Resident Physician University of North Carolina at Chapel Hill Chapel Hill, North Carolina
Rationale: Status epilepticus is a life-threatening condition with a mortality of up to 60% in the advanced cases. Antiepileptic drugs (AEDs) fail to control epileptic activity in about 20% of cases, leading to refractory status epilepticus with sustained injury to brain parenchyma (1). Surgical evaluation is rarely considered for refractory status epilepticus despite potential. Intracerebral EEG can help determine the focality of seizures, and whether a patient can benefit from intervention (2). This study highlights that urgent surgical evaluation can successfully treat refractory status epilepticus, and reduce morbidity, morality and disability. Methods: We report the outcomes of three retrospective cases from 2013 to 2019 who were found to be in refractory status epilepticus despite optimal medical therapy and underwent surgical intervention with either resection or neurostimulator placement (RNS®, NeuroPace Inc). Inclusion criteria: 1) convulsive or non-convulsive status epilepticus, confirmed by video EEG, 2) failed medical management and underwent surgical intervention. Outcome measures included 1) burden of seizure activity post intervention, 2) correlation of GCS at discharge with seizure burden and length of hospitalization, and 3) correlation of change in neurological disability score (measured by modified Rankin Score prior to admission and on day of discharge) with seizure burden and length of hospitalization. Results: All three patients presented with focal refractory status epilepticus and were treated with optimal dose of four to six AEDs and burst suppressed over 16 to 55 hospital days with ten to 20 breakthrough seizure days prior to intervention with either resection or RNS placement. After intervention, two patients had complete seizure-freedom on home AEDs prior to discharge whereas one had four breakthrough seizures while adjusting antiepileptic medications.The change in neurological disability score during hospitalization was positively correlated with seizure burden prior to intervention (CC 1.00) and total length of hospitalization (CC 0.76). The change in GCS during hospitalization was negatively correlated with seizure burden prior to intervention (CC -0.75) and total length of hospitalization (CC -1.00). Conclusions: Refractory status epilepticus cases are often difficult to manage with medical therapy alone and have poor prognosis. This case series demonstrates that surgical evaluation and intervention can help break the cycle of status epilepticus and reduce seizure burden, length of hospitalization and potentially improve long-term prognosis. Further research is needed to determine the significance of surgical evaluation and build guidelines of surgical intervention for refractory status epilepticus cases.
Trinka E., Brigo F. Neurostimulation in the treatment of refractory and super-refractory status epilepticus. Epilepsy & Behavior. 2019; 101, 106551.
Karthick PA, Tanaka H, Khoo HM, Gotman J. Prediction of secondary generalization from a focal onset seizure in intracerebral EEG. Clin Neurophysiol. 2018;129(5):1030-1040.
Funding: Please list any funding that was received in support of this abstract.: None