fluctuating neurologic findings, subtle nystagmus, or focal twitching In addition, complex partial status epilepticus may ha"e the following characteristics2
• • • • •
<istory of recurrent or prolonged simple partial seizures or may follow or precede a generalized con"ulsi"e seizure =onfused and "ariable responsi"eness) fluctuating or bizarre beha"ior Impaired memory of the e"ent =linical automatisms (eg, repetiti"e lip-smac ing, fumbling, swallowing mo"ements) Subtle nystagmus
See =linical :resentation for more detail.
Diagnosis
Examination for status epilepticus includes the following2
• • • • •
9eneralized con"ulsi"e status epilepticus2 6ypical rhythmic tonic-clonic acti"ity, impaired consciousness) rarely, may present as persistent tonic seizure Status epilepticus due to the use of illicit, or street, drugs2 needle-trac mar s Status epilepticus due to possible mass lesion or brain infection2 :apilledema, lateralized neurologic features Subtle or transformed status epilepticus2 5ny patient without impro"ing le"el of consciousness within 0>-;> minutes of cessation of generalized seizure acti"ity 5ssociated in#uries in patients with seizures2 !ay include tongue lacerations (typically lateral), shoulder dislocations, head trauma, facial trauma
Classification 6he ?uders and 8ona semiologic classification consists of ; axes, as follows$0& 2
• • •
6he type of brain function predominantly compromised 6he body part in"ol"ed 6he e"olution o"er time
6he 6reiman classification is as follows2
• • • •
9eneralized con"ulsi"e status epilepticus Subtle status epilepticus /oncon"ulsi"e status epilepticus (eg, absence, complex partial) Simple partial status epilepticus
Testing 6he wor up for potential status epilepticus is similar to that for any self-limited seizure but is done more expeditiously to confirm the diagnosis and to abort or limit the seizures. Stat laboratory studies that should be obtained include the following2
• • • • •
9lucose and electrolyte le"els (including calcium, magnesium) =omplete blood count 8enal and li"er function tests 6oxicologic screening and anticon"ulsant drug le"els 5rterial blood gas results
4ther tests that may be appropriate depending on the clinical setting include the following2
• • •
Electroencephalography2 =riterion standard for diagnosing status epilepticus$;, *& ) howe"er, neurologic consultation is usually re.uired 1lood cultures 7rinalysis and@or cerebrospinal fluid analysis
Imaging studies Imaging modalities used to e"aluate status epilepticus may include the following2
• •
=6 scanning and@or !8I of the brain =hest radiography
Procedures
If a central ner"ous system infection is suspected, consider performing a lumbar puncture (after neuroimaging to rule out potential cerebral herniation). See Aor up for more detail.
Management
5ggressi"e treatment is necessary for status epileptics. =linicians should not wait for blood le"el results before administering a loading dose of phenytoin, regardless of whether the patient is already ta ing phenytoin. Pharmacotherapy !ost patients with status epilepticus who are treated aggressi"ely with a benzodiazepine, fosphenytoin, and@or phenobarbital experience complete cessation of their seizures. If status epilepticus does not stop, general anesthesia is indicated. !edications used in the treatment of status epilepticus include the following2
• • • •
1enzodiazepines (eg, lorazepam, diazepam, midazolam)2 3irst-line agents 5nticon"ulsant agents (eg, phenytoin, fosphenytoin) 1arbiturates (eg, phenobarbital, pentobarbital) 5nesthetics (eg, propofol)
Supportive therapy Supporti"e care in patients with status epilepticus includes the following2
• • • •
!aintenance of "ital signs 5irway, breathing, circulation (eg, hemodynamic@cardiac monitoring) 8espiratory support, with intubation and@or mechanical "entilation if necessary :eriodic neurologic assessments
Surgery Surgical inter"ention for status epilepticus is a last resort and rarely performed.$B, -, (, ,& 4perati"e procedures depend on the etiology of this condition and may consist of ablating a structural abnormality, hemispherectomy, subpial resection, or placement of a "agus ner"e stimulator.
