Thinking about status epilepticus

Even for neurologists, managing a patient with epilepsy can be terrifying. Attacks can come on unprovoked and can dramatically alter a patient’s quality of life. In an adult patient without a history of epilepsy, seizures should be very concerning. Often, they indicate structural damage to the brain, which should be worked up in a safe and expedient manner. In this week’s BrainWaves episode, Dr. Chloe Hill, takes us through a case of a 45-year-old gentleman with the first seizure of life.

An fitness center slogan I found in NYC…

The patient in question presented with altered mental status, followed by a generalized convulsive seizure in the emergency department with right gaze deviation lasting 1 and a half minutes. Now, in someone with an unprovoked first seizure of life, 2015 guidelines from the American Academy of Neurology recommend against empiric anti-epileptic treatment. Every adult is allowed one unprovoked seizure in their lifetime. Any more than that, and it’s basically epilepsy.

A summary of things to consider in a patient who presents with “first seizure of life.” From Angus-Leppan, BMJ 2014.

So this gentleman, who has experienced his first seizure of life, should be monitored for his airway, breathing, and circulation, and that’s it. He should be worked up for seizure, no doubt, but the risks of treating him empirically with an anti-epileptic drug outweigh the benefits of that drug. For now.

A head CT scan was performed.

Axial view of a non-contrast head CT scan of this patient. Note the calcified ring-shaped lesion of the left frontal lobe with slight vasogenic edema and trivial midline shift.

At this point, there is an obvious explanation for the patient’s seizure: a brain tumor. But alternative mechanisms should be explored in less obvious cases of first time seizure. Things to consider:

  • Metabolic panel (including liver function)
  • Lumbar puncture if meningitis, encephalitis, or malignancy are suspected
  • EKG & orthostatic vital signs to exclude causes of syncope, which can mimic seizure
  • MRI brain to evaluate for structural lesions not seen on head CT
    • gadolinium may be used when a lesion is suspected, or an incompletely identified lesion is seen on non-contrast MRI
  • Routine EEG
    • highest yield within 24 hours, but even in epileptic patients an interictal EEG may be normal
  • In select patients: urine and/or serum toxicology, thyroid function, HIV, and other laboratory tests

In the midst of this workup, the patient experiences a second seizure without return to his baseline mental status. Two consecutive seizures without return to baseline mental status is how we define status epilepticus. The patient should be treated with a benzodiazepine as a first-line drug, and should be started on an anti-epileptic medication tailored to treat the cause of his seizure–in this case, a brain lesion. So he received intravenous lorazepam and intravenous levetiracetam, but with continued right gaze deviation concerning for non-convulsive seizures. At this point, the patient is in refractory status epilepticus and requires more aggressive intervention (likely intubation, intravenous anesthetic use, ICU care) and continuous EEG monitoring. Unlike status epilepticus, which carries a 10-20% short-term mortality rate, refractory status epilepticus leads to death in almost 40% of patients. So you must treat these patients early and aggressively.

For more information on the status of the patient in status, tune in to this week’s episode and see what Dr. Hill has to say about this patient and his condition.

 

[Jim Siegler]


The content in this episode was vetted and approved by Chloe Hill.

REFERENCES

Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, Handforth A, Faught E, Calabrese VP, Uthman BM, Ramsay RE and Mamdani MB. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group. The New England journal of medicine. 1998;339:792-8.

Claassen J, Hirsch LJ, Emerson RG and Mayer SA. Treatment of refractory status epilepticus with pentobarbital, propofol, or midazolam: a systematic review. Epilepsia. 2002;43:146-53.

Mayer SA, Claassen J, Lokin J, Mendelsohn F, Dennis LJ and Fitzsimmons BF. Refractory status epilepticus: frequency, risk factors, and impact on outcome. Archives of neurology. 2002;59:205-10.

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