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					           Is It Status?

Epilepsia, 43(Suppl. 3): 103-113, 2002

        Ri 陳怡中 2002-11-18
        Principal Types of Seizures
   Partial (focal slowing/sharp wave)
     Simple partial seizures
     Complex partial seizures

     Secondarily generalized partial seizures

   Generalized (spike-wave pattern)
     Absence seizures (petit mal)

     Primarily generalized tonic-clonic seizures
      (grand mal)
          Status Epilepticus (SE)
   Definition
       >30min of continuous seizure activity
       >30min of two or more sequential seizures
        without full recovery of consciousness
   Classification
       Convulsive or Nonconvulsive
       Generalized or Partial
    Convulsive Status Epilepticus
   Loss of consciousness
   Recurrent or continuous convulsions
   Generalized ictal activity on EEG
    Convulsive Status Epilepticus
   Medical emergency
   High morbidity and mortality
   Pseudostatus
       Pschogenic SE
       Iatrogenic complication: IV BZDs,
        barbiturates or anesthetics
       Respiratory suppression & hypotension
Nonconvulsive Status Epilepticus
   Absence status or petit mal status
       Generalized EEG findings
   Complex partial SE
       Partial EEG findings
    NCSE in Ambulatory Patients
   Generalized
       Absence status / petit mal status
   Complex partial
    Generalized v.s. Partial NCSE
   Generalized
       Ends abruptly without postictal abnormality
   Partial
       Associated with postictal confusion,
        depression, or general malaise
          EEG Patterns in NCSE
   Generalized NCSE
       Spike-and-wave
       Polyspike-and-wave
       Frequency < 3Hz
   CPSE
       Focal
       Most often affecting the temporal area
   Sometimes, it is difficult to classify
          Absence Status EEG
   Continuous generalized
   Bilaterally synchronous
   Symmetric epileptic activity
   Usually maximal anteriorly
        D/D of Absence Status
   Primary psychiatric disorder
   Drug intoxication
   Postictal state
   Metabolic encephalopathy
   Transient global amnesia
   CPSE
     NCSE in Comatose Patients
   Subtle generalized SE
   Electrographic SE
   SE in comatose patients
   Generalized electrographic SE
   Non-tonic-clonic SE
   Subclinical SE
   NCSE
        NCSE in Comatose Patients
   Symptoms/signs
       Subtle, intermittent focal or multifocal
        rhythmic movements
   Etiology
       Hypoxia, metabolic disturbances, and after
        convulsive seizures
   Diagnosis, Treatment and Prognosis
        EEG Patterns in NCSE
   Periodic lateralized epileptiform
    discharges (PLEDs)
   Bilateral independent PLEDS (BIPLEDs)
   Periodic epileptiform discharges (PEDs)
   Generalized triphasic waves (TWs)
                     PLEDs
   Lateralized complexes recurring every 1-2 s
   Sharp waves or spikes followed by a slow
    wave
   Acute unilateral lesions (infarcts or tumors)
   Chronic seizure disorders or old static lesions
   Recent seizures, alcohol withdrawal, or a
    toxic-metabolic disorder
EEG
              S/S of PLEDs
   Obtundation, focal seizures, and focal
    neurologic signs
   Dynamic pathophysiologic state:
    unstable neurobiologic processes create
    an ictal-interictal continuum.
                 BIPLEDs
   The complexes are asynchronous
   Differing in morphology, amplitude, rate
    of repetition, and site of maximal
    involvement
   Hypoxic encephalopathy, CNS infection,
    and chronic seizure disorder
                    PEDs
   Generalized periodic bisynchronous sharp
    complexes
   Drug-related disorders, metabolic
    encephalopathies, and after anoxia-ischemia
    and CSE. Degenerative disease, such as CJD.
   Epileptic encephalopathy: spikes & sharp
    waves may not impair clinical function, but
    rather reflect damage from severe brain
    injury
                    TWs
   Bursts of moderate to high amplitude
    activity, usually of 1.5-2.5 Hz, often
    occurring in clusters
   Predominant in the frontal regions
   Persistent asymmetry: underlying
    structural lesion
   Metabolic encephalopathies, particularly
    hepatic or renal dysfunction
           Diagnostic Criteria
   NCSE is very difficult to diagnose
   The diagnostic criteria for NCSE are
    controversial
   Young et al. proposed the following
    primary and secondary criteria for NCS
   Al least one of primary + one or more
    secondary
              Primary Criteria
   Repetitive generalized or focal spikes, sharp
    waves, spike-and-wave, or sharp-and-slow
    wave complexes > 3/s
   Repetitive generalized or focal spikes, sharp
    waves, spike-and-wave, or sharp-and-slow
    wave complexes < 3/s and 2nd criterion #4
   Sequential rhythmic waves and 2nd criteria 1,
    2, and 3 with or without 4.
            Secondary Criteria
   Incrementing onset: increase in voltage
    and/or increase or slowing of frequency
   Decrementing offset: decrease in voltage or
    frequency
   Postdischarge slowing or voltage attenuation
   Significant improvement in clinical state or
    baseline EEG after intravenous antiepileptic
    drug
            Clinical Features
   Prolonged “postictal state” after
    convulsive seizures
   Unexplained alteration of mental status
    or coma, with or without subtle motor
    activity
   After CSE was controlled, 48% had
    persistent electrographic seizures, and
    14% manifested NCSE
                  Incidence
   The incidence of NCSE in comatose
    patients is uncertain
   42/124 (34%) of NICU had NCS and
    33/124 (27%) had NCSE. Neurology
    1992;42:194
   Partial > generalized
   Routine?
                 Treatment
   A, B, C
   IV, O2
   0.9% or 0.45% N/S, with Vit B1 100mg IV
   50ml 50% glucose
   Diazepam 5mg IV
   Dilantin loading 20mg/kg IV, <50mg/min
   Phenobarbital 15-20mg/kg, <100mg/min
                       Outcome
   Outcome of patients in NCSE is poor
   Mortality: subtle SE > overt SE
       65% within 30 days v.s. 27%
   After CSE, poor outcome EEG manifestation
       PEDs
       PLEDs
       After SE ictal discharges
   Seizure duration and delay to diagnosis were
    associated with mortality↑
                 Summary
   NCSE: generalized & complex partial
   NCSE is difficult to diagnosis, and EEG
    is the only way to verify it
   Emergent treatment, then correct the
    underlying disorder
   The outcome of patients in NCSE is
    poor
          EEG Findings Summary
   PLEDs
       Acute unilateral lesions (infarcts or tumors)
       Chronic seizure or old static lesions
   BIPLEDs
       Hypoxic encephalopathy, CNS infection, and
        chronic seizure disorder
   PEDs
       Drug-related, metabolic encephalopathies, anoxia-
        ischemia, CSE, and degenerative disease
   TWs
       Metabolic encephalopathies, particularly hepatic or
        renal dysfunction
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posted:3/29/2011
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