Try, Try Again: Success Rates After Continued Treatment Attempts in Refractory Status Epilepticus

Staged Treatment Response in Status Epilepticus: Lessons From the SENSE Registry Beuchat I, Novy J, Rosenow F, Kellinghaus C, Ruegg S, Tilz C, Trinka E, Unterberger I, Uzelac Z, Strzelczyk A, Rossetti AO. Epilepsia. 2023. doi:10.1111/epi.17817 Objectives: Although in epilepsy patients the likelihood of becoming seizure-free decreases substantially with each unsuccessful treatment, to our knowledge this has been poorly investigated in status epilepticus (SE). We aimed to evaluate the proportion of SE cessation and functional outcome after successive treatment steps. Methods: We conducted a post-hoc analysis of a prospective, observational, multicenter cohort (SENSE), in which 1049 incident adult SE episodes were prospectively recorded at 9 European centers. We analyzed 996 SE episodes without coma-induction before the third treatment step. Rates of SE cessation, mortality (in ongoing SE or after SE control), and favorable functional outcome (assessed with modified Rankin Scale) were evaluated after each step. Results: SE was successfully treated in 838 (84.1%) patients, 147 (14.8%) had a fatal outcome (36% of them died while still in SE), and 11 patients were transferred to palliative care while still in SE. Patients were treated with a median of three treatment steps (range 1-13) with 540 (54.2%) receiving more than two steps (refractory SE, RSE) and 95 (9.5%) more than five. SE was controlled after the first two steps in 45%, with additional 21% treated after the third, and 14% after the fourth step. Likelihood of SE cessation (p < 0.001), survival (p = 0.003), and reaching good functional outcome (p < 0.001) significantly decreased between the first two treatment lines and the third, especially in patients not experiencing convulsive generalized SE, but remained relatively stable afterwards. Significance: The significant worsening of SE prognosis after the second step clinically supports the concept of RSE. However, and differing from findings in human epilepsy, RSE remains treatable in around one third of patients even after several failed treatment steps. Clinical judgement remains essential to determine the aggressiveness and duration of SE treatment and avoid premature treatment cessation in SE patients.