Features affecting treatment decisions and outcome in refractory status epilepticus

Refractory status epilepticus (RSE) is associated with worse outcomes than responsive established status epilepticus (SE). Guidelines recommend that refractory convulsive SE should be treated with continuous intravenous anesthetic drugs (CIVADs). Many cases of nonconvulsive SE are not reated with CIVADs, and the use of anesthesia might be associated with increased mortality. The factors leading to the decision to use anesthesia and how these might affect outcome are still largely unknown. Our goal was to identify features of refractory SE associated with treatment choices and outcome.

A single-center, retrospective study was conducted of all consecutive patients with RSE admitted to a tertiary center between January 2015 and December 2020. We collected demographic and clinical variables at SE onset and at time of third-line treatment, including ictal burden during the hour preceding the administration of the third-line treatment. The primary outcome measure was the decision to use CIVADs as third-line treatment. Secondary outcome measures were in-hospital mortality and functional outcome at discharge.

One hundred sixty-one RSE episodes were included. Of these, 29 (18%) received CIVADs as third-line treatment and 61 (38%) died. The type of third-line treatment was not associated with mortality. CIVADs were more likely to be used with higher ictal burden, fewer comorbidities, a lower Glasgow Coma Scale (GCS) score at time of third-line administration, and in the absence of history of epilepsy (odds ratio [OR] = 1.03, .76, .66, and .25, respectively). Multivariable analyses also identified comorbidities, an acute etiology, and lower GCS score at time of third-line administration as risk factors of mortality (OR = 1.43, .09-.28, and .80, respectively). Ictal burden was not associated with outcome.

Ictal burden, semiology, and consciousness at time of third-line treatment are associated with the decision to use CIVADs in SE. Semiology and consciousness at time of third-line treatment are also associated with mortality.