Abstracts

Rationale: Status Epilepticus (SE) is a common disorder which consists of prolonged, uncontrolled seizure activity, and constitutes one of the most commonly seen neurological emergencies in every day practice.There are varying accepted definitions regarding the duration of seizure required for diagnosis of SE, but little doubt that this disorder is associated with a high risk of mortality.For a small subset of this entity, there exists a cohort of patients in whom we see uncontrolled multi-medication refractory seizures that persist beyond usual durations.These cases of malignant SE are clinically challenging and there remains little objective information regarding best management and parameters that predict good outcome.Hence, there are no guidelines to assist the treating physician on how best to manage these patients, how long to pursue medical therapies despite continuing confirmed electrographic seizure activity and how best to council a patient’s loved ones regarding outcome. Methods: We reviewed the electronic pharmacy log to identify all patients who received intravenous(IV) pentobarbital in Massachusetts General Hospital from January 2001 until August 2007.This review identified 199 patients receiving IV pentobarbital for all indications.By review of the electronic medical record we have identified that 42 of 199 received this medication for a primary indication of seizure control and that 39 of these 42 patients received this medication for a stated diagnosis of Status SE.Within this group of 39 patients with SE, there existed a cohort of 22 patients with highly refractory SE, who continued to have documented seizure activity on EEG despite at least 7 days of prolonged anti-seizure therapy, which included at least a trial of IV pentobarbital to control seizures, an entity we define as Prolonged Refractory Status Epilepticus(PRSE).We reviewed the medical records of this group of 22 patients with PRSE to identify clinical, EEG, imaging and laboratory findings, to identify predictors of survival to discharge from hospital. Results: We identify 13 patients with PRSE who survived to discharge and who received intravenous pentobarbital in our hospital for PRSE between January 2001 and August 2007.These patients had prolonged uncontrolled seizures a result of a variety of neurological diseases, including Cryptogenic Status Epilepticus.We present the clinical, EEG, imaging and laboratory findings of this cohort, with a view to identifying potential clinical features and markers of good outcome, as defined by survival to discharge. Conclusions: This study identifies a small group of patients with highly refractory seizures who present with a commonly seen neurological emergency.To date there is little evidence to assist the treating clinician regarding best clinical practice for Prolonged Refractory Status Epilepticus(PRSE).We identify a clinical profile of those who survived to discharge from hospital, despite prolonged uncontrolled seizure activity. This cohort of survivors outlines clinical features which suggest a possibility of good outcome in the face of prolonged apparently unresponsive seizures.