Abstracts

Rationale: Refractory status epilepticus (RSE) is an entity that is poorly defined and for which there is not a standardized treatment protocol to date. Even more so, there is no current definition as to what constitutes prolonged RSE. This study was used to examine the epidemiology of prolonged RSE in a large urban university hospital and the treatment approach including neurosurgical intervention. Methods: A retrospective chart review was performed on patients from 2003-2008, selected from a database who had a minimum of 7 days of continuous EEG monitoring. Patients who continued to seize despite treatment with at least two first line antiepileptic drugs (AEDs) and continuous intravenous infusion of appropriate antiepileptic agents were considered to be in RSE. The patient was included in the study if seizures continued on EEG monitoring for at least 7 days. All relevant clinical information including patient demographics, AEDs used, underlying etiology and Glasgow outcome scores (GOS) were recorded. Results: Out of 29 patients initially screened, 17 were found to be in prolonged RSE. Of these 17 patients, 53% were men and 47% were women. The age range was 20-80 years, with a mean age of 49.6 years. Only 17.6% had a previous history of seizures. The etiology of RSE was as follows: tumor-4, vasculitis-3, trauma-2, strokes-6, and infection-2. Average number of AED’s used was 3.7. About a third of the patients (35%) presented with status epilepticus. The mean GOS was 2.2. A total of 7 (41%) patients had GOS score of 1 (death), while GOS was 2 in 2 patient (12%), 3 in 6 (35%), and 4 in 2(12%). No patient recovered to baseline or had a GOS of 5. Of the 17 patients, 4 or 24% received neurosurgical intervention in the form of biopsy or resection. The two patients who underwent biopsies had vasculitis/necrotizing vasculopathy from lupus. Both were treated with immunosuppression and one survived with GOS of 3, while the other died waiting for resective surgery. Of the two patients who had resection of their epileptic focus, one had vasculitis and the other had malignant glioma. Both of them survived in spite of prolonged status epilepticus (51 and 12 days respectively). The average duration between onset of status and neurosurgical intervention was 9.75 days. Conclusions: Prolonged RSE is accompanied by high morbidity and mortality. It usually occurs in older individuals. Contrary to many patients with status epilepticus where status is often due to withdrawals of AEDs from their underlying epilepsy, refractory status is more likely to occur in patients with new onset seizures and is frequently the presenting symptom. Most of the patients also have underlying identifiable structural abnormalities of the brain. Neurosurgical intervention can help to either remove the seizure focus or help guide better management of the patient’s RSE. Thus, when seizures continue beyond one week despite appropriate medical management, including use of continuous infusion of AEDs, neurosurgical intervention including resection of the seizure focus should be considered.