Non Convulsive Status Epilepticus

Related Subjects: | Status Epilepticus (Epilepsy) | Non Convulsive Status Epilepticus | Coma management | Lorazepam | Phenytoin | Levetiracetam | Epilepsy - General Management | First Seizure | Epilepsy in Pregnancy | Febrile seizures

An underdiagnosed cause of coma and confusion at all ages. A left cortical irritative focus will lead to eyes deviated to the right and can cause flickering eye movements and vice versa

Initial NCSE Management
ABC, High flow oxygen, Consider a CT scan EEG is confirmative but may not be available so treat on clinical evidence Small doses of Lorazepam 1 mg which may be repeated Long term anticonvulsants may be needed If cause is not apparent e.g. old stroke then consider other causes and need for LP Consider Encephalitis, SOL, Meningitis

About

• Non-Convulsive Status Epilepticus (NCSE) is a persistent change in the level of consciousness, behaviour, autonomic function, and sensorium from baseline associated with continuous epileptiform EEG changes, but without major motor signs
• Possibly underdiagnosed at times. A treatable cause of coma or hypoactive delirium

Aetiology

• Can affect all age groups from children to the elderly

Types

• Absence, Simple, Complex partial
• Subtle status epilepticus

Clinical

• Can be subtle but Confusion or diminished responsiveness
• Occasional blinking or twitching, lasting hours to days
• Eyes deviated to one side by irritative focus
• Confusion in the elderly
• Nystagmus in a stuporous patient
• Unexplained stupor or confusion, especially in the elderly
• Altered mental status in the elderly, benzodiazepine withdrawal
• History of seizures and a new medical or surgical stress

Investigations

• FBC, U&E, Ca, Mg, LFTS. Lactate. VBG.
• CT scan : may show underlying pathology e.g. tumour, stroke, haemorrhage, abscess, encephalitis
• MRI: may help identify stroke or inflammation but patients often too unstable for prolonged imaging.
• Lumbar Puncture when infection or inflammation suspected
• EEG: Diagnostic with generalized spike and slow-wave discharges but can be difficult to get and this should not delay treatment.

Management

• EEG is diagnostic but may be difficult to get acutely so treat if high suspicion
• Exclude other causes of coma : hypoglycaemia, opiates etc..
• Treatment as for status epilepticus usually with IV Lorazepam 1 mg IV which can be repeated.
• Consider starting IV Phenytoin or IV Levetiracetam
• Start long term anticonvulsants
• Cover other differentials e.g. Cefotaxime and Aciclovir