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      Clinical presentation, epidemiology, neurophysiological findings, treatment and outcome of nonconvulsive status epilepticus: a 3-year prospective, hospital-based study

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          Abstract

          Objective: This study reports the prevalence of Nonconvulsive Status Epilepticus (NCSE) in patients with altered mental status (AMS), and describes the clinical presentation, etiology, neurophysiological findings, neuroimaging, treatment, and outcome of NCSE in Qatar. Recording duration of continuous EEG monitoring was also discussed.

          Methods: This was a 3-year, prospective, hospital-based study involving patients with AMS and continuous EEG monitoring admitted to the Emergency and ICUs of Hamad Hospital, Qatar. Patients with confirmed diagnosis of NCSE were compared to the patients who did not show EEG and clinical features compatible with NCSE. Descriptive statistics in terms of mean with standard deviation, as well as frequency and percentages for categorical variables, were calculated; Student’s t test as well as Chi-square tests or Fisher’s exact tests were applied. Logistic regressions NSCE was performed using significance level 0.05 for independent variables at univariate analysis.

          Results: Number of patients with AMS and continuous EEG monitoring was 250. Number of patients with EEG compatible with NCSE: 65 (age range, 12–79 ys; m, 37; f, 28). Number of controls (defined as patients with EEG not compatible with NCSE): 185 (age range, 12–80 ys; m, 101; f, 84). Rate of occurrence of NCSE in patients with AMS: 26%. NCSE group was younger than controls ( p < .001). Twenty patients with NCSE (31%) and 35 patients in the control group (19%) died. Death was more frequent in comatose NCSE compared to controls ( p < .0007). NCSE proper and comatose NCSE had longer hospital stays than controls ( p < .02 and p < .03, respectively). Complete recovery occurred in 26 NCSE patients (40%) and in 98 controls (53%) ( p < .08). Twenty-one patients (31%) presented with refractory NCSE: 12 patients survived, 9 died.

          Conclusion: This was the first prospective study reporting a high number of NCSE in Qatar, a small country in the MENA region. This prevalence (26%) was in the middle range. NCSE patients did not perform better than controls, outcome being worse with comatose NCSE. NCSE is an emergent condition warranting expedited diagnosis and management. Three days of continuous EEG monitoring were able to diagnose most cases of NCSE.

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          EFNS guideline on the management of status epilepticus in adults.

          H Meierkord, P Boon, I B Engelsen … (2010)
          The objective of the current article was to review the literature and discuss the degree of evidence for various treatment strategies for status epilepticus (SE) in adults. We searched MEDLINE and EMBASE for relevant literature from 1966 to January 2005 and in the current updated version all pertinent publications from January 2005 to January 2009. Furthermore, the Cochrane Central Register of Controlled Trials (CENTRAL) was sought. Recommendations are based on this literature and on our judgement of the relevance of the references to the subject. Recommendations were reached by informative consensus approach. Where there was a lack of evidence but consensus was clear, we have stated our opinion as good practice points. The preferred treatment pathway for generalised convulsive status epilepticus (GCSE) is intravenous (i.v.) administration of 4-8 mg lorazepam or 10 mg diazepam directly followed by 18 mg/kg phenytoin. If seizures continue more than 10 min after first injection, another 4 mg lorazepam or 10 mg diazepam is recommended. Refractory GCSE is treated by anaesthetic doses of barbiturates, midazolam or propofol; the anaesthetics are titrated against an electroencephalogram burst suppression pattern for at least 24 h. The initial therapy of non-convulsive SE depends on type and cause. Complex partial SE is initially treated in the same manner as GCSE. However, if it turns out to be refractory, further non-anaesthetising i.v. substances such levetiracetam, phenobarbital or valproic acid should be given instead of anaesthetics. In subtle SE, in most patients, i.v. anaesthesia is required.
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            Incidence of status epilepticus in adults in Germany: a prospective, population-based study.

            S Knake, N Katsarou, M Vescovi … (2001)
            To determine the incidence and case-fatality rate of status epilepticus (SE) in adults in Hessen, Germany, we performed a prospective, population-based study from July 1997 through June 1999. All adult patients residing within the zip-code area 35 (area-35) with SE were included. Area-35 had 743.285 adult inhabitants, including 123.353 adult inhabitants of the primary service area of the University Hospital Marburg (PS-area). Patients were reported by 16 hospitals in the area and were prospectively identified and carefully reviewed within 5 days by one of the authors. Based on the crude annual incidence of SE and a rate of underascertainment of 10% determined for the PS-area, the corrected, age-adjusted incidence of SE in area 35, more representative of the population of Germany, was calculated. The crude annual incidence in the PS-area was 15.8/100,000 [95% confidence interval (CI), 11.2-21.6]. The calculated, corrected, age-adjusted incidence of SE in area 35 was 17.1/100,000. It was higher for men compared with women (26.1 vs. 13.7) and for those aged 60 years and older (54.5 vs. 4.2/100,000, p < 0.0001). The etiology was mainly remote symptomatic due to cerebrovascular disease. Epilepsy was previously diagnosed in only 50% of the patients. The case-fatality rate was 9.3%. Based on our data, at least 14,000 patients would be affected by SE in Germany, associated with approximately 1,300 deaths annually. The incidence of SE in Germany is similar to that found in the white United States population. Furthermore, this study confirms the higher incidence of SE in male patients and in the elderly population. This may be due to a higher incidence of cerebrovascular disease in these subpopulations.
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              Prevalence of nonconvulsive status epilepticus in comatose patients.

              J. Smith, A Towne, Robert DeLorenzo … (2000)
              Nonconvulsive status epilepticus (NCSE) is a form of status epilepticus (SE) that is an often unrecognized cause of coma. To evaluate the presence of NCSE in comatose patients with no clinical signs of seizure activity. A total of 236 patients with coma and no overt clinical seizure activity were monitored with EEG as part of their coma evaluation. This study was conducted during our prospective evaluation of SE, where it has been validated that we identify over 95% of all SE cases at the Medical College of Virginia Hospitals. Only cases that were found to have no clinical signs of SE were included in this study. EEG demonstrated that 8% of these patients met the criteria for the diagnosis of NCSE. The study included an age range from 1 month to 87 years. This large-scale EEG evaluation of comatose patients without clinical signs of seizure activity found that NCSE is an underrecognized cause of coma, occurring in 8% of all comatose patients without signs of seizure activity. EEG should be included in the routine evaluation of comatose patients even if clinical seizure activity is not apparent.
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                Author and article information

                Journal
                Journal ID (nlm-ta): J Drug Assess
                Journal ID (iso-abbrev): J Drug Assess
                Journal ID (archive): IJDA
                Journal ID (publisher-id): ijda20
                Title: Journal of Drug Assessment
                Publisher: Taylor & Francis
                ISSN (Electronic): 2155-6660
                Publication date Collection: 2017
                Publication date (Electronic): 10 November 2017
                Volume: 6
                Issue: 1
                Pages: 18-32
                Affiliations
                [ a ] Hamad Medical Corporation Doha Qatar
                [ b ] Weill Cornell Medical College Doha Qatar
                [ c ] Johns Hopkins University School of Medicine Baltimore USA
                [ d ] University of Zurich Zurich Switzerland
                Author notes
                CONTACT Boulenouar Mesraoua boulenouar.mesraoua@ 123456wanadoo.fr Hamad Medical Corporation, Neurology Department, and Weill Cornell Medical College – Qatar, Neurology Department, Hamad Hospital Po Box 3050 DohaQatar
                Article
                Publisher ID: 1396992
                DOI: 10.1080/21556660.2017.1396992
                PMC ID: 5700530
                PubMed ID: 29201532
                SO-VID: 2e11b6f8-b927-4a8f-8dfd-fb775573b24d
                Copyright © © 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 10 May 2017
                Date revision received : 20 September 2017
                Date accepted : 16 October 2017
                Page count
                Pages: 15, Words: 6893
                Funding
                Funded by: Qatar National Research Fund
                Categories
                Subject: Article
                Subject: Neurology

                Keywords: ceeg monitoring,ncse,epidemiology,treatment,outcome
                Data availability:
                Keywords: ceeg monitoring, ncse, epidemiology, treatment, outcome

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