Status epilepticus: What’s changed, what to know, and a global perspective

A watch marking 5 minutes, with a globe
A new review outlines best practices for diagnosing and managing status epilepticus in both resource-rich and resource-limited settings. (Images: Adobe Stock; Illustration: David Chrisom, Boston Children's Hospital)

Status epilepticus, or a prolonged seizure lasting more than five minutes, is a rare complication of epilepsy and a medical emergency that can occur even in people without a diagnosis of epilepsy. If not treated quickly, it can cause brain damage, lifelong complications, and even death.

“A prolonged seizure is a race against time to save brain tissue,” says Jennifer Gettings, BMBS, FRCPC, an attending neurologist at Boston Children’s Hospital who specializes in epilepsy and neurocritical care. “It may require ICU care, intubation, and a prolonged hospital admission.”

Over the past decade, a series of improvements in diagnostic and treatment options have changed the picture for status epilepticus. Gettings and her colleague Fatemeh Mohammad Alizadeh Chafjiri, MD, a postdoctoral fellow in the lab of Tobias Loddenkemper, MD, felt it was time to update the literature. Together with Archana A. Patel, MD, MPH, director of global neurology at Boston Children’s, and others, they published a review in The Lancet Neurology that takes a global perspective, highlighting best practices for diagnosing and managing status epilepticus in both resource-rich and resource-limited settings.

Status epilepticus: Causes and diagnostic testing

Status epilepticus has multiple potential causes. In people with epilepsy, insufficient doses of antiseizure medications or a febrile illness can lead to status epilepticus. Other causes include:

  • Head trauma
  • Systemic or central nervous system infections
  • Cerebrovascular disease or stroke
  • Metabolic disturbances
  • Brain tumors
  • Genetic disorders
  • Toxic exposures

A long list of potential tests and studies can help identify the underlying causes of status epilepticus. The new review provides a diagnostic flow chart indicating which studies are essential, which should be added if possible, and which are helpful in specific clinical situations.

“Exhaustive lists of investigations are easy to find,” Gettings says. “But we synthesized them so that health care providers can quickly identify which have the greatest yield.”

At a minimum, laboratory studies should include a complete blood count, measurement of glucose and electrolytes, blood and urine cultures, and a lumbar puncture with cerebrospinal fluid testing if infection is suspected. When possible, further studies should include tests of renal and liver function, blood gases, lactate, troponin, and creatine kinase and a toxicology screen.

Ongoing alterations in mental state after status epilepticus — confusion, lethargy, agitation, delirium, or speech disturbances — could indicate the patient is having non-convulsive seizures. EEG monitoring is important if available.

Rapid treatment is key

Gettings emphasizes that if patients in status epilepticus are stabilized quickly with rescue medications, such as buccal, intranasal, or rectal benzodiazepines (diazepam, lorazepam, or midazolam), their risk for further prolonged seizures and further complications is reduced.

On average, in about 70 percent of cases, prompt benzodiazepine treatment will terminate status epilepticus. A second dose should be given if a seizure persists 5 to 10 minutes after the first benzodiazepine dose.

Chafjiri notes that even in settings where rescue medications are readily available, health care providers tend to under-dose patients for fear of causing respiratory depression. However, ongoing seizures themselves can lead to respiratory depression, she says. “It’s important to train caregivers and EMS staff to give the rescue medications as soon as possible and at adequate doses.”

Caring for status epilepticus in low-resource settings

The review is unique in offering a global health perspective on status epilepticus and a diagnostic and treatment approach that can be implemented when resources are minimal, says Loddenkemper, the paper’s senior author.

The treatment algorithm created by Gettings and Chafjiri is mindful that not all tests and interventions will be available everywhere. For example, treatment guidance for low-resource settings includes using benzodiazepines, such as diazepam and midazolam, that do not require refrigeration, making them more widely available. When benzodiazepines are unavailable or intravenous delivery is not feasible, levetiracetam can be given via nasogastric tube, or phenobarbital can be given through an intramuscular injection.

New developments in diagnosis and treatment

The review also highlights recent medical advances in the care of status epilepticus.

New intranasal rescue medications eliminate the need for rectal administration of benzodiazepines, offering a more comfortable, socially acceptable alternative for patients and caregivers. However, they are not yet widely available in low- and middle-income countries.

Wearable seizure detection devices enable rapid recognition of seizure activity, especially when patients are asleep or unobserved. These devices can detect seizures and may have a role in settings where conventional EEG systems are not readily available.

Headbands and caps with reduced numbers of electrodes can be slipped on to quickly screen patients for seizure activity and determine whether they will need conventional EEG monitoring, which can require up to an hour to apply. These devices can be combined with smartphone or tablet-based apps; a positive finding notifies health care providers that seizure activity may be occurring.

Future agenda

Gettings and Chafjiri hope their review will inspire policymakers and health care systems to disseminate the guidelines, provide education, and make sufficient rescue medications and monitoring technologies available to neurologists as well as EMS staff, emergency departments, and urgent care centers.

“We have tools available to diagnose and manage status epilepticus, but we need to make them accessible everywhere,” says Gettings.

Read the review in The Lancet Neurology

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