The Treatment and Prognosis of Refractory and Super-Refractory Status Epilepticus

Status epilepticus (SE) is one of the most common emergencies in neurocritical care. In Germany, the incidence of SE is about 17/100 000 per year, increasing with age [1]. Especially generalized convulsive (tonic-clonic) status epilepticus (GCSE) is still associated with a high risk of morbidity and mortality [2]. SE is defined as a single prolonged seizure or a series of two or more consecutive seizures without return to neurological baseline between seizures. According to the most recent definition, a generalized convulsive status epilepticus is already diagnosed after a minimum seizure duration of five minutes, because the likelihood of spontaneous termination decreases after this time period; consequently, treatment should be initiated without further delay [3]. With significantly less experimental data on focal SE and absence SE available, the reported minimum seizure duration for the two conditions is 10 min and 10–15 min, respectively, reflecting the assumption that neuronal damage is to be expected at a later point in time or to a lesser degree with focal SE and absence SE compared to GCSE [3]. However, already after 5 min the likelihood that a seizure will terminate spontaneously is low, regardless of the type of SE [4]. Three clinical stages with different treatment regimens are differentiated: 1. The initial phase: seizure duration ≤ 10 min in a previously untreated patient; treatment with benzodiazepines (lorazepam, midazolam, clonazepam). 2. Established SE: SE persisting for 10-30 (max. 60) min. Besides benzodiazepines, non-sedating IV anticonvulsants (phenytoin, valproic acid, levetiracetam) can be used. 3. Refractory SE: The status epilepticus has already continued for 60 min, despite appropriately dosed anticonvulsant treatment. Refractory GCSE is an acute life-threatening situation, requiring fast initiation of intensive-care monitoring with preparedness for endotracheal intubation and treatment escalation to IV anesthetic administration. 4. If SE continues after 24 h of treatment with anesthetic agents, it is termed super-refractory SE. With no The Treatment and Prognosis of Refractory and Super-Refractory Status Epilepticus