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Status epilepticus in the ICU

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Abstract

Status epilepticus (SE) is a common medical emergency associated with significant morbidity and mortality. Management that follows published guidelines is best suited to improve outcomes, with the most severe cases frequently being managed in the intensive care unit (ICU). Diagnosis of convulsive SE can be made without electroencephalography (EEG), but EEG is required to reliably diagnose nonconvulsive SE. Rapidly narrowing down underlying causes for SE is crucial, as this may guide additional management steps. Causes may range from underlying epilepsy to acute brain injuries such as trauma, cardiac arrest, stroke, and infections. Initial management consists of rapid administration of benzodiazepines and one of the following non-sedating intravenous antiseizure medications (ASM): (fos-)phenytoin, levetiracetam, or valproate; other ASM are increasingly used, such as lacosamide or brivaracetam. SE that continues despite these medications is called refractory, and most commonly treated with continuous infusions of midazolam or propofol. Alternatives include further non-sedating ASM and non-pharmacologic approaches. SE that reemerges after weaning or continues despite management with propofol or midazolam is labeled super-refractory SE. At this step, management may include non-sedating or sedating compounds including ketamine and barbiturates. Continuous video EEG is necessary for the management of refractory and super-refractory SE, as these are almost always nonconvulsive. If possible, management of the underlying cause of seizures is crucial particularly for patients with autoimmune encephalitis. Short-term mortality ranges from 10 to 15% after SE and is primarily related to increasing age, underlying etiology, and medical comorbidities. Refractoriness of treatment is clearly related to outcome with mortality rising from 10% in responsive cases, to 25% in refractory, and nearly 40% in super-refractory SE.

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Abbreviations

ASM:

Antiseizure medication

FIRES:

Fever-induced refractory epilepsy syndrome

GABA:

Gamma-amino-butyric-acid

GRAW:

Generalized periodic discharges related to anesthetic withdrawal

IL:

Interleukin

NMDA:

N-Methyl-d-aspartate

NORSE:

New-onset refractory status epilepticus

ICU:

Intensive care unit

RSE:

Refractory status epilepticus

SE:

Status epilepticus

SRSE:

Super-refractory status epilepticus

SSEP:

Somatosensory evoked potentials

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Authors and Affiliations

  1. Department of Neurology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland

    Andrea O. Rossetti

  2. Department of Neurology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA

    Jan Claassen

  3. Service de Neurologie, Hôpital Universitaire de Bruxelles, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium

    Nicolas Gaspard

  4. Department of Neurology, Yale University School of Medicine, New Haven, CT, USA

    Nicolas Gaspard

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  1. Andrea O. Rossetti
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  2. Jan Claassen
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Correspondence to Nicolas Gaspard.

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Conflict of interest

NG received research funding from the Fonds de la Recherche Scientifique (FNRS), Fonds Erasme pour la Recherche Médicale, and INNOVIRIS. NG received royalties for authoring a chapter for MedLink Neurology. NG served on speakers’ bureau and advisory board for UCB Pharma and Angelini Pharma AR has nothing to disclose. JC is supported by grant funding from the NIH R01 NS106014 and the McDonnell Foundation. JC is a minority shareholder at iCE Neurosystems.

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Rossetti, A.O., Claassen, J. & Gaspard, N. Status epilepticus in the ICU. Intensive Care Med 50, 1–16 (2024). https://doi.org/10.1007/s00134-023-07263-w

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