Status epilepticus is one epiprime lasting more than 30 minutes, or a series of seizures of the same duration, between which there is no complete or almost complete restoration of consciousness and normalization of the state. Disease can have a convulsive and non-convulsive form, occur against the background of epilepsy or be symptomatic. Diagnosis is carried out on the basis of anamnesis and clinical condition, supplemented by EEG data, laboratory tests, MRI, CT of the brain. Status epilepticus of any etiology requires urgent medical care. Sedative, anticonvulsant, dehydration, symptomatic therapy is carried out.
ICD 10
G41 Status epilepticus
General information
Status epilepticus is a condition that can occur not only in patients with epilepsy, but also in other brain lesions (traumatic brain injuries, intoxication, intracranial volume formations, ACVA, infections, hydrocephalus, etc.). Cases of status without a history of indications of epileptic paroxysms account for approximately 50%. The frequency of occurrence of epistatus does not exceed 20 cases per 100 thousand population. Young children are more prone to its development, they account for half of all cases.
Among patients with epilepsy, status epilepticus is more often observed in children (10-25%), while among adult epileptics, the status is noted only in 5%. Status epilepticus is an urgent condition that can be encountered by specialists working in various fields of medicine: neurology, traumatology, oncology, intensive care, narcology, psychiatry, infectology.
Causes
In half of the cases, the status epilepticus occurs against the background of already existing epilepsy. In such situations, the reason for the status, as a rule, is the abrupt cancellation or irregularity of anticonvulsant (antiepileptic) therapy. The reason may be a relative decrease in the dose of the anticonvulsant used in case of sudden weight gain or the occurrence of diseases with impaired intestinal absorption (malabsorption). Predisposing factors are: violation of the regime, somatic diseases, infections, pregnancy. The status epilepticus may occur as a manifestation of the first-time epilepsy.
Among the causes of non – epilepsy – related symptomatic epistatus are:
- TBI;
- disorders of cerebrospinal fluid dynamics (for example, occlusive hydrocephalus);
- brain tumor, cerebral cyst;
- stroke;
- encephalitis, meningoencephalitis;
- infectious diseases occurring with severe hyperthermia and intoxication;
- alcohol withdrawal syndrome;
- dysmetabolic disorders: decompensated diabetes mellitus, hypothyroidism, hypoglycemia, porphyria, hyponatremia, eclampsia, lipoidosis, gangliosidosis.
The status can be initiated by the abrupt cancellation of narcotic or sedative pharmaceuticals that have been taken by the patient for a long time. In young children, epistatus is possible as a consequence of brain malformations.
Pathogenesis
The pathogenetic substrate of the status epilepticus is the continuous or rapidly following paroxysmal bioelectric activity of cerebral neurons. It can cover different parts of the brain and have a variable degree of generalization. Epistatus, especially with its long duration, is an extremely dangerous condition, since it causes a number of pathological processes in the body:
- cerebral (brain hypoxia and neuronal death, cerebral edema);
- respiratory (hypoxia, aspiration pneumonia, airway obstruction, pulmonary edema);
- dyscirculatory (arterial hypertension or hypotension, arrhythmia, collapse);
- metabolic (acidosis, hypoglycemia, hypercapnia, hypoglucocorticemia);
- hemostatic (thrombosis, obligate DIC syndrome).
The longer the duration of the status, the higher the probability of irreversible cerebral changes (death of some neurons) with the formation of persistent neurological deficit.
Classification
The variability of the types of epileptic paroxysms causes the existence of various clinical forms of epistatus. All of them are classified into 2 large groups: convulsive and non-convulsive.
- The status of generalized convulsive paroxysms is characterized by expanded tonic-clonic convulsions (grand mal) with complete unconsciousness.
- The status of incomplete generalized paroxysms is manifested by atypical muscle contractions (isolated tonic or isolated clonic, convulsions of individual muscle groups) with complete loss of consciousness. The tonic status is more typical for children with Lennox-Gastaut syndrome; it can be observed at different ages as a manifestation of an epileptogenic focus of the prefrontal cortex. Clonic status is noted in infantile epilepsy (including West’s syndrome), febrile convulsions in young children.
- The status of focal paroxysms proceeds according to the type of Jackson’s epilepsy with muscle contractions of a certain localization (only mimic, only 1 arm or half of the trunk), may not be accompanied by unconsciousness. This can also include myoclonic status epilepticus, for which permanent or serial myoclonia — muscle twitching is typical.
- The status of absences (petit mal) and the status of complex partial paroxysms are non-convulsive. The first is characterized by a complete loss of consciousness without muscle contractions, the second by unconscious actions or automatisms with complete or partial disconnection of consciousness. Non-convulsive statuses have the easiest course, however, due to the absence of seizures, there are certain difficulties in their diagnosis.
Symptoms
The status epilepticus is spoken of when the epiprime lasts more than 30 minutes. or longer than this period, there are several paroxysms, in the intervals between which there is no complete restoration of consciousness. It is necessary to distinguish the status from serial paroxysms, in the pauses between which there is a complete or almost complete restoration of consciousness and relative normalization of the general condition of the patient.
There are 2 phases in the clinical course of convulsive status epilepticus. In the first, compensatory changes occur, aimed at maintaining blood circulation and metabolism, in the form of increased blood flow, increased blood pressure, tachycardia. Along with convulsions, vomiting, urinary incontinence and feces are observed. The second phase occurs after 30-60 minutes and is marked by a breakdown of compensation. Arterial hypotension, bradycardia, somatic organ disorders are noted: respiratory failure, PE, heart failure, arrhythmia, acute renal failure, acute liver failure, etc. Against the background of increasing respiratory and vascular disorders, epileptic prostration occurs: the convulsions stop, the pupils are dilated, the mouth is half open, the gaze is indifferent. In this condition, a fatal outcome is possible.
The convulsive status epilepticus is characterized by a disorder of consciousness of varying depth. With the status of absences, the patient is detached and immobilized, which resembles a trance state. With the status of complex partial paroxysms, there is a change in behavior, confusion of consciousness, signs of psychosis are possible. Such symptoms of non-convulsive epistatus often cause an erroneous diagnosis of the condition as a psychiatric pathology.
Complications
Convulsive status epilepticus can lead to bruises and fractures of limbs. Its complications can be intracranial hypertension, cerebral edema, ischemic and hemorrhagic stroke, intracranial vein thrombosis, aspiration pneumonia, PE, pulmonary edema, cardiogenic shock, renal and hepatic insufficiency, intercurrent infections, thrombophlebitis, etc.
Diagnostics
Since the status epilepticus is an urgent condition, a minimum of time should be spent on its diagnosis. It is important to clarify the epileptic history with the determination of the type and doses of anticonvulsants previously taken by the patient. Basically, the diagnosis is made taking into account the anamnesis (trauma, intoxication, epilepsy, etc.) and the clinical picture.
Additional examinations are necessary to clarify the etiology and assess the state of the somatic systems of the body. It is possible to urgently conduct a biochemical blood test, urine analysis, blood gas composition studies; EEG and blood pressure monitoring. Diagnosis of non-convulsive forms of status is performed according to electroencephalography. Accurate diagnosis of the cause of symptomatic epistatus can be carried out using MRI or CT of the brain.
Treatment
Therapy of status epilepticus is urgent and can be carried out by an epileptologist, neurologist, traumatologist, resuscitator, neurosurgeon, and other specialists. If possible, the patient should be placed in the intensive care unit. To protect him, it is necessary to fix the limbs. The primary task is to restore the patency of the respiratory tract and relieve hypoxia until the use of a ventilator. Almost simultaneously, intravenous administration of diazepam is necessary. In most cases, 1-2-fold administration allows, if not completely stop, then at least interrupt the course of the epistatus.
In cases where the status epilepticus could not be stopped, they switch to the constant administration of diazepam using an automatic dispenser or dropper. In parallel, the fight against cerebral edema is carried out (mannitol is injected drip, inside or through a probe – acetazolamide) and symptomatic therapy (administration of corticosteroids, cardiovascular agents, niketamide, heparin in DIC syndrome). If the status epilepticus has arisen against the background of epilepsy, anticonvulsant therapy with the previously used drug is continued with an increase in its dose by 1.5 times.
The absence of the effect of the treatment is an indication for the use of reserve methods: thiopental anesthesia, craniocerebral hypothermia, intravenous bolus administration of glucocorticosteroids, etc. If the status epilepticus is due to a voluminous intracranial formation, urgent neurosurgical intervention is necessary: decompressive trepanation of the skull, removal of intracerebral hematoma, stopping intracranial bleeding, etc.
Prognosis and prevention
The outcome and consequences of epistatus are largely determined by its etiology, duration and type. Thus, deaths in the development of status in epileptics are less than 5%, and mortality in symptomatic epistatus reaches 30-50%. Death occurs due to irreversible cardiovascular, respiratory, metabolic, and cerebral disorders. In surviving patients with a status duration of more than 30 minutes, persistent neurological and neuropsychic disorders are noted. In childhood, mental retardation and oligophrenia are possible. Convulsive status epilepticus is not as dangerous as generalized convulsive status, but it can lead to cognitive impairment.
It is possible to prevent the status epilepticus in patients suffering from epilepsy by adequate selection and compliance with the rules of anticonvulsant therapy. Prevention of symptomatic epistatus consists in the correct and timely treatment of TBI, neuroinfections and general infectious diseases; conducting proper antipyretic therapy (especially in young children); correction of dysmetabolic disorders; prevention of intoxication; combating alcoholism and drug addiction.