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• W2994580462 abstract "One of the rare joys of compiling a special edition for a Journalis being able to write a more informal prologue. On putting this collection of manuscripts together, I was reminded of a comment made to me by a rather portly, now rather famous, London nephrologist while I was a junior doctor. Over a mouthful of lunch, he told/ instructed me that there were only two things that necessitated running from the canteen. The first was a cardiac arrest, the second status epilepticus. While the concept that cardiac pathology requires immediate intervention, and the types of intervention available have progressively advanced over the past twenty years, the same cannot necessarily be said of status epilepticus. The ILAE reclassification in 2017 [[1]Trinka E. et al.A definition and classification of status epilepticus – report of the ILAE Task Force on Classification of status epilepticus.Epilepsia. 2015; 56: 1515-1523Crossref PubMed Scopus (1217) Google Scholar] helps reframe the debate and the epilepsy community (people with epilepsy, carers/ family members and medical professionals) should all agree that urgent treatment of convulsive status epilepticus is mandated. However, still, the idea that treatment of status epilepticus – whether convulsive or non-convulsive – is more likely to be effective the earlier it is commenced needs bolstering and there is even less surety over appropriate investigations and subsequent management. In the current edition, we aim to tackle some of these areas and guide the reader from the basic cellular changes that may underpin status epilepticus to treatment and management of that most difficult of epilepsies – new onset super refractory status epilepticus (NORSE). The current articles are all seeded from talks given at the 2018 Oxford Masterclass in Epileptology which specifically addressed adult status epilepticus. These Masterclasses began in 2013 and are held annually. The aim of the conference is to tackle a complex area of epileptology over the course of one day in a lively and interactive meeting for medical professionals who care for people with epilepsy. Topics that have been dissected include cognitive co-morbidity, epilepsy and the older person and epilepsy in resource poor nations. However, the Masterclass on Status Epilepticus attracted particular attention as it led, quickly, to changes in hospital protocols and approaches to treatment. The current special edition essentially follows the course of the day itself. In the opening article, we discuss how difficult it has proved to determine a working definition of status epilepticus and how, in turn, this has limited epidemiological studies [[2]Shorvon Simon Sen Arjune What is status epilepticus and what do we know about its epidemiology?.Seizure: Eur J Epilepsy. 2020; (in this issue)https://doi.org/10.1016/j.seizure.2019.10.003Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar]. We highlight that at the 2017 Status Epilepticus Colloquium most of the audience still favoured defining status epilepticus as being seizures that continue for more than 30 min. While this may play to the notion that status epilepticus is part of a continuum or a ‘maximum expression’ of epilepsy, we showcase how status epilepticus is actually very different from other seizure types [[2]Shorvon Simon Sen Arjune What is status epilepticus and what do we know about its epidemiology?.Seizure: Eur J Epilepsy. 2020; (in this issue)https://doi.org/10.1016/j.seizure.2019.10.003Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar]. This concept is further underpinned by Burman and colleagues who discuss the molecular changes that are seen as healthy tissue transforms and then persists in an epileptic state [[3]Burman Richard J. Raimondo Joseph V. Jefferys John G.R. Sen Arjune Akermana Colin J. The transition to status epilepticus: how the brain meets the demands of perpetual seizure activity.Seiz European Journal of Epilepsy. 2020; (in this issue)https://doi.org/10.1016/j.seizure.2019.09.012Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar]. They propose four key pathways that might act synergistically to perpetuate seizure activity; delineate how future work to better understand the basis of status epilepticus requires improved understanding of these mechanisms and consider how such molecular cascades might in turn contribute to aberrant neuronal network activity [[3]Burman Richard J. Raimondo Joseph V. Jefferys John G.R. Sen Arjune Akermana Colin J. The transition to status epilepticus: how the brain meets the demands of perpetual seizure activity.Seiz European Journal of Epilepsy. 2020; (in this issue)https://doi.org/10.1016/j.seizure.2019.09.012Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar]. We then move to how we may better improve things clinically. In people presenting with status epilepticus, just as my senior nephrology colleague was attuned to, treatment initially trumps investigation. The first of our pieces on this aspect is by Crawshaw and Cock and takes us from the emergency department up to the doors of intensive care [[4]Crawshaw Ania A. Cock Hannah R. Medical management of status epilepticus: emergency room to intensive care unit.Seiz Eur J Epilepsy. 2020; (in this issue)https://doi.org/10.1016/j.seizure.2019.10.006Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar]. They reiterate the benefits of early treatment, initially with benzodiazepines, and discuss the importance of video-ing the seizure for subsequent reference. The authors highlight salient differences between prolonged dissociative seizures and status epilepticus – important because many presentations of seeming status epilepticus may not be epileptic in origin [[5]Holtkamp M. Othman J. Buchheim K. Meierkord H. Diagnosis of psychogenic non-epileptic status epilepticus in the emergency setting.Neurology. 2006; 66: 1727-1729Crossref PubMed Scopus (81) Google Scholar]. Crawshaw and Cock also discuss second line treatments and, crucially, explore the much-anticipated results of the Established Status Epilepticus Treatment Trial (ESETT) which examined the efficacy and safety of levetiracetam, fosphenytoin or valproate in people with benzodiazepine-refractory status epilepticus [[6]Kapur Jaideep Elm Jordan Chamberlain James M. Barsan William Cloyd James Lowenstein Daniel Shinnar Shlomo Conwit Robin Meinzer Caitlyn Cock Hannah Fountain Nathan Connor Jason T. et al.for the NETT and PECARN InvestigatorsRandomized trial of three anticonvulsant medications for status epilepticus.N Engl J Med. 2019; 381: 2103-2113Crossref PubMed Scopus (223) Google Scholar]. Prisco and a team of co-authors including neuro-intensivists, anaesthetists, neurologists, neurophysiologists and pharmacists then consider the options for people with refractory and super-refractory status epilepticus – those in whom neither first nor second line agents have aborted seizures [[7]Prisco Lara Ganau Mario Aurangzeb Sidra Moswela Olivia Hallett Claire Raby Simon et al.A pragmatic approach to intravenous anaesthetics and electroencephalographic endpoints for the treatment of refractory and super-refractory status epilepticus in critical care.Seiz Eur J Epilepsy. 2020; (in this issue)https://doi.org/10.1016/j.seizure.2019.09.011Abstract Full Text Full Text PDF Scopus (18) Google Scholar]. They highlight how important it is to ensure systemic aspects are addressed and that continuous electroencephalographic monitoring may offer additional benefits to patient care. A flow chart of the intravenous anaesthetic protocol used on for status epilepticus on the Neuro-intensive care Unit in Oxford, UK, is also provided [[7]Prisco Lara Ganau Mario Aurangzeb Sidra Moswela Olivia Hallett Claire Raby Simon et al.A pragmatic approach to intravenous anaesthetics and electroencephalographic endpoints for the treatment of refractory and super-refractory status epilepticus in critical care.Seiz Eur J Epilepsy. 2020; (in this issue)https://doi.org/10.1016/j.seizure.2019.09.011Abstract Full Text Full Text PDF Scopus (18) Google Scholar]. While treating status epilepticus, and even once the patient is stabilised, multiple investigations will be initiated. Craig and colleagues explore a strategy that tries to rationalise an approach to the tests that could be considered to determine both the cause and the consequences of prolonged seizure activity [[8]Craig Donald P. Mitchell Tejal N. Thomas Rhys H. A tiered strategy for investigating status epilepticus.Seiz Eur J Epilepsy. 2020; (in this issue)https://doi.org/10.1016/j.seizure.2019.10.004Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar]. Dividing these investigations into immediate tests for all and then more targeted testing dependent on clinical scenario and evolution allows for an easier handle on the necessary investigations. Specific consideration is once more given to the role of the electroencephalogram in guiding management. In the final piece, we aim to bring all of these aspects together Aurangzeb and co-authors present management and outcomes of cases of new onset super-refractory epilepticus (NORSE) admitted over an approximately five-year period [[9]Aurangzeb Sidra Prisco Lara Adcock Jane Speirs Mahiri Raby Simon Westbrook Jon et al.New-onset super refractory status epilepticus: a case-series.Seiz Eur J Epilepsy. 2020; (in this issue)https://doi.org/10.1016/j.seizure.2019.10.005Abstract Full Text Full Text PDF Scopus (9) Google Scholar]. Their index case was in status epilepticus for 210 days – one of the longest durations of status epilepticus published – and survived; illustrating that although super refractory status epilepticus can be extremely challenging, close co-operation across multiple specialities can yield favourable outcomes. So, it is clear that status epilepticus is indeed a condition worth leaving a soggy hospital sandwich for. With timely and appropriate interventions, substantial improvements can be made to patient care and I do hope that this message is exemplified through all of the articles. As a final indulgence, I hope that readers will forgive my extending special thanks to my co-editor, Professor Simon Shorvon. Not only are his contributions to epileptology, and especially status epilepticus, legendary he has offered me sterling mentorship since I was 19. It was as a first-year medical student that I visited the Epilepsy Research Group, as it was then called, at The National Hospital, Queen Square, and we have been in touch ever since. Professor Shorvon has been instrumental in developing the Oxford Masterclass series and continues to offer salient advice on our most complex clinical cases. It has been a great privilege to work with him on this special edition and, especially because it can be very difficult truly thank teachers who offer such profound influence, I am grateful to you for allowing me to do so here. I very much hope that you enjoy reading this edition at least as much as we have enjoyed putting it together – perhaps more – and that the papers will help in your understanding and care of people with status epilepticus. AS is supported by the Oxford NIHR Biomedical Research Centre." @default.
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