1. DUNE, Paris, December 13 2012 Status epilepticus prognosis
Andrea O. Rossetti, Service de Neurologie, CHUV,
Lausanne, Switzerland

2. Role of SE in other disorders
Overview
Introduction
Mortality predictors
Functional impact
Role of SE in other disorders
Practical impact
Conclusion

3. Role of SE in other disorders
Overview
Introduction
Mortality predictors
Functional impact
Role of SE in other disorders
Practical impact
Conclusion

4. Why care? Prognosis of what ? « Framing » of clinical setting
Should orient treatment resources
Might improve SE patients care
Prognosis of what ?
Mortality
Functional outcome

5. Role of SE in other disorders
Overview
Introduction
Mortality predictors
Functional impact
Role of SE in other disorders
Practical impact
Conclusion

6. Mortality Short-term: 7%-39%
Long-term: 43% at 10 years (RR=3 vs. controls) Logroscino Neurology 2002

7. Etiology Epilepsia 1993, DeLorenzo Neurology 1996, Rossetti JNNP 2006
Acute symptomatic (60%-80%)
Remote symptomatic (10%-20%)
Progressive symptomatic (10%-20%)
Idiopathic (1%-3%)
Up to 50% without previous seizures !

8. Etiology De Lorenzo Neurology 1996
Adults
AED withdrawal 34%
Remote sympt. (stroke) 24%
Acute stroke 22%
Metabolic 15%
OH %
Anoxia 13%
Idiopathic %
Children
Infection 52%
Remote symptomatic 39%
AED withdrawal 21%
CNS infection 36%
AED withdr %
Idiopathic %
Amare Epilepsia 2008

9. Mortality predictors
Etiology Towne Epilepsia 1994, Logroscino Epilepsia 1997, Novy Epilepsia 2010
Age Towne Epilepsia 1994, Logroscino Epilepsia 1997, Rossetti JNNP 2006
Consciousness impairment Shneker Neurology 2003, Rossetti JNNP 2006
Treatment >1h Towne Epilepsia (but ≠ Logroscino Epilepsia 1997, Rossetti JNNP 2006, Drislane Epilepsia 2009 !)
Infections Sutter Epilepsia 2012 9

10. Prognosis : semiology GC-SE
Depends on systemic complications, etiology
Non-Convulsive SE Thomas Epilepsia 2007
Absence (also elderly) : excellent (BDZ)
CPSE : usually good, but not always (…etiology!)
In coma (« subtle ») : very poor (ominous etiologies)

11. Refractory SE (RSE) Definition
SE resistant to BDZ and 1 AED (20-40% SE)
Related to
De novo SE
Encephalitis
Severe consciousness impairment
Holtkamp JNNP 2005, Novy Epilepsia 2010

12. Prognosis after RSE
Novy Epilepsia 2010
But: reasonable prognosis after prolonged RSE (15%-40%) Cooper Arch Neurol 2009, Bausell Neurology 2011, Drislane Epil Behav 2011 12

13. Role of SE in other disorders
Overview
Introduction
Mortality predictors
Functional impact
Role of SE in other disorders
Practical impact
Conclusion

14. Prognosis in SE : Risk of epilepsy
3x as after single seizure Hesdorffer Ann Neurol 1998
higher after RSE Holtkamp JNNP 2005

15. Prognosis in SE: cognition Dodrill Neurology 1990

16. Prognosis in SE: cognition 2 Adachi Epilepsia 2005
No difference at all between the groups !

17. Prognosis in SE : Structural damage
Fernandez-Torre J Neurol 2006
Tien Radiology 1995 17

18. Prognosis in SE : Structural damage
No MRI sequelae after 1 year in patients with GTC SE (median duration 1h44) Salmenperä Epilepsy Res 2000
CPSE (« limbic »)  neuronal damage ?!?
Young Arch Neurol 1998, Bauer Epil Behav 2006, Vespa Neurology 2010 vs. Aminoff Arch Neurol 1998, Kaplan Neurophysiol Clin 2000, Meierkord Lancet Neurol 2007
Interpretation: GTC SE also leads to systemic changes Meldrum Arch Neurol 1973, Lothman Neurology 1990, therefore more dangerous

19. Role of SE in other disorders
Overview
Introduction
Mortality predictors
Functional impact
Role of SE in other disorders
Practical impact
Conclusion

20. Impact of SE on other disorders
Anoxia: SE  independent death predictor (RR=6) Rossetti Neurology 2007
Similar results for:
Post-stroke SE vs. non-SE (RR=2) Knake Epilepsia 2007
Cryptogenic SE vs. seizures (RR =2) Logroscino Arch Neurol 2008

21. Role of SE in other disorders
Overview
Introduction
Mortality predictors
Functional impact
Role of SE in other disorders
Practical impact
Conclusion

22. Complications of prolonged ICU stay
Complications of prolonged ICU stay Cereda Neurocrit Care 2009, Cooper Arch Neurol 2009
Infections
Thrombosis, embolism
ICU myopathy, neuropathy
Ileus
AED side effects …

23. Outcome predictors: practical impact
Status Epilepticus Severity Score (STESS) Rossetti Neurology 2006, J Neurol 2008

24. Outcome predictors: practical impact
With similar STESS and mortality, lower intubation rate at CHUV (12%) vs. BWH / MGH (36%) Rossetti J Neurol 2008
« Only » 12/29 RSE patients required therapeutic intubation ! Novy Epilepsia 2010
Interpretation: Patients with favorable STESS may not need early intubation

25. Does SE treatment influence prognosis?
Yes ! Aranda Epilepsia 2010
 !? 36%(USA) vs. 12%(CH) intubated, same prognosis Rossetti J Neurol 2008
Hospit. cohort, 225 incident episodes Rossetti J Neurol 2012
ICU-based, 144 episodes Kowalski Crit Care Med 2012
Model
Predictors
Area 11
Etiology
0.72 12
Etiology, STESS
0.80 13
Etiology, STESS, Comorbidity
0.85 14
Etiology, STESS, Comorbidity, Treatment

26. Role of SE in other disorders
Overview
Introduction
Mortality predictors
Functional impact
Role of SE in other disorders
Practical impact
Conclusion

27. Conclusion 1 Mortality: keep in mind etiology and age
RSE: higher mortality and more epilepsy

28. Conclusion 2 Do not over- (nor under-) treat
Try to use predictors to orient treatment

29. Merci !
Luke Fildes, The doctor, 1891, National Gallery, London