PROBLEM 3A

JESLY CHARLIES
405100171
Group 10, Emergency Medicine Block

Emergencies???
Seizures become emergencies when :
an individual is either in danger of harming themselves
seizure continues for a long period of time
immediate medical attention is necessary

Status Epilepticus
Foundation of Americas Working Group on Status

Epilepticus defines Status Epilepticus as:

(established status epilepticus)
continuous seizure activity (partial or generalized,
convulsive or nonconvulsive) lasting 30 min or
more
or
intermittent seizure activity lasting 30 min or more
during which consciousness is not regained

Roos, Karen L. Neurology Emergency

Early / impending status epilepticus

continuous or intermittent seizures lasting more than 5
min, without full recovery of consciousness between
seizures
Refractory status epilepticus
Seizures lasting > 2 hour / seizures recurring at a rate of
two or more episodes per hour without recovery to
baseline between seizures, despite treatment with
conventional antiepileptic drugs

Roos, Karen L. Neurology Emergency

Roos, Karen L. Neurology Emergency

Epidemiology
3 million cases in the worldwide
USA 150.000 cases
50.000 60.000 refractory cases
Highest incidence
Young children < 1 yo
Elderly > 85 yo

Males : females = 1,5-2 : 1

Roos, Karen L. Neurology Emergency

Classification

Roos, Karen L. Neurology Emergency

Etiology

Roos, Karen L. Neurology Emergency

Pathophysiology
Isolated seizure status epilepticus
marked changes in ionic channels, adenosine
formation/release, electrical synchronization, failure of
GABA-mediated inhibition
Failure of terminating mechanisms
blockade of N-methyl- d -aspartate (NMDA) channels by

magnesium
activation of K+ conductances
repolarization of neurons and neuropeptide Y
change in GABAA receptors
expression of proconvulsive neuropeptides (substance P,

neurokinin B)

Roos, Karen L. Neurology Emergency

Time dependent pharmacoresistance

alteration in the functional properties of GABA receptors
present in the hippocampal dentate granule cells
potency of benzodiazepines decrease by 20 times within 30

min of self-sustaining status epilepticus

Translocation of calmodulin from the membrane to the

cytosol
phenytoin resistance

Seizure-induced neuronal injury & death

Neuron-specific enolase, a marker of neuronal death >> in
the serum of patients after status epilepticus
excessive neuronal firing through excitotoxic
mechanisms

Roos, Karen L. Neurology emergency

Clinical presentation

Clinical presentation
convulsive sE
most common and serious form of status

epilepticus
subtle GCSE :
profound coma with
convulsive activity limited to nystagmoid movement of the

eyes or
intermittent brief clonic twitches of the extremities or trunk,
and bilateral ictal discharges on the EEG

Generalized myoclonic status epilepticus

common in children

 Convulsive simple partial status epilepticus ( i.e. ,

epilepsia partialis continua) is characterized

repeated partial motor seizures,
Preserved consciousness,
preserved neurovegetative regulations.

Repeated clonic jerks with localization depending

on the localization of the epileptogenic lesion in

the primary motor cortex are the cardinal clinical
feature

Clinical presentation
non convulsive SE
Negative symptoms
(coma, catatonia, aphasia, confusion)
positive symptoms
(agitation, automatisms, delirium, delusion, psychosis)

NCSE is applied to patients who are severely

obtunded or comatose with minimal or no motor

movements.

 NCSE should include:

(1) unequivocal electrographic seizure activity,
(2) periodic epileptiform discharges or rhythmic discharges
with clinical seizure activity,
(3) rhythmic discharges with either clinical or
electrographic response to treatment

 Typical absence status epilepticus

prolonged absence attacks with continuous or
discontinuous 3-Hz spike and wave occurring in patients
with primary generalized epilepsy.
Isolated impairment of consciousness, at times with subtle
jerks of the eyelids essential symptom.

 complex partial status epilepticus implies a

prolonged epileptic episode in which focal

fluctuating or frequently recurring electrographic
epileptic discharges, arising in temporal or extra
temporal regions confusional state with variable
clinical symptoms.
Clinical features :
clouding of consciousness,
various automatisms (oroalimentary, gestural),
language disturbances.

 Electrical status epilepticus during sleep is

characterized by
spike-and-wave discharges in 85100% of nonrapid eye

movement (REM) sleep.

associated with certain epilepsy syndromes such as
LandauKleffner and LennoxGastaut syndromes

Roos, Karen L. Neurology Emergency

Complications

Investigation
Investigations are done to find :
the etiology of the status epilepticus,
to define the type of status epilepticus syndrome
to differentiate from other acute neurologic conditions that
can simulate complex partial status epilepticus, ex :
(intoxications, encephalitis, metabolic disorders,

pseudostatus).

Treatment

Roos, Karen L. Neurology Emergency

Treatment

Roos, Karen L. Neurology Emergency

Roos, Karen L. Neurology Emergency

References
Roos KL: Emergency Neurology, Springer: 2012