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Status Epilepticus

Status Epilepticus is a topic covered in the 5-Minute Clinical Consult.

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The various forms of status epilepticus (SE) represent critical neurologic conditions associated with significant morbidity and mortality rates, requiring prompt diagnosis and rapid seizure control to minimize permanent neuronal injury.


  • Recently revised definition of SE asserts that SE is a result of failure of the processes responsible for seizure cessation or from the initiation of mechanisms which lead to abnormally prolonged seizures (T1).
    • T1 defines the time point that is considered “prolonged” and is different depending on the type of SE that is present.
    • T1 determines the earliest time when treatment should be started.
    • For convulsive SE, it is set at 5 minutes; for nonconvulsive SE, it is set at 10 minutes; and for absence SE, it is set at 2 minutes.
  • Furthermore, SE is defined as a condition that can have long-term consequences, if not terminated within a set time period (T2), leading to neuronal death, neuronal injury, and/or alteration of neuronal networks.
    • T2 defines the time point at which SE should be controlled to prevent long-term consequences.
    • For convulsive SE, it is set at 30 minutes; for nonconvulsive SE, it is set at 30 to 60 minutes; and for absence SE, it is unknown.
  • SE presents in various forms and revised classification has divided it into the following:
    • SE with prominent motor symptoms: encompassing convulsive SE, characterized by excessive abnormal muscle contractions, which may be sustained, or interrupted; generally tonic-clonic in nature
    • SE without prominent motor symptoms: encompassing nonconvulsive SE, characterized without prominent motor symptoms, comprising continuous or fluctuating states of mentation without tonic–clonic activity
    • Refractory SE: seizure activity persisting despite adequate treatment with initial and secondary pharmacologic treatment


  • Overall incidence is 9.9 to 41 cases per 100,000 per year.
    • A recent meta-analysis found the pooled incidence rate to be 12.6/100,000 per year.
  • Results of trend studies show an increase in incidence of SE in the past few decades in the United States.
  • 760,117 hospital discharges with a diagnosis of SE from 1979 to 2010, with SE accounting for 0.07% of all hospital admissions in the United States over this period
  • Predominant sex: male > female (annual relative risk 1.1 in males, p < 0.0001)
  • Racial differences: blacks (13.7/100,000) > other races (7.4/100,000) > whites (6.9/100,000)
  • Bimodal age distribution: greatest number in those <1st decade of life (14.3/100,000) and >60 years (28.4/100,000)
    • Other prospective population studies show similar bimodal distribution of SE.

  • 125,000 to 195,000 patients per year present with generalized convulsive SE.
  • Mortality rates in the United States range from 19% to 22% based on two large prospective population-based studies.
    • The overall mortality rates do not show a change in trend over the last few decades.
    • Elderly patients experience the highest case fatality rate.
  • Cost: Mean hospital cost $18,834 in United States and annual direct costs are projected at $4 billion.

Etiology and Pathophysiology

  • Acute symptomatic etiology is the leading etiology-specific cause of SE, with epilepsy history, CNS infection, and CVA being the most common overall.
  • Pediatric consideration:
    • Infection with fever not involving CNS (52% of cases) was the major etiology of SE and then remote CNS insult (39%) and low anticonvulsant levels (21%).
  • Adults consideration:
    • Three major etiologies include low anticonvulsant levels (34%), remote symptomatic epilepsy (24%), and CVA (22%).
  • Geriatric consideration:
    • The most important cause of SE is CVA, followed by acute cardiac, respiratory, or hepatic decompensation, trauma, epilepsy, and dysnatremia.
  • Cerebrovascular diseases:
    • Ischemic stroke, bleeding (intracerebral, subarachnoid), hematoma (subdural, epidural), sinus venous thrombosis, vascular dementia, tumors
  • CNS infections:
    • Meningitis, encephalitis, PML, toxoplasmosis, TB, prion disease, fungal disease, HIV-related disease
  • Neurodegenerative diseases:
    • Alzheimer disease, frontotemporal dementia, etc.
  • Head trauma:
    • Closed, open, penetrating head injury
  • Intoxications:
    • Alcohol (intoxication, withdrawal, Wernicke), drugs, neurotoxins, heavy metals
  • Withdrawal or low antiepileptic drugs levels
  • Cerebral hypoxia or anoxia
  • Metabolic disturbances:
    • Electrolyte imbalance, glucose imbalance, organ failure, acidosis, renal failure, hepatic encephalopathy
  • Autoimmune disorders:
    • Multiple sclerosis (MS), Hashimoto encephalopathy, anti-NMDA encephalopathy, Rasmussen encephalitis, etc.
  • Idiopathic, cryptogenic

Risk Factors

Risk factors of SE linked to its etiology above; other factor, a previous history of SE (recurrence rate in children, 17%; in those with neurologic abnormality, 50%)

Commonly Associated Conditions

Movement disorders, psychogenic; transient ischemic attack (TIA), CVA, migraines, somatoform disorders, Todd paralysis

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Stephens, Mark B., et al., editors. "Status Epilepticus." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116567/all/Status_Epilepticus.
Status Epilepticus. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116567/all/Status_Epilepticus. Accessed April 18, 2019.
Status Epilepticus. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116567/all/Status_Epilepticus
Status Epilepticus [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 18]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116567/all/Status_Epilepticus.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Status Epilepticus ID - 116567 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116567/all/Status_Epilepticus PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -