Status epilepticus
Status epilepticus is a generalized tonic-clonic seizure lasting more than 5 minutes, or repeated seizures without return to baseline, and is a neurologic emergency. Treatment is a timed escalation: IV benzodiazepine first, then an IV antiepileptic drug, then anesthetic coma with continuous EEG if convulsions persist.
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What this article covers
- Overview
Definition: convulsive status epilepticus (CSE) is a generalized tonic-clonic seizure (GTCS) lasting more than 5 minutes, or 2 or more GTCS within 5 minutes of each other without return to baseline…
- Epidemiology
Incidence: status epilepticus occurs across all ages with a bimodal distribution favoring young children and older adults, and may be the first presentation of epilepsy in a minority of patients.
- Risk factors
Subtherapeutic or discontinued AED: nonadherence or abrupt withdrawal of a chronic antiepileptic regimen is the leading precipitant in established epilepsy.
- Pathophysiology
Failure of seizure termination: normal termination depends on GABAergic inhibition; in status epilepticus this fails, with progressive internalization of synaptic GABA-A receptors reducing…
- Clinical features
Convulsive status epilepticus: continuous or repetitive generalized tonic-clonic activity (rhythmic jerking of all extremities, tonic posturing, eye deviation) without return to baseline between events.
- Differential diagnosis
Psychogenic nonepileptic spells (functional seizure): asynchronous, waxing-waning movements, pelvic thrusting, and ictal eye closure with preserved awareness; a normal postictal EEG background and…
- Diagnosis
Status epilepticus is diagnosed clinically by observing continuous or repetitive generalized convulsive activity over 5 minutes, or repeated seizures without return to baseline; treatment is not delayed for confirmatory testing.
- Management
First, secure the airway and obtain IV access while giving oxygen and starting continuous cardiorespiratory monitoring; fear of respiratory depression should not delay benzodiazepine treatment, since…
- Complications
Cardiorespiratory failure: hypoventilation, aspiration, and hypoxia during prolonged convulsions, with mechanical ventilation often required once anesthetic coma starts.
- Prognosis
Duration-dependent outcome: a longer duration of CSE before treatment is strongly linked to worse neurologic outcomes, underscoring early, protocolized escalation.
- Prevention
Medication adherence: consistent adherence to a prescribed AED regimen is the single most modifiable strategy in established epilepsy, since abrupt discontinuation is a leading precipitant.
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A first or provoked seizure requires a focused history to distinguish it from syncope or a nonepileptic event, urgent glucose and electrolyte testing, brain MRI, and outpatient EEG; an unprovoked seizure with normal imaging and EEG usually does not require antiepileptic drug therapy, since epilepsy is defined only after a second unprovoked seizure or a high-risk first one.
- Epilepsy
Epilepsy is a disease of recurrent unprovoked seizures, defined as two unprovoked seizures more than 24 hours apart or one unprovoked seizure with at least a 60% recurrence risk; treatment is guided by seizure type, with levetiracetam or lamotrigine preferred first-line for most adults.
- Increased intracranial pressure
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- Encephalitis
Encephalitis is inflammation of the brain parenchyma, most often viral (herpes simplex virus 1 being the classic treatable cause), presenting with fever, headache, altered mental status, and seizures; empiric IV acyclovir is started immediately whenever it is in the differential, pending confirmatory CSF PCR.