(732) More Is Not Always Better: A Critical Review of the Management of Nonconvulsive Status Epilepticus

Introduction: Nonconvulsive status epilepticus (NCSE) is a heterogenous condition of ongoing or intermittent clinical epileptic activity associated with electroencephalographic (EEG) evidence of seizure but without overt convulsions. NCSE is a distinct clinical entity with a more variable natural history. Time to neuronal injury is likely longer and less severe so we have the option to consider less aggressive management. Absence status epilepticus (ASE) represents an important subcategory of NCSE with poor consensus on diagnostics and management. Here we review a case of ASE in our institution’s neurointensive care unit (NICU) and provide a critical review of the management considerations of NCSE.

Description: A 36-year-old female with a history of Lennox-Gastaut Syndrome, quadriplegia secondary to spastic cerebral palsy, and multidrug resistant infections presented with breakthrough seizures. She had right gaze preference, head version with tongue and bilateral upper extremity movements which were refractory to rescue diazepam and emergent antiepileptic loading. She was subsequently intubated and started on propofol. Her 24-day hospitalization was characterized by EEG evidence of activity consistent with NCSE which warranted antiepileptic and sedative escalation with a goal of burst suppression. Further scrutiny revealed active state stimulus-induced 2-3 Hz triphasic poly-spike wave activity consistent with ASE. Once identified, decision was made for pharmacologic de-escalation which resulted in EEG improvement and return to neurologic baseline.

Discussion: Here we discuss a case of ASE, a subcategory of NCSE. ASE is defined under the Salzburg criteria for NCSE and is defined as a stuporous or confused state with generalized onset of approximately 2-3 Hz triphasic spike-wave activity. Multiple variants have been described and with no clear standard of care. In ASE, evidence suggests that neurological damage occurs via a different pathophysiologic mechanism distinct from generalized status epilepticus. Given this, an important risk versus benefit discussion should be weighed in the management of NCSE with special consideration given to the clinical context with which it is occurring- including traumatic brain injury, electro-clinical dissociation, and other etiologies.