00:01
Now, let's focus on treatment.
00:03
We've talked about
the early stabilization
of patients with status
and let's go into
how we approach treatment
both initially,
and in cases of refractory, and
super refractory status epilepticus.
00:14
Again,
in the incipient phase
that first five minutes
of stabilization,
we look to stabilize the patient
with the ABCs,
IV access oxygen,
and rapid glucose check.
00:25
Rapid screening,
history and physical
is performed either with the patient
or frequently with a caregiver.
00:30
In the early 5 to 15 minutes,
we look at initial
abortive pharmacotherapy.
00:35
Benzodiazepines
to abort the seizure, the status
and resolve status
at that time.
00:41
Lorazepam
is commonly given
but you can see
the list of medications
that we can use
in the setting.
00:47
We repeat each of these
benzodiazepines
once every five minutes or so
up to three doses typically.
00:55
Antipyretics
if the patient is febrile
and other interventions can be
considered in selective cases,
such as neonates
and then in adults.
01:04
During this phase,
we also send electrolytes,
drug levels, toxicology screen,
CBC cultures
looking for the potential
cause of the status.
01:12
And if we can manage those causes,
we may be able to
abate the status early.
01:18
And then we move to
definitive treatment of the status.
01:21
And I want to review
one trial with you
that is established the medications
that we use for status epilepticus.
01:28
In this trial,
385 children and adults
with benzodiazepine
refractory status epilepticus
were evaluated.
01:36
They were treated with
60 mg/kg of levetiracetam,
20 mg/kg of fosphenytoin and,
and or 40 mg/kg of valproic acid.
01:44
So patients were randomized
to one of these three treatments.
01:48
The study looked at absence
of clinically evident seizures
and improve responsiveness
at 60 minutes.
01:54
So they wanted a medication
that would work
and all three drugs
were equivalent.
01:59
47% of patients responded
to levetiracetam,
45% of patients to fosphenytoin,
and 46% of patients
to valporic acid.
02:07
The thing to take home from this
is these are
the three definitive treatments
of status epilepticus,
with about 50% of patients
responding.
02:14
That also means 50% of patients
will continue to have
status epilepticus
after first definitive therapy.
02:22
There are no significant differences
in late seizure cessation
or in safety between
either of these three medications
and so we can use them
interchangeably
based on their side effect,
profile, and availability.
02:34
For those patients who continue
to have status epilepticus.
02:38
After two definitive
anti-convulsive treatments,
fosphenytoin, valproic
acid, and or levetiracetam,
we look at additional
interventions.
02:47
We may start by adding additional
fosphenytoin and or phenobarbital.
02:52
And then typically,
we move to admitting the patient
to ICU for intubation
and continuous EEG monitoring.
02:59
Patients are put into a
medically induced burst suppression.
03:02
So this is using a high dose
of an intravenous anesthetic
to quiet the brain
and suppress brain activity.
03:09
Trying to reset the brain
out of that status epilepticus.
03:12
There are a number of
intravenous anesthetics that are use
pentobarbital, IV medazepam,
propofol,
and high doses of other
anti-epileptics can be used.
03:23
And the goal is to put the brain
into burst suppression,
low EEG activity,
resetting the brain for 24 hours.
03:32
In rare cases,
we'll consider other interventions
and sometimes
these are referred
to the super-refractory
status epilepticus.
03:38
And when stable,
we typically obtain
neuroimaging and LP.
03:42
Again, to look for potential causes
of refractory status epilepticus
that could be treated and
help to resolve the patient's
clinical situation.
03:52
For patients that fail treatment of
refractory status epilepticus,
we classify that as
super-refractory status epilepticus.
04:00
That's defined as
ongoing seizure activity.
04:02
Despite intravenous drips
for 24-hours of burst suppression.
04:06
This is extremely
difficult to treat.
04:09
And we're looking at
other interventions
that have not been used
up till this time
to manage these patients.
04:15
There's no one single agent
and we tailor the treatment
to the patient's clinical scenario.
04:21
We can consider the
ketogenic diet, immunotherapy,
lesional treatment,
and that's a seizure surgery,
or laser interstitial
thermal therapy.
04:29
That's a laser to treat or
ablate to kill a seizure nidus,
or additional
intravenous medication,
another 24-hours
of birth suppression.
04:41
Let's talk a little bit about
a couple of those treatments.
04:43
They're interesting
treatments that we use
in these rare and exceptional cases.
04:47
The ketogenic diet.
04:48
We hear about commonly
in the lay media,
but this is used as a
medical intervention for seizures,
and for status epilepticus.
04:55
It is a high fat, low protein,
low carbohydrate,
almost no carbohydrate diet.
05:01
It shifts metabolism from
glycolysis to fatty acid oxidation.
05:06
Instead of glucose circulating
as the primary source of energy
we see a rise in ketone bodies,
which can be metabolized.
05:15
We replace glucose
with ketone bodies
and those become
the primary energy source
for the brain.
05:21
The brain is a glucose avid organ
and this shift in metabolic activity
can shift the brain
and is a treatment
for both seizures and kids
and is used in cases
of refractory status
and super-refractory status
epilepticus.
05:35
We can also consider
surgical treatments
for refractory status epilepticus,
as well as other patients
with epilepsy.
05:42
Resective surgery is a treatment
for focal or lateralized,
and localized epilepsies.
05:48
It may be more effective than
prolonged medical therapy
and things like
temporal lobe epilepsy
where there is a
specific seizure nidus
that can be safely
removed with surgery.
05:59
Anteromedial temporal resection
is considered in patients with
intractable mesial
temporal lobe epilepsy.
06:05
And patients
may become seizure free
not requiring further AED therapy
with this intervention.
06:11
Typically, we would consider
a patient medically refractory
a seizure patient
medically refractory.
06:16
After two trials of medications
at sufficient doses.
06:21
That's a sufficient dose
of medication one
and a sufficient dose
of medication two.
06:25
An epileptic patient who fail
two drug therapies
would be considered for a
seizure surgery evaluation.
06:32
Early seizure surgery
is more effective
than delayed seizure surgery.
06:35
And so this is something
that we consider
in patients with
refractory epilepsy,
as well as in selected patients
with status epilepticus
Of the vagal nerve stimulator
is also a surgical adjunct
for treatment of
partial onset epilepsies.
06:50
It appears effective
and well tolerated
for patients with partial seizures.
06:54
It reduces seizure frequency
in patients with drug-resistant
idiopathic epilepsy.
06:59
And some of the generalized
epilepsies like Lennox-Gastaut.
07:03
So we use it in both partial onset
and generalized epilepsies.
07:07
Vagal nerve stimulation
is again considered
for patients with
medically refractory epilepsy.
07:12
And those are patients
who have failed
two drug trials at sufficient doses.
07:17
And rarely in cases
of status epilepticus.
07:19
It's not as effective
in status epilepticus
as medically refractory epilepsy.
07:25
Brain stimulation is
a new, a newer therapy
to be considered for
patients with epilepsy,
it is a surgical treatment.
07:32
Patients have
implanted intracranially a device
a responsive neurostimulator.
07:38
This RNS system is
able to read seizures
through electrocorticography
and deliver a stimulation
to try and stop the seizure
when it starts.
07:48
This treatment is capable of sensing
those abnormal electrical discharges
those spike and waves activities
when they occur
on the cortical surface.
07:56
And that automatic delivery
of an electrical stimulation
is intended to stop the seizure
before it's able to spread.
08:03
Deep-brain stimulation is also
another experimental treatment
for the treatment of epilepsy.
08:09
We are looking at novel targets
to treat patients with epilepsy
and specifically
the anterior thalamus
which is involved in relays
to the frontal lobe
and other areas of the brain.
08:18
Deep-brain stimulation
is placed surgically
with a placement
of an electrode
that delivers a stimulation
to reduce activity
in a selective area of the brain.
08:27
It's used frequently
for Parkinson's disease
and certain tremors
and has shown some success
in patients with epilepsy.
08:35
And then lastly,
let's talk a little bit about
nonconvulsive status and
other types of status epilepticus
outside of the convulsive setting.
08:44
Nonconvulsive status
is electro graphic status
without prominent motor signs.
08:49
So the EEG shows seizures.
08:52
The patient's brain
is having seizures,
but we don't see that
prominent motor activity
With absence status epilepticus
that status from
primary generalized epilepsy
from absences we see disorientation,
staring, and blinking.
09:06
This may be triggered
by certain medications.
09:09
Carbamazepine
is a really important one.
09:11
This is a medicine
that we use for seizures
but not for management of
primary generalized epilepsy,
because it can make that worse.
09:18
We can also see this
with toxic doses of phenytoin
and other medications.
09:22
This does respond to
benzodiazepines, Depakote,
and other typical interventions
for status epilepticus.
09:28
We manage it in the same way.
09:31
Complex partial status epilepticus
can also cause
nonconvulsive appearance
on clinical exam.
09:37
Patients present with
a confusional state
or bizarre behavior
and automatisms
that continue again
beyond 30 minutes
without return to baseline.
09:44
It can ultimately progress
to patients becoming
comatose, paralyzed,
or appearing sedated.
09:50
And then subtle generalized
convulsive status epilepticus
can mimic nonconvulsive status.
09:56
These are patients who presented
with convulsive status epilepticus
that is burned out.
10:00
We don't see
those motor signs.
10:02
We only see the
electrographic appearance.