articol statusul epileptic
TRANSCRIPT
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Summary
Status epilepticus (SE) is a major neurological emergency [1,2,3], potentially
life-threatening that requires immediate and vigorous treatment [1,2,3] to stop
the ongoing seizures, in order to prevent severe neuronal injuries, associated
complications or even death [3,4].
This study was designed to evaluate the incidence of SE in the neurological
intensive care unit, the basic etiology favored the development of SE, the
management in stopping the seizures and recurrence prevention.
In the study was performed a retrospective analysis of the medical records ofthe Emergency Hospital over a period of 3 years (01.01.2008-01.10.2011) that
included evaluation of 220 patients hospitalized with SE. The mean age of
patients was 53.52.6 years with the highest percentage among males (54.1%).
The most common cause of SE was appreciated to be of toxico-dysmetabolic
genesis (47.27%).According to the morphology of seizures the highest incidence
returns to SE generalized convulsive (SECG) type (85%). In the study group
was found that every patient has more than one probable cause of SE
development of which alcohol abuse was in 41.1%, on the second being placed
history of stroke (16.81%). To elderly patients acute and chronic
cerebrovascular pathology together form more than 50% of cases.
Clinical outcome during the period immediately after finalization was
characterized by a polymorphism of neurological and systemic symptoms thatappreciate entirely the clinical picture and severity of the process.
The management was performed according to international and institutional
protocols, which was primary directed on early seizure termination and
prevention of recurrence, in parallel with treatment of underlying etiology and
secundary complications. The mortality due to consequences of SE in this group
was 16.81%.
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Introduction
SE constitute a potentially fatal medical emergency, that occurs as a result of
primary neurologic disease or secondary to critical illness [2,3,4,6] and is
manifested by continuous seizure activity >30min. or 2 sequential seizures
during this period without full recovery of consciousness [3,6], being associated
with a high rate of morbidity and mortality [3,4,5]. SE accounts for 3.5% of
admissions to emergency departments in the developed nations and for 11% in
developing country [4,6]. The average incidence of SE is 20/100.000 for
industrialized countries [1,5]. SE affects males and females equally, the major
causes in adults are: cerebrovascular diseases (23-25%), trauma (4.6%),
ethanol/drug-related (12.2%) tumors (4.3%), CNS infections (1.8%) [2,4,6].
Approximately 25% of SE occurs in patients with epilepsy and more than 15%
of patients with epilepsy experience at least one episode of SE [1,3].
Complications of SE include: epilepsy (20-40%), encephalopathy (6-15%) and
focal neurological deficits (9-11%) [1,4,5]. SE mortality rates are 15-20% [4,6].
Death usually occurs as a consequence of brain injury underlying the
development of SE and no more than 2% of patients die directly from it [1,5].
Fortunately, SE responds to relatively simple treatment, but when simple
interventions fail, refractory SE requires more aggressive measures to prevent
complications [3,5,6].
Purpose of the study: Analysis of SE incidence, etiology, the management
features and mortality rates.
Materials and Methods: This study was based on retrospective analysis of
medical records from the Stroke/Intensive Care Unit and Neurology departments
over a period of 3 years (01.01.2008-01.01.2011). All medical records were
standardized according to: general data, medical history/pathological history,
etiology, type of SE, methods of diagnosis, management of SE.
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Results: During the period 01.01.2008-01.01.2011 in Neurological Clinic of
Emergency Hospital, 220 patients were admitted with the diagnosis of SE,
patient age ranged from 15-88 years, mean age 53.5years 2.6. Structure of the
patients according to age is presented in Table 1.
Table 1. Structure of the patients according to age (%)
Age (years)
80 Total
Total 8 50 101 57 4 220
% 3,63 22,72 45,90 25,90 1,81 100
The distribution by sex was: females -101p (45.9% 3.2) respectively males -
119p (54.1% 3.3).
Structure of the SE etiology is represented in Table 2.
Tabel 2. Structure of the SE etiology (%)
The polymorphism of SE according to seizures morphology is represented inFigure1.
Etiologic factor Number of
cases
% eP
Idiopathic epilepsy 11 5,9 1,58
Secondary
epilepsy
vascular 41 18,63 2,62
posttraumatic 24 10,90 2,1
Secondary epilepsy withunspecified etiology
8 3,63 1,26
Encephalopathy toxico-
dysmetabolic
93 42,27 3,52
Anoxic encephalopathy (CO
intoxication)
1 0,45 0,44
Stroke ischemic 22 10 2
hemorrhagic 9 4,09 1,31
Secondary purulent
meningoencephalitis
2 0.9 0,63
Cerebral arterio-venous
malformation
2 0,9 0,63
Expansive process 2 0,9 0,63
Brain metastases 1 0,45 0,44
Fluid and electrolyte disorders 2 0,9 0,63
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Figure 1. Polymorphism of SE according to seizures morphology.
In study group have been determined the antecedents and comorbidities present
in patients, which would be favored the installation of SE, shown in Table 3.
Tabel 3. The structure based on antecedents and present comorbidities.
Of all patients diagnosed with idiopathic epilepsy (11p) reduced compliance
to treatment was recorded at 5p (45.45% 3.35), canceling treatment because of
side-effects without medical advice -3p (27.27%3.0), change of the preparation
-2p (18.18% 2.6) causes that induced SE development.
85%
4.09% 8.18% 1.36% 1.36%0%
10%
20%30%
40%
50%
60%
70%
80%
90%
SEGC SE simple
partial
Partial SE with
secundary
generalization
SENC SE polimorph
SE- Status Epilepticus
SEGC- SE generalized convulsiveSENC- SE non-convulsive
Antecedents/Comorbidities Absolute number % eP
Idiopathic epilepsy 11 5 1,46Trauma 31 14,09 2,31
Antecedents of stroke 39 17,72 2,57
Neurosurgical intervention 5 2,27 1,0
Meningoencephalitis 1 0,45 0,44
Chronic alcoholism 92 41,81 3,32
Drug addiction 2 0,9 0,63
Hepatic cirrhosis 10 4,54 1,4
Diabetes mellitus 6 2,72 1,09
Tuberculosis 5 2,27 1,0
Cerebral arterio-venous
malformation
3 1,36 0,77
Pulmonary adenocarcinoma 1 0,45 0,44
Expansive intracerebral process 2 0,9 0,63
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Clinical evolution of SE in the period immediately after completion was
characterized by an polymorphism of clinical symptoms which appreciated
integral and defined the gravity of the process, so vegetative disorders with
systemic involvement were appreciated to the forefront such as deviations in
blood pressure -hypertension/hypotension 89.54% (2.06) cases, these
symptoms being associated with cardiac rhythm disturbances -arrhythmias/
tachycardias -57, 26% (3.33). Have been present and clinical manifestations
generated by the inflammatory process -pneumonia (22.72% 2.82), fever
(51.3% 3.36) with the association of pulmonary edema in 16.8% (2.51) cases.
The severity of the process was determined by metabolic disturbances especially
-metabolic acidosis (3.63% 1.26), hyperglycemia (15.9% 2.46), renal failure
(8.63% 1.8). Signs of cerebral involvement with different degrees of
expressions of the consciousness disturbances were in 100% of cases, the most
severe cases being associated with cerebral edema (33.18% 3.17), coma and
death.
Methods used for establishing the etiology of SE have included: general
laboratory analysis and instrumental investigations such as: computerized EEG-
104p (47.27% 3.36), cerebral CT -139p (63.18% 3.25 ) Angio-CT cerebral -
3p (1.36% 0.78), chest radiography -86p (39.1% 3.18), lumbar puncture -18p
(8.18% 1.84), ultrasonography -62p (28.18% 3.03), transcranial Doppler -19p
(8.63% 1.83), EKG -170p (77.27 2.82%).
The management constituted: primary assessment of ABC, the airways was
secured with Guedel tube or nasopharyngeal, continuous O2 flow and cardio-
respiratory function monitoring, blood pressure. The next step was the
establishment of the i/v approach and administration of anticonvulsant
preparations. As preparations of first line in resolving SE were used the
benzodiazepines (Diazepam 10mg) i/v or rectal tube, followed by intravenous
infusion of Phenytoin (Phenydan) 15-20 mg/kg with speed 50mg/min in order to
prevent recurrence, in parallel with treatment of the underlying etiology that
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favored the installation of SE. From all patients, about -55p (25% 2.91) have
been registered repeated recurrent seizures in a period from several hours to
several days after solving SE that were resolved by the administration of sol.
Luminal (phenobarbital 15-18 mg/kg i/v infusion rate of 25-60 ml/min).
The mortality rate was 37 cases (16.81% 2.5) from which 16p (43.24% 3.3)
men and respectively 21p (56.76% 3.33) women. Age of the deceased ranged
from 18-82 years, average age 54.05 3.7 years.
Discussion: Analyzing the obtained data was appreciated that the highest
incidence of SE was in the age group 41-60 years (45.9%), with predominant
involvement of male patients (54.1%). Therefore, results that the incident is
higher in the elderly population and in males in comparison with females in
adult population. Considering the aging of the population in the future SE will
become a major problem, increasingly, in the public health and practice.
According to the etiology, SE has developed mainly on the background of
toxico-dysmetabolic disorders (42.27%), on second place being the secondary
epilepsy (31.81%) and only 5.09% of cases assigned to idiopathic epilepsy.
Thus, in the study group, SE was present predominantly in patients with
secondary generalized epilepsy than in those with idiopathic generalized
epilepsy. Pursuant to the type of SE, predominant type was SECG in 85% of
cases and just 1.36% is assigned to type SE non-convulsive (SENC). Evaluating
patient's history and comorbidities was determined that in the study lot has
prevailed on the forefront the alcohol abuse (41.81%) and 16.81% belonging to
history of stroke that have been aggravated with SE. As we notice in the Table 2
and 3 for each patient is present more than a cause responsible to the
development of SE, which includes both an acute and chronic determinant (to a
patient returning to four cases).
The management was performed according to international and institutional
treatment protocols approved. Therefore treatment is continued simultaneously
in several directions and focused on early seizure termination, prevention of
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recurrent seizures, identification of underlying etiology, and treatment of
secondary complications. The mortality rate constituted 16.81% of cases; the
patient's age at diagnosis, etiology of SE, severity of the underlying disease, and
duration of SE are the main predictors of increased short-term mortality.
Conclusions:
1. SE is a major emergency, potentially fatal which requires prompt
recognition according to diagnostic schemes and the use of treatment protocols
adopted in neurological intensive care unit to prevent serious neurological
complications.
2. The toxico-dysmetabolic etiology constituted primary cause (42.27%) of
development of the SE in this study group.
References:
1. DeLorenzo RJ, Pellock JM, Towne AR, Boggs JG. Epidemiology of statusepilepticus. J Clin Neurophysiol 1995; 12:31625.
2. Edward M. Manno, MD. New Management Strategies in the Treatment ofStatus Epilepticus. Mayo Clin Proc. 2003;78:508-518
3. Groppa St. Antiepilepticele i tratamentul Epilepsiei. Chiinu, 2006. 176 p.4. Hussam Seif-Eddeine, David M Treiman. Problems and controversies in
status epilepticus: a review and recommendations. Expert Review of
Neurotherapeutics 12/2011; 11(12):1747-58.
5. Nathan B. Fountain Status Epilepticus: Risk Factors and Complications.Epilepsia, 41(Suppl. 2):S23-S30, 2000
6. Shorvon S D. The management of status epilepticus. J Neurol NeurosurgPsychiatry 2001. 70II22II27.II27.
7. Susanne Knake, Felix Rosenow, Mathias Vescovi. Incidence of StatusEpilepticus in Adults in Germany: A Prospective, Population-Based Study.
Epilepsia Volume 42, Issue 6, pages 714718, June 2001
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