![]() The stages of treatment of status epilepticus. It is interesting in passing to note that anaesthesia has been recommended since the mid-19th century, and John Hughlings Jackson (who is commemorated in this issue of Brain) for instance writes that 'chloral is the best drug and if the fits are very frequent, etherisation will help' (Hughlings Jackson, 1888). If seizures continue despite this treatment for up to 2 h, the patient is said to be in Stage 3 (refractory status epilepticus) and general anaesthesia is usually recommended, at a dose that results in EEG burst suppression (a level of anaesthesia at which all seizure activity is usually controlled). If seizures continue despite this therapy, the patient is said to be in Stage 2 (established status epilepticus) and therapy is with intravenous anti-epileptic drugs such as phenytoin, phenobarbital or valproate. Typically, in Stage 1 (early status epilepticus), therapy is with benzodiazepines. Treatment is aimed at stopping seizures largely in order to avoid cerebral damage and other morbidity.Īll contemporary protocols take a staged approach to treatment (Fig. Tonic–clonic status epilepticus is a medical emergency. In view of the small number of published reports, there is an urgent need for the establishment of a database of outcomes of individual therapies. A protocol and flowchart for managing super-refractory status epilepticus is suggested. The importance of treating the identifying cause is stressed. The published world literature on the following treatments was critically evaluated: anaesthetic agents, anti-epileptic drugs, magnesium infusion, pyridoxine, steroids and immunotherapy, ketogenic diet, hypothermia, emergency resective neurosurgery and multiple subpial transection, transcranial magnetic stimulation, vagal nerve stimulation, deep brain stimulation, electroconvulsive therapy, drainage of the cerebrospinal fluid and other older drug therapies. There are no controlled or randomized studies, and so therapy has to be based on clinical reports and opinion. This article reviews the treatment approaches. It is an uncommon but important clinical problem with high mortality and morbidity rates. Super-refractory status epilepticus is defined as status epilepticus that continues or recurs 24 h or more after the onset of anaesthetic therapy, including those cases where status epilepticus recurs on the reduction or withdrawal of anaesthesia.
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