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Frequency, Risk Factors, and Impact on Outcome

Stephan A. Mayer, MD; Jan Claassen, MD; Johnny Lokin, MD; Felicia Mendelsohn, BA; Lyle J. Dennis, MD; Brian-Fred Fitzsimmons, MD

Arch Neurol. 2002;59:205-210.

Background  Refractory status epilepticus (RSE) is a life-threatening condition in which seizures do not respond to first- and second-line anticonvulsant drug therapy. How often RSE occurs, risk factors that predispose to this condition, and the effect of failure to control seizures on clinical outcome are poorly defined.

Objective  To determine the frequency, risk factors, and impact on outcome of RSE.

Design  Retrospective cohort study.

Setting  Large academic teaching hospital.

Patients  Consecutive sample of 83 episodes of status epilepticus in 74 patients (mean age, 63 years).

Main Outcome Measures  Refractory status epilepticus was defined as seizures lasting longer than 60 minutes despite treatment with a benzodiazepine and an adequate loading dose of a standard intravenous anticonvulsant drug. Factors associated with RSE were identified using univariate and backward stepwiselogistic regression analyses.

Results  In 57 episodes (69%), seizures occurred after treatment with a benzodiazepine, and in 26 (31%), seizures occurred after treatment with a second-line anticonvulsant drug (usually phenytoin), fulfilling our criteria for RSE. Nonconvulsive SE (P= .03) and focal motor seizures at onset (P= .04) were identified as independent risk factors for RSE. Eleven (42%) of 26 patients with RSE had seizures after receiving a third-line agent (usually phenobarbital). Although mortality was not increased (17% overall), RSE was associated with prolonged hospital length of stay (P<.001) and more frequent functional deterioration at discharge (P= .02).

Conclusions  Refractory status epilepticus occurs in approximately 30% of patients with SE and is associated with increased hospital length of stay and functional disability. Nonconvulsive SE and focal motor seizures at onset are risk factors for RSE. Randomized controlled trials are needed to define the optimal treatment of RSE.

From the Division of Critical Care Neurology, Department of Neurology, College of Physicians and Surgeons of Columbia University, New York, NY.

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