Prognostication and Risk factors of Status Epilepticus in patients treated in Neurointensive Care Units

INTRODUCTION

Previous studies on the epidemiology of SE found incidence rates ranging from 3.5 to 41 per 100 000 per year in North America, 9.9 to 27.2 in Europe, 1.3 to 5.2 in Asia, and 10.8 in Africa. ¹

    In 2015, the International League Against Epilepsy (ILAE) proposed a new definition of status epilepticus (SE): 5 minutes of ongoing seizure activity to diagnose convulsive SE (CSE, ie, bilateral tonic–clonic SE) and 10 minutes for focal SE and absence SE, rather than the earlier criterion of 30 minutes. Based on semiology, several types of SE with prominent motor phenomena at any time (including CSE) were distinguished from those without (ie, nonconvulsive SE, NCSE) ¹. Non-convulsive status epilepticus (NCSE) is existing in 10 to 30% of Intensive Care Unit (ICU) cases with altered mental status (AMS) and is accompanied to weak outcome, while non-convulsive seizure is present in 14.5% of cases with critical illness in ICU, NCS and NCSE may be a reason of coma and changed mentation in 18-45% of cases presented to the ICU. ²

Status epilepticus (SE) may be fatal or cause dangerous sequelae. The occurrence of SE, conventionally outlined as seizures durable for more than 30-min, the occurrence in accordance to the most recent operative definitions of 5-min period, previously called “impending SE” ³, isn’t known. This quicker period limit assists the clinician regarding to when to initiate anti-convulsive intervention. The 30-mins limit will more dependably detect cases with a significant risk of sequelae and mortality till the seizures are ended. ⁴

SE is a disorder and utmost extreme form of epilepsy, that causes irregular and extended seizure (at minimum 5-min). If SE perseveres longer 30-min, it can have severe long-term results. regarding the novel SE sorting scheme, there are 2 operative dimensions of the description: time point 1 (T1) is accompanying with oddly extended seizure, when treatment must be started, whereas time point 2 (T2) is correlated to the time of on-going seizure activity including a risk of lasting results. ⁵

SE is one of the commonest neurological emergencies. It is a possibly deadly condition that requires a fast and specific intervention so as to avoid cerebral damages because of initial excito-toxicity. Management is vital as GABA sensitivity reductions and the sensitivity to excito-toxic neuro-transmitters rises quickly, parting only a short period for operative intervention. SE can as well have lifetime results and, particularly in intractable SE, the possibility of being epileptic is elevated. ⁶

Identification of Predictors for intractable SE is critical for detecting cases at risk early in the course of the disorder. Therefore, tailoring the intervention growth approaches for such cases can, instead, avoid opposing impacts, and instead, decrease the danger for rising longstanding RSE involving its harmful results. Up to now, a retrospective cohort research has proposed that the semiotics of status can comprise prognostic data, with NCSE and focal motor status found significantly more frequently in RSE in comparison to non-RSE (NRSE), while the primary reason of SE didn’t have a significant influence on refractoriness. ⁷

Many researches have evaluated outcomes in SE generally. Death within 30-days (short-term death) thereafter SE was defined as from 7 to 39%. Morbidity involving severe focal neurologic shortages, cognitive impairments, and advance of epilepsy was found in 3 to13% of patients. But systematic predictive information concentrating on RSE are in general missing. Particularly, rate of post-SE symptomatically epilepsy is mostly not known and, up to now, haven’t been deeply analyzed. ⁸

Inopportunely, the description of refractoriness in SE as yet was subject to much disagreement and misperception. In various investigations, in addition to fail of anti-convulsants, a smallest period that has passed since seizure beginning was employed as the cornerstone of the description. But, in others the necessity was the fall of a number of anti-convulsants nevertheless of period of seizure activity, Rebellious SE has required a agreement definitions; most nowadays respect it as SE that lasts in spite of management with benzodiazepine (benzo) and one anti-epileptic drugs (AEDs). Others respect refractory SE as failures of benzos and 2 AED, as: Lorazepam + phenobarb + phenytoin. The 1^st description is frequently stated to as 2 AED failures and the 2^nd one is labelled the 3 AED failures. ^{9, 10}

The current work aimed to recognize risk factors and outcomes in SE. We matched in retrospect the prognostic characteristics of SE-episodes with those of NSE in cases managed in a neurological-ICU (NICU) over an interval of 2-yrs.

PATIENTS AND METHODS

The present study was conducted at Al-Azhar University Hospitals. The study protocol was approved by the local ethical committee and all participants provided informed consent. The present operative description of SE is ≥5 min of nonstop seizure or 2 or more discrete seizures among which there isn’t complete consciousness recovery. This time-frame applies to sudden or tonicclonic SE. For focal seizures with consciousness reduction and nonattendance seizures, the time-frame is 10 (-15) min. ⁴

Refractory SE was definite as SE episodes needing 3 or more AEDs for terminating. ⁹ The case with refractory CSE treated by propofol as the 3rd-line agent according to our protocol. SE was sorted as either de novo (no prior seizures) or as happening in cases with preceding seizures.

The clinical diagnosing of SE was, in NCSE patients, established by a neurologist. For index refractory CSE episodes, 8/18 have been approved by EEG throughout the ictal phase. An extra 2 out of 18 cases have postictal EEG recordings giving epileptic activities. For cases with no EEG recordings throughout the ictal or postictal phase, 6 out of 8 have preceding or following EEGs with epileptic activities. For index NCSE episodes, 20 out of 39 have been approved by EEGs throughout the ictal stage. A further 8 out of 39 have EEG recordings just afterward end, revealing focal deceleration or focal functional conflicts reliable with the semiotics. Amongst the residual, 8 have preceding recordings with epileptic activities. ¹¹

We in retrospect analyzed all SE-episodes managed throughout an interval of 2-yrs (April 2019 to April 2021) in the NICU at the …… Hospital.

To confirm identifications of all potential episodes we performed a computer supported searches of cases records via definite keywords e.g., ‘‘seizure clustering’’, ‘‘SE’’, and ‘‘prolonged epileptic seizures’’. Episodes have been involved if SE commenced thereafter admittance to the NICU, earlier admittance but still ongoing afterward admittance to the NICU, and SE ended near-term previous to admittance to the NICU, if the admittance was causally linked to the SE.

Exclusion criteria:

• Episodes have been excepted if the cases reports were not accessible.
• If loss of consciousness among 2 seizures in 5-min was iatrogenic.
•  If the episodes sorted as SE was in retrospect a paroxysmal event of nonepileptic origin—that is, psychogenic nonepileptic seizure, extended convulsive syncopes, temporary ischemic attacks, etc.

The cases with ‘‘de novo’’ SE have been followed-up using phone calls regarding the progress of symptoms of epilepsy afterward SE. Previously the phone call cases have been communicated via mail giving them the option to reject the interviews.

The local ethics committee of the accepted the procedures and written agreement has been attained from the access taking part in the following-up investigation.

Clinical data

To analyze the clinical parameters, we used structured data collecting grid that has been employed by 2 non-dependent reviewers.

For all SE-episodes, the case’s demographic information (ages, gender) and medical history (acute/chronical, neurologic/non-neurologic) have been recorded. Data on one-on-one semiology, aetiology, and clinical courses have been assessed. Furthermore, para-clinical information from the 1st day afterward the beginning of SE involving serum sodium and glucose level, rectal temp, and CSF parameters have been analyzed.

Outcome Measures 

Lastly, we analyzed the outcomes involving SE-period, short-term re-occurrence of epileptic activities in 24-h thereafter SE end, hospitalization period and in the NICU, in hospital death, and, in cases with ‘‘de novo’’ SE, progress of symptoms epilepsy.

As the prognosing of complex partial-SE (CPSE) and generalized convulsive-SE (GCSE) might vary, sub-group analyzing of these 2 kinds of SE regarding outcomes was done.

For the NCSE group, the outcomes substitutes were mortality, severe sequelae (long-term and highly impacting everyday living), moderate sequelae (severe, long-lasting for >1-mth, but not long-term or long-term with a minor or moderate influence on everyday living), mild sequelae (small and temporary or more serious permanent for semiology, were therefore involved with no EEG approval.

Statistical analysis

Collected data have been analyzed via SPSS 20.0. Frequency distributions of predictive and prognostic parameters of RSE and NRSE were matched so as to recognize features of RSE and have been counted via the x2 testing. The t testing has been utilized for analysis of continuous data with normal distributions and the Mann-Whitney U testing for data with nonnormal distributions. Where applicable, Pearson’s association coefficient has been estimated. Results have been considered significant at p-value 0.05.

RESULTS

Table 1: Basic features of the cases and it shows that 58% of the patients were males, 82% were urban, and 44% were married. 74% of the cases have epilepsy history.

Table 2: Clinical data of SE and it shows that the commonest cause was idiopathic (40%), the commonest trigger factor was poor compliance (38%). 88% of the patients were recurrent SE.

Table 3: Comparison between patients with SE regarding epilepsy history, shows 

A high significant change was found among the groups regarding causes and Trigger factors

Table 4: Distribution of studied group as regard to epilepsy history, shows that Among patients with epilepsy history, 65% were generalized, 48.6% were on mono AED and the commonest etiology was idiopathic (54%).

Table 5: Individual etiologies of SE

Table 1: Basic features of the cases.

Table 2: Clinical data of SE.

Table 3: Comparison between patients with SE regarding epilepsy history.

Table 4: Distribution of studied group as regard to epilepsy history.

Table 5: Individual etiologies of SE.