Therapeutic coma in status epilepticus: Determinants of treatment intensity and its impact on outcomes

To investigate the determinants of physicians' therapeutic decision-making in status epilepticus (SE), with a focus on factors influencing the choice between therapeutic coma (TC) and less aggressive antiseizure medication (ASM) approaches, and to assess the impact of treatment intensity on clinical outcomes.

In this prospective multicenter study including 145 adult SE cases, refractory SE (RSE) occurred in 55%. TC was used in 47% of RSE patients and was preferentially applied to individuals with acute or potentially fatal etiologies, higher severity (STESS score), and intensive care unit admission at SE onset. Conversely, vascular and tumor-related SE were more often managed conservatively with multiple ASMs. Although TC-treated patients showed worse functional outcomes and higher mortality, these differences were not significant after adjustment for confounders, indicating that baseline disease severity largely accounted for outcome disparities. Etiology was the main factor influencing decisions to withdraw TC in RSE, whereas comorbidities and premorbid functional status guided decisions to withhold aggressive treatment. Semiology emerged as the primary determinant of treatment intensity, with less aggressive approaches involving multiple ASMs - still proving effective in a substantial proportion of cases - being reserved for patients with clinical presentations considered less harmful. EEG correlates were seldom cited as influential in treatment decisions and, when reported, were almost exclusively associated with decisions to withdraw therapy.

Treatment decisions in RSE are primarily driven by etiology, semiology, and premorbid functional status, rather than electrographic findings. TC is reserved for the most severe cases, and outcome differences between treatment strategies reflect underlying disease severity rather than treatment-related harm. Conservative ASM escalation remains effective in a substantial proportion of RSE patients.