“Non-Convulsive Status Epilepticus” From EM Quick Hits

In this post, I link to and excerpt from Non-Convulsive Status Epilepticus, from EM Quick Hits 46.*

Brit Long on identification of non-convulsive status epilepticus (21:18-29:23)

*Helman, A. Hensley, J. Billin, A. Targonsky, E. Long, B. Petrosoniak, A. McLaren, J. Poyner, M. EM Quick Hits 46 – Wilderness Medicine, Bowel Prep Hyponatremia, Non-Convulsive Status Epilepticus, Morel Lavallee Lesions, Pacemaker ECGs, Loans vs Investing. Emergency Medicine Cases. February 2023. https://emergencymedicinecases.com/em-quick-hits-february-2023/. Accessed February 22, 2023.

All that follows is from the above resource.

Non-Convulsive Status Epilepticus

• Non-convulsive status epilepticus (NCSE) is a change in cognition or mental status with no significant convulsive activity and accounts for 47% of all status epilepticus.
• EEG definition of NCSE is abnormalities on EEG for 10 continuous minutes or intermittent seizure activity for >20% of an hour
• It is important have NCSE on our differential for alteration in mental status and treat appropriately if suspected.
• Consider NCSE in patients with:
  • altered mental status and abnormal ocular movements, lip smacking or subtle muscle twitches
  • medication history with anti-epileptic
  • patients that were seizing, treated, and are having a prolonged post-ictal period
  • unexplained altered mental status with no findings on ED testing
• Causes:
  • Most common: inadequately treated convulsive status epilepticus
  • Acute brain injury
  • Structural brain lesion
  • Infection
  • Encephalopathy
  • Chronic alcohol use
  • Medications
• Presentation *a careful ocular exam showing subtle abnormalities is often the clue to NCSE
  • Most common: change in mental status
  • Abnormality in ocular movement (i.e. eye deviation, nystagmus, eyelid twitching. Specificity of altered mental status and ocular movement abnormality is 85% for NCSE).
  • Changes in speech (aphasia): occurs in 15% of cases
  • Motor twitching of face or hands (e.g. lip smacking)
  • Other findings: hypertension, diaphoresis, flushing, catatonia, repeated crying or laughing

• Key ED diagnostic clue: a trial of benzodiazepines with an improvement in LOA is suggestive of NCSE

Best Case Ever 22 Non-Convulsive Status Epilepticus

References

1. Trinka E, Cock H, Hesdorffer D, et al. A definition and classification of status epilepticus—report of the ILAE Task Force on Classification of Status Epilepticus. Epilepsia. 2015;56:1515-1523.
2. Hirsch LJ, Fong MWK, Leitinger M, et al. American clinical neurophysiology society’s standardized critical care EEG terminology: 2021 version. J Clin Neurophysiol. 2021;38:1-29.
3. Leitinger M, Beniczky S, Rohracher A, et al. Salzburg consensus criteria for non-convulsive status epilepticus—approach to clinical application. Epilepsy Behav. 2015;49:158-163.
4. Wang X, Yang F, Chen B, Jiang W. Non-convulsive seizures and non-convulsive status epilepticus in neuro-intensive care unit. Acta Neurol Scand. 2022 Dec;146(6):752-760.
5. Kinney MO, Craig JJ, Kaplan PW. Non-convulsive status epilepticus: mimics and chameleons. Pract Neurol. 2018 Aug;18(4):291-305.
6. Bravo P, Vaddiparti A, Hirsch LJ. Pharmacotherapy for nonconvulsive seizures and nonconvulsive status epilepticus. Drugs. 2021;81:749-770.