00:01
When we think about status
and that treatment algorithm,
the status presents in stages
as we look at treating
through these stages.
00:09
There's the premonitory phase,
where patients may have
confusion, myoclonus,
or increased seizure frequency.
00:15
And that's happening
right before
this continuous
seizure activity develops.
00:19
And there may be
discrete ictal activity
that can be seen
on the EEG
during this period of time.
00:25
This gives rise
to the incipient phase
the first 0 to 5 minutes,
when that seizure is occurring.
00:31
When we're looking
at stabilizing the patient,
we see frequent seizure activity
and waxing and waning
of ictal activity on the EEG.
00:39
In the early portion of status
the first 5 to 30 minutes
there is continuous
seizure activity, both clinically
and we see that with continuous
ictal discharges on the EEG.
00:49
Late we can see that sometimes
the seizure activity will burn out
during that 30 to 60 minutes
of prolonged seizure activity.
00:56
Clinically, the patient may have
continuous seizure activity
and continuous ictal discharges.
01:01
And we may start to see that
continuous clinical activity
break up
as well as some flat periods
on the EEG,
as the brain becomes
overrun by the status,
and some of those nutrients
that we talked about
in the pathophysiology
start to be depleted.
01:16
Ultimately,
in refractory cases
where seizures
last longer than 60 minute,
we see convulsive status
morphin progress into subtle
convulsive status or nonconvulsive
status epilepticus.
01:28
We lose the motor activity,
clinically,
and sometimes we can lose that
continuous spike and wave activity
with periods of
flattening on the EEG.
01:36
We can see periodic
epileptiform discharges
with a flat background
in the middle.
01:41
And those all indicate
a more progressed
and refractory status epilepticus,
which is harder to treat and
associated with a poor prognosis.
01:49
As we think about
the stages of status
and move further away
from the acute stabilization
to long-term management of status.
01:56
Stage 1
was the early phase,
that premonitory and
impending status epilepticus.
02:01
Stage 2 is the established
status epilepticus
that first 30 to 60 minutes
when we're evaluating the patient,
when we're intervening,
giving definitive
seizure management,
and trying to rescue the patient
from further progression
of the status.
02:16
Patients who do not respond
to one and then two
definitive seizure treatments,
and a refractory to definitive
seizure management
of status epilepticus
move into stage 3.
02:27
Stage 3 is classified as
refractory status epilepticus.
02:31
That status that continues despite
stage one or two treatment.
02:35
Progresses after the
benzodiazepine abortion
and after two definitive
seizure medications.
02:41
Oftentimes,
we'll see patients progress to
subtle status epilepticus,
nonconvulsive status epilepticus,
or a stuporous status epilepticus
during that phase.
02:50
This is treated with high dose
intravenous antiepileptics.
02:53
Often patients are put
into the ICU intubated
and put into a burst suppression,
where the medications are titrated
to a level
that the brain almost becomes
very flat and attenuated.
03:05
At that stage, patients are kept
in a burst depressions pattern
for about 24-hours,
to try and reset the brain
to stop the brain
from remembering how
to have continuous seizure activity
and aborting the status epilepticus.
03:20
Seizures that continue after that
stage three intervention
are considered super-refractory.
03:26
And those patients with
super-refractory status epilepticus
have continuous seizure activity,
despite the use of anesthetics
for 24-hours.
03:34
And that stage 4
becomes very difficult to treat
and with this
extremely poor prognosis.
03:41
So let's walk through
the pathophysiology
of what's happening in the brain
during those stages,
so we can understand how
we're going to manage patients
in the importance
of early intervention.
03:51
Again, we considered
the acute seizure,
the early status epilepticus,
and then we'll talk about
what's happening in the brain
during these refractory and
malignant status epilepticus phases.
04:03
Let's start by
thinking of the neurophysiology.
04:05
During the acute seizure
and early status phase,
we see receptor trafficking.
04:11
There's reduced GABA tone
and increase release of NMDA,
and glutamate.
04:16
Less inhibitory tone
and more excitatory tone,
and those are building in the brain
during that early acute seizure
and status epilepticus period.
04:25
Ultimately, this transitions
into synaptic plasticity.
04:29
Changes in the way
the synapse looks,
and biochemically communicate.
04:34
There's modification of the
GABA receptor and composition
and this drives further
seizure activity.
04:41
seizures, begetting seizures.
04:44
What about in terms
of the motor activity?
What do we see in the patient?
Well, early for convulsive status,
we see generalized convulsions,
both with the acute seizure and
the early status epilepticus.
04:56
Over time,
those generalized convulsions
that jerking
back and forth of the body
peter out into myoclonus.
05:03
And we see less motor activity
as the brain and the motor system
become overrun by the
continuous seizure activity.
05:11
And ultimately we can see
electromechanical dissociation,
where the body is jerking,
but it doesn't line up with
the epileptiform discharges
that we see on the brain.
05:22
And that's seen in these
severe and refractory cases.
05:26
How about systemic pathology?
What's going on systemically?
First, we see
in the early acute seizure
and early status epilepticus phase,
a compensatory phase
there is sympathetic overdrive.
05:38
the heart will speed up and
there's increased sympathetic tone
as the body tries to compensate for
the continuous seizure activity.
05:46
This gives way to decompensation
and homeostatic failure,
and we can start to see
organ dysfunction
in patients who have had
significant status
for a prolonged period of time.
05:57
Some of the things that we see
in the compensatory phase
are increased cardiac output,
increased blood pressure,
increased blood glucose,
and increased blood lactate.
06:06
The body is trying
to support the brain
through the seizure activity
by increasing things
like ejection fraction,
cardiac output, and glucose.
06:14
Ultimately, those
compensatory mechanisms fail
with prolonged seizure activity.
06:19
Cardiac output may decline,
blood glucose may go down,
as glucose is depleted.
06:23
Blood lactate may decline,
and blood oxygen may decline.
06:26
And so you can start to see
some of the potential reasons
why we see multi organ failure
in patients with
long term status epilepticus.
06:34
Ultimately,
in most of your cases,
Cardiorespiratory collapse
can occur,
electrolyte imbalances,
hyperthermia,
as a result of
temperature dysregulation.
06:43
Rhabdomyolysis from the
continuous motor activity
and delayed tubular necrosis
or damage to the kidneys
as a result of that.
06:50
And ultimately, in severe cases,
again, multi organ failure.
06:54
So this is emergency.
06:56
We must act quickly
to stop this situation
before those
complications develop.
07:01
How about brain metabolism?
What's going on in the brain
during status?
We initially see,
sometimes increases
or stabilization of
cerebral blood flow
as autoregulation kicks in
to maintain blood flow
during this event.
07:13
We see glucose and oxygen
are sufficiently
where they should be normal
glucose and oxygen in the brain,
as well as brain tissue
oxygenation, and brain glucose.
07:24
And we can see over time
as we get out of the early
status epilepticus phase,
we see declines
in cerebral blood flow,
blood glucose and oxygen,
brain tissue oxygenation,
and brain glucose
as the seizure activity continues.
07:38
And ultimately, that results in
the potential for brain damage,
We don't tend to see
any risk of brain damage
in the first 0 to 5 minutes,
or 5 to 30 minutes.
07:47
But as we start
to get beyond 60 minutes
into multiple hours and days,
we can see particularly
with convulsive status,
but also with nonconvulsive status,
the potential risk of brain damage.
07:58
So again,
this underscores
the importance of early intervention
for this medical emergency.