Electrical status beyond convulsive status epilepticus

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Information about Electrical status beyond convulsive status epilepticus
Health & Medicine

Published on September 16, 2014

Author: teikbengkhoo

Source: slideshare.net

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Presentation at PNU 2014

Electrical (non-convulsive) status epilepticus Paediatric Neurology update 2014 28 August 2014 Ahmad Rithauddin bin Mohamed Paediatric Neurologist, IPHKL

Non-convulsive status epilepticus (NCSE) a state of ongoing (or non-recovery between) seizures without convulsions, usually for more than 30 min Intensive care setting ‘comatose’, ‘encephalopathic’ post convulsive status Out-patient setting ‘not quite right’ neuroregression

Case example 1 •5 yr old, unwell with fever and diarrhoea •Had 2-3 brief seizures initially, then convulsive status epilepticus after several hours •Continued to have intermittent seizures while ventilated (2/52) •Post extubation – brief eye deviation, remained encephalopathic

after 20 seconds

NCSE in febrile illness related epilepsy syndrome (FIRES)

How common is NCSE in ICU setting?

% of electrographic seizures and status epilepticus in PICU overall IPHKL North American Paediatric Critical Care EEG Group, 50 consecutive EEG monitoring at each centre Sanchez et al, 2013

% of electrographic seizures and status epilepticus in PICU overall IPHKL IPHKL Khoo TB, 2014

Prevalence of NCS/NCSE •Sanchez 2013 (11 centres, N=550) –162/550 (29%) had electrographic seizures –61/550 (11%) had electrographic status epilepticus –114/550 (21%) had non-convulsive (+/- convulsive) seizures •Khoo 2014 (IPHKL, N=50) –11/50 (22%) had electrographic seizures –4/50 (8%) had electrographic status epilepticus –8/50 (16%) had non-convulsive (+/- convulsive) seizures; 4/50 (8%) had NCSE

Prevalence of NCS/NCSE •Sanchez 2013 (11 centres, N=550) –162/550 (29%) had electrographic seizures –61/550 (11%) had electrographic status epilepticus –114/550 (21%) had non-convulsive (+/- convulsive) seizures •Khoo 2014 (IPHKL, N=50) –11/50 (22%) had electrographic seizures –4/50 (8%) had electrographic status epilepticus –8/50 (16%) had non-convulsive (+/- convulsive) seizures; 4/50 (8%) had NCSE 4 FIRES, 1 NMDA encephalitis, 1 viral encephalitis, 2 epilepsy exacerbation

Predictors of NCSE •Greiner 2012 – witnessed seizure, abnormal brain imaging •McCoy 2011 - epilepsy, witnessed seizure, acute structural brain injury, interictal discharges on EEG •IPHKL – witnessed seizure

Predictors of NCSE •Greiner 2012 – witnessed seizure, abnormal brain imaging •McCoy 2011 - epilepsy, witnessed seizure, acute structural brain injury, interictal discharges on EEG •IPHKL – witnessed seizure ADC DWI Acute stroke

Predictors of NCSE •Greiner 2012 – witnessed seizure, abnormal brain imaging •McCoy 2011 - epilepsy, witnessed seizure, acute structural brain injury, interictal discharges on EEG •IPHKL – witnessed seizure HSV encephalitis

Non-convulsive status epilepticus (NCSE) a state of ongoing (or non-recovery between) seizures without convulsions, usually for more than 30 min Intensive care setting ‘comatose’, ‘encephalopathic’ post convulsive status Out-patient, epilepsy setting ‘not quite right’, neuroregression

Case example 2 •10 yr old boy •Fever provoked convulsions at 7 years •Unprovoked nocturnal seizures from 8 years, EEG showed GSW, started on Epilim •Old brother with GTCs, on Epilim •Now presenting with abnormal behaviour, less responsive, drooling

3 Hz spike waves during spells

Absence SE, underlying idiopathic generalised epilepsy

Case example 3 •10 yr old boy, underlying mild developmental delay •Infrequent nocturnal seizures from 4 years, EEG showed centrotemporal spikes, treated as BRE •From 6 years – had more seizures, unsteady gait, cognitive regression •EEG encephalopathic, unchanged despite treatment

EEG awake

EEG sleep

BRE with atypical evolution to Electrical Status Epilepticus or Continuous Spikes and Waves during Slow wave sleep (ESES or CSWS)

language delay/regression no / rare seizures frequent, bisynchronous CTS language delay / regression oromotor problems / ataxia many + & - rolandic seizures frequent, bisynchronous CTS severe global delay / regression motor and behavioural deficits many rolandic & other seizures continuous CTS seizures development normal ESES CSWS delayed development no or rare seizures “normal” child no seizures uni or independent CTS normal (2%) “normal” child rare rolandic seizures uni or independent CTS BRE Atypical BRE LKS

Other examples of epilepsies with frequent occurences of NCSE Syndrome Etiology or clinical context Clinical form EEG Benign occipital epilepsy Idiopathic Autonomic status epilepticus Occipital ictal rhythms NCSE in Lennox- Gastaut syndrome Various, often cryptogenic Atypical absence status epilepticus 2-2.5 Hz GSW NCSE in other syndromes (eg ring chromosome 20, Angelman, myoclonic– astatic epilepsy) Various, usually genetic or cryptogenic Atypical absence and other nonspecific forms Various

Non-convulsive status epilepticus (NCSE) When to suspect Intensive care setting Suspect in ‘comatose’ & ‘encephalopathic’ patients, especially following witnessed seizures & when imaging is abnormal Out-patient, epilepsy setting Suspect in certain epilepsy syndromes when patient is ‘not quite right’ or shows neuroregression

Do NCS/NCSE in ICU cause any harm?

Midline shift after intracranial haemorrhage Vespa 2003 Presented by Hirsch, AES meeting 2010

NCS in TBI: effect on ICP Vespa 2007 Presented by Hirsch, AES meeting 2010

Presence of NCS/NCSE is an independent predictor of worse outcome De Lorenzo 1998

Variable Mortality OR (95% CI) p-value Worsened PCPC OR (95% CI) p-value Seizure Category No Seizures Ref Ref Ref Ref Electrographic Seizures 1.3 (0.3, 5.1) 0.74 1.2 (0.4, 3.9) 0.77 Electrographic Status 5.1 (1.4, 18) 0.01 17.3 (3.7, 80) <0.001 Presence of NCSE but not NCS is associated with worse outcome Topjian 2013

Treatment of NCS/ NCSE •Same AEDs as for convulsive status •Balance between side effects and benefits

Do NCS/NCSE in outpatient setting cause any harm?

Neurospychiatric evolution of patients with ESES typical negative Brain lesions Motor manifestations Pera 2013

Preferred drugs for treatment of CSWS RCH/ IPHKL Valproate Benzodiazepine Ethosuximide Sulthiame Steroids IVIG N=196 N=187 Fernandez 2014

Conclusion •NCSE is an important cause of encephalopathy in the ICU setting, especially in patients with witnessed seizures and abnormal brain imaging •NCSE may complicate certain epilepsy syndromes, anticipating such complication will assist early detection and effective treatment •Successful treatment of NCSE may impact positively on mortality and long term neurodevelopmental outcome

Electrical (non-convulsive) status epilepticus Thank you Acknowledgment Dr Khoo IPHKL EEG unit IPHKL Paed Neuro team Patients and families

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