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DUNE, Paris, December 13 2012 Status epilepticus prognosis

DUNE, Paris, December 13 2012 Status epilepticus prognosis. Andrea O. Rossetti, Service de Neurologie, CHUV, Lausanne, Switzerland. Overview. Introduction Mortality predictors Functional impact Role of SE in other disorders Practical impact Conclusion. Overview. Introduction

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DUNE, Paris, December 13 2012 Status epilepticus prognosis

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

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

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

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

  5. 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. EtiologyEpilepsia 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 • CNS infection 36% • AED withdr. 18% • Idiopathic 17% • Amare Epilepsia 2008 Adults • AED withdrawal 34% • Remote sympt. (stroke) 24% • Acute stroke 22% • Metabolic 15% • OH 13% • Anoxia 13% • Idiopathic 3% Children • Infection 52% • Remote symptomatic 39% • AED withdrawal 21%

  9. Mortality predictors • EtiologyTowne Epilepsia 1994, Logroscino Epilepsia 1997, Novy Epilepsia 2010 • AgeTowne Epilepsia 1994, Logroscino Epilepsia 1997, Rossetti JNNP 2006 • Consciousness impairmentShneker Neurology 2003, Rossetti JNNP 2006 • Treatment >1hTowne Epilepsia 1994 (but ≠ Logroscino Epilepsia 1997, Rossetti JNNP 2006, Drislane Epilepsia 2009 !) • InfectionsSutter 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. Related to De novo SE Encephalitis Severe consciousness impairment Holtkamp JNNP 2005,Novy Epilepsia 2010 Refractory SE (RSE) • Definition • SE resistant to BDZ and 1 AED (20-40% SE)

  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. 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 RSEHoltkamp 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 Tien Radiology 1995 Fernandez-Torre J Neurol 2006 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 Neurol1998, Kaplan Neurophysiol Clin 2000, Meierkord Lancet Neurol 2007 Interpretation: GTC SE also leads to systemic changesMeldrum Arch Neurol 1973, Lothman Neurology 1990, therefore more dangerous

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

  22. 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 prognosisRossetti J Neurol 2008 Hospit. cohort, 225 incident episodesRossetti J Neurol 2012 ICU-based, 144 episodes Kowalski Crit Care Med 2012

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

  27. Conclusion 1 Mortality: keep in mindetiology and age RSE: highermortality and more epilepsy

  28. Conclusion 2 Do not over- (norunder-) treat Try to use predictors to orient treatment

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

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