Management strategies for refractory status epilepticus

Summary & key facts

This review looks at seizures that do not stop after the usual first and second medicines. These stubborn seizures are called refractory status epilepticus. The authors summarize recent studies and suggest different treatment plans depending on whether seizures are convulsive (with shaking), nonconvulsive (not obvious without brain monitoring), or a special new-onset form. They report that older and newer intravenous seizure medicines, general anesthesia, ketamine, and treatments beyond drugs — like immune therapies and a ketogenic diet — are all being used or studied when usual medicines fail.

Key facts:

• Refractory status epilepticus means seizures keep happening even after a first benzodiazepine and a suitable second anti-seizure drug have been given.
• For convulsive refractory seizures, third-line treatment often includes putting the person into a medical coma using intravenous anesthetics such as midazolam or propofol.
• Recent studies support using ketamine to treat refractory seizures in both adults and children.
• Newer intravenous anti-seizure drugs, including levetiracetam and lacosamide, have shown safety and usefulness for status epilepticus and its refractory forms.
• Nonconvulsive status epilepticus (seizures without obvious shaking) is treated with similar drugs, but the true benefits of anesthetics and anti-seizure drugs in this form have not been fully studied.
• For new-onset refractory status epilepticus, including fever-related forms, standard anti-seizure drugs often do not work well, so doctors consider immune treatments and dietary approaches like the ketogenic diet.

Abstract

Refractory status epilepticus (RSE) is defined as the persistence of either clinical or electrographic seizures despite the administration of appropriate doses of an initial benzodiazepine and suitable second-line antiepileptic drugs (AEDs). The Neurocritical Care Society and the American Epilepsy Society have proposed a treatment paradigm for the management of convulsive status epilepticus (CSE). The third-line therapy in refractory CSE may involve general anesthesia using intravenous midazolam, propofol, or other agents, while recent evidence supports the use of ketamine to manage RSE in both adults and children. However, although these treatment strategies are frequently employed in nonconvulsive status epilepticus (NCSE), the efficacy of AEDs and anesthetics in NCSE has not been thoroughly investigated. Recent evidence has demonstrated the safety and efficacy of newer AEDs, including levetiracetam and lacosamide, in the treatment of status epilepticus (SE) and RSE, which also encompasses NCSE. Use of multiple combinations of various intravenous AEDs can also be considered in NCSE before the administration of general anesthesia. In addition, AEDs alone exhibit limited effectiveness in managing SE for new-onset RSE (NORSE) and its subset, febrile infection-related epilepsy syndrome. Therefore, in cases of refractory status, it is imperative to explore treatment options beyond AEDs, including immunotherapy and the incorporation of a ketogenic diet. The present review suggests treatment approaches for RSE based on subgroups, including CSE, NCSE, and NORSE. A discussion of recent clinical studies on AEDs and anesthetics in the management of RSE, as well as proposed treatment methods for NORSE, is also provided.

Topics

Epilepsy research and treatment

Categories

Health Sciences Medicine Psychiatry and Mental health

Tags

Anesthesia Astrobiology Benzodiazepine Epilepsy Intensive care medicine Internal medicine Ketogenic diet Lacosamide Levetiracetam Medicine Midazolam Neurointensive care Pediatrics Physics Propofol Psychiatry Receptor Refractory (planetary science) Sedation Status epilepticus

Substances

Ketamine