Simone Beretta1, Anna Coppo2, Elisa Bianchi2, Clara Zanchi2, Davide Carone2, Andrea Stabile2, Giada Padovano2, Endrit Sulmina2, Alice Grassi2, Graziella Bogliun2, Giuseppe Foti2, Carlo Ferrarese2, Antonio Pesenti2, Ettore Beghi2, Leonello Avalli2. 1. From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy. simone.beretta@unimib.it. 2. From the Epilepsy Center (S.B., C.Z., D.C. A.S., G.P., G.B., C.F.), Department of Neurology, and Department of Intensive Care (A.C., E.S., A.G., G.F., L.A.), San Gerardo Hospital ASST Monza, University of Milano Bicocca, Monza; Department of Neuroscience (E.B., E.B.), IRCCS Mario Negri Institute for Pharmacological Research; and Department of Anesthesia (A.P.), Critical Care and Emergency, IRCCS Ospedale Maggiore Policlinico, Milano, Italy.
Abstract
OBJECTIVE: To investigate neurologic outcome of patients with cardiac arrest with refractory status epilepticus (RSE) treated with a standardized aggressive protocol with antiepileptic drugs and anesthetics compared to patients with other EEG patterns. METHODS: In the prospective cohort study, 166 consecutive patients with cardiac arrest in coma were stratified according to 4 independent EEG patterns (benign, RSE, generalized periodic discharges [GPDs], malignant nonepileptiform) and multimodal prognostic indicators. Primary outcomes were survival and cerebral performance category (CPC) at 6 months. RESULTS: RSE occurred in 36 patients (21.7%) and was treated with an aggressive standardized protocol as long as multimodal prognostic indicators were not unfavorable. RSE started after 3 ± 2.3 days after cardiac arrest and lasted 4.7 ± 4.3 days. A benign EEG pattern was recorded in 76 patients (45.8%); a periodic pattern (GPDs) was seen in 13 patients (7.8%); and a malignant nonepileptiform EEG pattern was recorded in 41 patients (24.7%). The 4 EEG patterns were highly associated with different prognostic indicators (low-flow time, clinical motor seizures, N20 responses, neuron-specific enolase, neuroimaging). Survival and good neurologic outcome (CPC 1 or 2) at 6 months were 72.4% and 71.1% for benign EEG pattern, 54.3% and 44.4% for RSE, 15.4% and 0% for GPDs, and 2.4% and 0% for malignant nonepileptiform EEG pattern, respectively. CONCLUSIONS: Aggressive and prolonged treatment of RSE may be justified in patients with cardiac arrest with favorable multimodal prognostic indicators.
OBJECTIVE: To investigate neurologic outcome of patients with cardiac arrest with refractory status epilepticus (RSE) treated with a standardized aggressive protocol with antiepileptic drugs and anesthetics compared to patients with other EEG patterns. METHODS: In the prospective cohort study, 166 consecutive patients with cardiac arrest in coma were stratified according to 4 independent EEG patterns (benign, RSE, generalized periodic discharges [GPDs], malignant nonepileptiform) and multimodal prognostic indicators. Primary outcomes were survival and cerebral performance category (CPC) at 6 months. RESULTS:RSE occurred in 36 patients (21.7%) and was treated with an aggressive standardized protocol as long as multimodal prognostic indicators were not unfavorable. RSE started after 3 ± 2.3 days after cardiac arrest and lasted 4.7 ± 4.3 days. A benign EEG pattern was recorded in 76 patients (45.8%); a periodic pattern (GPDs) was seen in 13 patients (7.8%); and a malignant nonepileptiform EEG pattern was recorded in 41 patients (24.7%). The 4 EEG patterns were highly associated with different prognostic indicators (low-flow time, clinical motor seizures, N20 responses, neuron-specific enolase, neuroimaging). Survival and good neurologic outcome (CPC 1 or 2) at 6 months were 72.4% and 71.1% for benign EEG pattern, 54.3% and 44.4% for RSE, 15.4% and 0% for GPDs, and 2.4% and 0% for malignant nonepileptiform EEG pattern, respectively. CONCLUSIONS: Aggressive and prolonged treatment of RSE may be justified in patients with cardiac arrest with favorable multimodal prognostic indicators.
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