Lancet publishes review on convulsive status epilepticus in childhood

Progress in the understanding of convulsive status epilepticus (CSE) in childhood has been made, but uncertainty remains about important aspects of investigation, outcome, and treatment, especially for patients with acute symptoms, a review in the Lancet concludes. CSE is the most common neurological emergency in childhood and is associated with substantial morbidity and mortality. The condition is defined as a tonic—clonic seizure, or a series of seizures lasting at least 30 minutes, between which full consciousness is not regained, the authors write. They suggest that the 30-minute period is too long to wait before starting treatment, noting that definitions with 5 minutes and 10 minutes have been proposed. Guidelines published by the American Academy of Neurology in 2006 on the diagnostic assessment of childhood CSE applied a four-tiered classification to establish the validity of a study, on the basis of yield of established diagnostic and screening tests. Recommendations were made on the basis of evidence about the usefulness of several tests, including blood culture and lumbar puncture, antiepileptic drug concentrations, toxicology screening, metabolic and genetic testing, electroencephalography (EEG), and neuroimaging. CSE in childhood is often associated with fever, and, therefore, advice on appropriate use of investigations to diagnose a serious infection (eg, meningitis or encephalitis) should be provided, write the authors. Noting that the Academy says there is insufficient evidence to either support or refute the use of blood culture or lumbar puncture, Scott and Kirkahm write that an ‘acceptable’ approach is to start appropriate antibiotics and antivirals without lumbar puncture in children with focal neurological signs and those who remain deeply unconscious. EEG should be considered after convulsive status epilepticus when generalised convulsive status epilepticus needs to be distinguished from a focal presentation, which could have prognostic and therapeutic (medical and surgical) implications, and when pseudostatus epilepticus needs to be diagnosed, they recommend. There is insufficient evidence for routine neuroimaging with CT or MRI after convulsive status epilepticus, and should be done when convulsive status epilepticus is unexplained, the patient remains unconscious, or new focal neurological signs become apparent, the reviewers write. “Thus there is little evidence for the current practices of investigating children with convulsive status epilepticus. Physicians should be aware of the limitations of the Academy guidance and be prepared to modify practice as more data become available,” the authors conclude. Future research should focus on accurate diagnosis of underlying abnormalities in intractable status by use of neuroimaging, and on predicting and improving outcome, they add. Reference...