Skip to main content

Sustained effort network for treatment of status epilepticus/European academy of neurology registry on adult refractory status epilepticus (SENSE-II/AROUSE)

Abstract

Background

Status Epilepticus (SE) is a common neurological emergency associated with a high rate of functional decline and mortality. Large randomized trials have addressed the early phases of treatment for convulsive SE. However, evidence regarding third-line anesthetic treatment and the treatment of nonconvulsive status epilepticus (NCSE) is scarce. One trial addressing management of refractory SE with deep general anesthesia was terminated early due to insufficient recruitment. Multicenter prospective registries, including the Sustained Effort Network for treatment of Status Epilepticus (SENSE), have shed some light on these questions, but many answers are still lacking, such as the influence exerted by distinct EEG patterns in NCSE on the outcome. We therefore initiated a new prospective multicenter observational registry to collect clinical and EEG data that combined may further help in clinical decision-making and defining SE.

Methods

Sustained effort network for treatment of status epilepticus/European Academy of Neurology Registry on refractory Status Epilepticus (SENSE-II/AROUSE) is a prospective, multicenter registry for patients treated for SE. The primary objectives are to document patient and SE characteristics, treatment modalities, EEG, neuroimaging data, and outcome of consecutive adults admitted for SE treatment in each of the participating centers and to identify factors associated with outcome and refractoriness. To reach sufficient statistical power for multivariate analysis, a cohort size of 3000 patients is targeted.

Discussion

The data collected for the registry will provide both valuable EEG data and information about specific treatment steps in different patient groups with SE. Eventually, the data will support clinical decision-making and may further guide the planning of clinical trials. Finally, it could help to redefine NCSE and its management.

Trial registration

NCT number: NCT05839418.

Peer Review reports

Background

Status epilepticus (SE) is a common neurological emergency defined by the International League Against Epilepsy (ILAE) Task Force on Classification of SE as “ a condition resulting either from the failure of the mechanisms responsible for seizure termination or from the initiation of mechanisms which lead to abnormally prolonged seizures and can have long-term consequences, including neuronal injury or death, and alteration of neuronal networks, depending on the type and duration of seizures” [1]. The duration threshold has been defined for convulsive SE as a seizure lasting longer than 5 min, for focal and/or non-convulsive SE as lasting longer than 10 min or for non-convulsive SE for a total duration of 20% of any 60-minutes period of recording [2, 3].

The current treatment strategies of SE use a tiered approach, in which the sequential administration of different drugs follow pre-defined temporal points. These may not always reflect the severity of the SE episode and need for urgent seizure cessation, hence are rarely strictly adhered to in clinical practice [4,5,6]. In early SE (5 to 20 min after seizure onset), a parenteral benzodiazepine should be given. In established SE (20 to 40 min) a non-sedating intravenous (IV) anti-seizure medication (ASM) is recommended. Refractory status epilepticus (RSE; 40 to 60 min) is defined as SE persisting despite administration of at least two appropriately selected and dosed parenteral medications, including a benzodiazepine. Super-refractory SE (SRSE) is defined as SE persisting or recurring after 24 h or more of treatment with continuous intravenous anesthetic drugs (CIVADs) [7].

In the last three decades, a few large randomized controlled trials provided evidence for the early stages of SE and established the role of benzodiazepines [8,9,10]. However, underdosing and/or absence of benzodiazepines as first-line treatment have been widely observed and has been associated with poorer outcome, among others things [11,12,13,14].

In 2019, the multicenter randomized double-blind “Established Status Epilepticus Treatment Trial” (ESETT) compared IV fosphenytoin, levetiracetam and valproate for established convulsive status epilepticus (CSE), with similar rates of SE cessation and adverse events, confirmed by recent pediatric studies [15]. Based on these trials, the first and second-line treatments of convulsive SE are well established. Previous studies also suggested that other non-sedative IV ASMs, such as lacosamide or brivaracetam could be effective and safe as second-line treatment or beyond [16,17,18,19,20,21,22,23, 23, 24].

Although CIVADs are recommended as third-line treatment and are safe to use as second-line [25], there is currently limited evidence to guide this third-line and later treatments on convulsive and other types of SE.

In RSE, a randomized trial comparing propofol and barbiturates was initiated in 2006 but was terminated early due to insufficient enrollment. Efficacy was similar between the two drugs but duration of intubation was much longer with barbiturates [26]. Few observational studies compared anesthetic drugs and different doses [27,28,29]. Overall, data support the choice of midazolam and propofol to treat refractory SE over barbiturates, which are associated with significantly more complications (especially infections) and mortality, but randomized controlled trials are lacking [30,31,32]. Non-sedating ASMs are an alternative to CIVADs in refractory nonconvulsive cases, but there is a lack of evidence regarding which drug to administer and how, as highlighted by several recent reviews [33] and observational case series [34,35,36].

There are even fewer data to guide the management of super-refractory SE [37] and for the use of uncommon strategies in this setting, including ketamine, isoflurane [38] the ketogenic diet, electroconvulsive therapy, and neurostimulation [39, 40], hypothermia or immune therapies in SE of suspected autoimmune or autoinflammatory etiology [41, 42].

Further investigation is needed to determine the optimal EEG target in patients with RSE and SRSE. Commonly used EEG surrogates of RSE control include seizure suppression, the emergence of a burst-suppression pattern (BS), or an isoelectric background. Achieving these surrogate endpoints often requires titrating intravenous antiepileptic drugs based on EEG readings. A multinational survey favored BS as the preferred target for CIVAD titration in RSE patients [43], with an interburst interval of around 10 s suggested by experts [44]. Achieving BS could be challenging and was not associated with sustained seizure termination or better outcome in a recent observational study [45]. The adequacy of BS as a surrogate target then lacks substantial evidence [46].

Finally, although the treatment of CSE is well established, these recommendations are often extrapolated to NCSE due to lack of data confirming the appropriateness of this practice. Currently, there is no clear consensus on the treatment of NCSE.

To address all these issues, randomized and controlled trials are needed. Such trials require substantial financial and human resources to achieve sufficient statistical power [47]. This is a challenge for RSE and SRSE, which have a low annual incidence of respectively up to 7 per 100.000 adults and 1 per 100.000 adults [48,49,50]. Other limitations include the challenges of clinical trials in the emergency setting and in temporarily incapacitated subjects.

Multicenter prospective observational registries offer an alternative approach to randomized controlled trials by collecting data on determinants of outcome, practice variability and allow comparative effectiveness and efficacy studies. Recently, the Sustained Effort Network for treatment of Status Epilepticus (SENSE) has provided real-life data about SE [51,52,53,54,55]. Between January 2011 and June 2015, 1179 episodes of SE in 1049 subjects from eight German-speaking centers in Austria, Germany, and Switzerland, were enrolled in SENSE. Collected data helped provide new insights into the factors contributing to SE cessation and refractoriness, functional outcome, and intubation.

The overarching goal of the Sustained Effort Network for Treatment of Status Epilepticus/European Academy of Neurology Registry on Refractory Status Epilepticus (SENSE-II/AROUSE) is to harmonize the collection of clinical and EEG data from multiple centers on SE to gain further insight on the management of SE across all its semiologies and etiologies, and to compare second- and third-line treatments and beyond. More specifically, we aim to:

  • identify risk factors of outcome, refractoriness, super-refractoriness.

  • perform comparative effectiveness studies on third-line treatment and beyond, and on the use of cEEG.

  • collect epidemiological data on rare forms and causes of SE.

  • identify key targets for future randomized controlled trials.

Methods/Design

Study design

SENSE-II/AROUSE is a prospective, multicenter, observational registry study on consecutive cases of SE in patients 18 years of age or older. We aim to involve university hospitals as well as non-university hospitals to enhance generalizability of our findings.

Currently, 12 high-volume medical centers in Belgium, Austria, Germany, Switzerland, Norway, Finland, and Denmark are involved:

  1. a)

    Belgium : Hôpital Universitaire de Bruxelles – Erasme Hospital (C. Damien, N. Gaspard) ; Centre Hospitalier Universitaire Brugmann (C.Damien).

  2. b)

    Austria: University Hospital Salzburg - Christian Doppler University Hospital (M. Leitinger, E.Trinka) ; Johannes Kepler University Linz (R. Helbok).

  3. c)

    Germany: Goethe-Universität Frankfurt am Main (A. Strzelczyk, F. Rosenow); Klinikum Osnabrück (C. Kellinghaus).

  4. d)

    United Kingdom: University Hospitals Birmingham (M. Damian).

  5. e)

    Switzerland: Universitätsspital Basel (S. Rüegg, R. Sutter); University Hospital of Geneva (P. De Stefano).

  6. f)

    Norway: Oslo University Hospital (E. Taubøll).

  7. g)

    Finland: HUS Helsinki University Hospital (L. Kämppi).

  8. h)

    Denmark: Odense University Hospital (C. Beier).

Personnel collecting data from the patient charts and entering data into the database are board certified neurologists, or neurology residents, or medical students in their final year, or study nurses, who will be specifically instructed prior to data collection and personally supervised by one of the principal investigators during the data collection and entry.

Patients will be treated in emergency departments, EEG-laboratories, or intensive care units with electronical data entry and management, or with dedicated data collection sheets in place [56]; thus, type, dosages and time points of drug administration will be easily ascertained. The increasing use of continuous video-EEG (cEEG) monitoring will also allow for exact and reliable determination of cessation of NCSE, and in some cases also of NCSE onset.

Objectives

The main objectives of the study are to assess patient characteristics, treatment modalities, to analyze and collect EEG features and outcome of adults treated for SE and identify predictors of outcome. Data assessed in this study could also identify gaps and opportunities of the management of this medical emergency.

More specifically, the following questions will be addressed:

  1. 1)

    Which factors determine global outcome at the time of hospital discharge?

  2. 2)

    Which factors are associated with refractoriness and super-refractoriness?

  3. 3)

    What are the efficacy and safety issues associated with each treatment?

  4. 4)

    What are the characteristics of EEG in NCSE and do they carry clinically relevant information?

  5. 5)

    How could we better classify SE taking semiology, etiology, and EEG into account?

  6. 6)

    Are there differences in the pattern of care and outcome between the centers?

Study population

We aim to enter all consecutive adult patients who are diagnosed with SE at admission or at any point of the inpatient treatment into the registry.

SE is defined as:

  1. a)

    Convulsive, i.e., bilateral tonic-clonic, seizure lasting 5 min or longer [1].

  2. b)

    SE with prominent motor symptoms other than convulsive SE lasting 5 or more minutes [1].

  3. c)

    Clinical seizures without prominent motor manifestations lasting 10 min or longer [1, 2].

  4. d)

    Recurrent seizures without regaining neurological baseline status between them and altogether fulfilling the above mentioned diagnostic time criteria [1, 57].

  5. e)

    Nonconvulsive or possible electrographic SE (synonymous: ictal-interictal continuum, IIC) diagnosed with EEG according to Salzburg Criteria [58, 59] or American Clinical Neurophysiology Society (ACNS) terminology 2021 (Electrographic SE is defined as an electrographic for ≥ 10 continuous minutes or for a total duration of > 20% of any 60-minute period of recording) [2].

RSE is defined as SE persisting despite administration of at least two appropriately selected and dosed parenteral medications including a benzodiazepine. SRSE is defined as SE persisting or recurring after 24 h or more of treatment with CIVADs [6].

Inclusion and exclusion criteria

Post-anoxic SE is considered to be distinct from other forms of SE and carries a very specific and generally poor prognosis. Therefore, we will exclude patients with post-anoxic SE. No other exclusion criteria will apply besides age (< 18 years).

Clinical data

Variables in Tables 1, 2 and 3 will be collected.

Table 1 Baseline, SE-related and outcome variables; SE: Status Epilepticus; mRS: modified Rankin Scale; ILAE: International League Against Epilepsy; NCSE: non convulsive status epilepticus; EMSE score: Epidemiology Based Mortality Score in Status Epilepticus
Table 2 Treatment-related variables; CIVAD: continuous intravenous anaesthetic drug; EEG: electroencephalography; IV: intravenous; ASM: antiseizure medication; NCSE: nonconvulsive status epilepticus
Table 3 Complications and life support therapies-related variable; ICU: intensive care unit; SE: status epilepticus

The modified Rankin Scale (mRS) [61] –a global outcome measure of morbidity and impairment -was chosen because of its easy applicability in a large variety of clinical scenarios with neurological diseases.

The premorbid Clinical Frailty Scale [60] was chosen in addition to the mRS for its greater sensitivity to premorbid functional status.

Of note, this study does not require any additional investigation apart from standard treatment and does not interfere in any way with the treatment decisions made by physicians during the inpatient phase. However, the patient will be called 90 days after onset/ discharge, which requires informed consent obtained during the inpatient phase in some countries.

Management protocol

No common management protocol will be imposed on the participating centers. However, most institutions have established a local protocol that is closely related to the most recent guidelines for the management of SE published by the American Epilepsy Society (AES) in 2016 [64].

In general, diagnosis of SE and related conditions is made based on clinical suspicion using physical examination and, where necessary, EEG (including, cEEG).

In most cases, emergency cerebral imaging with CT or MRI as well as standard emergency blood analysis, and CSF analysis if indicated, will be performed. Most frequently, the first treatment step consists of the administration of a benzodiazepine. If unsuccessful, intravenous administration of ASMs such as levetiracetam, valproate, (fos-)phenytoin, or lacosamide follows. As a third step, another ASM is added or anesthetics such as propofol or midazolam. All treatment decisions will remain at the discretion of the attending physicians.

The use of data acquisition sheets for the very early stages SE (Annex; modified from [56]) and ASM trials for IIC, which are already in place in some centers, will be encouraged to facilitate homogenous and complete data collection.

All participating centers perform cEEG for the following indications:

  • Management of refractory and super-refractory SE.

  • Suspicion of NCSE after a convulsive SE or seizure (lack of return to neurological baseline).

Some participating perform cEEG for additional indications, such as patients unexplained altered mental status, detection of delayed cerebral ischemia in aneurysmal, subarachnoid hemorrhage.

The availability of cEEG is specific to each center, varying from 7 days a week (including Sundays and holidays) to during working hours on weekdays.

Data security and quality assessment

Recorded data are pseudonymized using site-specific sequential alphanumeric codes known to the local investigators only. Data entry is compliant with General Data Protection Regulation (GDPR) 2016/679 of European Union law. In countries where more restrict data protection rules are in place, only anonymized data will be provided.

Data collection will be performed using Research Electronic Data Capture (REDCap) electronic data capture tools hosted at Erasme Hospital [65, 66] REDCap is a secure, web-based software platform designed to support data capture for research studies, providing (1) an intuitive interface for validated data capture, (2) audit trails for tracking data manipulation and export procedures, (3) automated export procedures for seamless data downloads to common statistical packages, and (4) procedures for data integration and interoperability with external sources. Data are collected prospectively from the admission of the patient to discharge. Documentation must be started latest at the third working day after treatment to guarantee data quality. In some centers, data collection will be not feasible for a limited number of weeks for organizational reasons. These times will be communicated in advance to the steering committee. However, in the other time the consecutive inclusion of patients will be guaranteed.

Center participation will be monitored by a study coordinator to ensure consecutive case assessment and timely data entry. An independent data monitoring committee will periodically review data entry for completeness and accuracy. Any query due to missing data or lack of consistency will be resolved with local investigators.

Ethics approval

The local ethics committee of each participating center approved the final study protocol. The following ethics committees reviewed and approved the study.

The study was registered at the Ethics Committee of Erasme Hospital (Committee Reference Number: 406; Protocol Number: CCB: B4062020000170; P2020/483).

The study was also registered in PRS with number NCT05839418.

In Switzerland, the collected data being part of this registry will not be used for research purpose (analyzed or published) without the formal approval by the Regional Research Ethic Committee (Ethikkommission Nordwest- und Zentralschweiz for Basel -EKNZ- and Commission Cantonale d’Ethique de la Recherche sur l’être humain for Geneva -CCER-).

This study will be performed in line with the principles of the Declaration of Helsinki.

Informed consent

In some countries, informed consent was waived due to the non-interventional character of this study. In other countries, informed consent is obtained as early as possible once the patient recovers from SE. If a patient does not recover and a legal representative is available, then this legal representative will provide informed consent. This rule also applies if a legal representative or a health care proxy has already been in place before SE occurred. If the patient dies, data are included for ethical reasons in terms of safety considerations. Informed consent is particularly necessary for the telephone call 90 days after discharge in some countries. If no informed consent can be obtained, the patient will only be logged as event but medical data will be deleted in some countries.

In some countries, informed consent is necessary purely due to the prospective nature of this study and due to data sharing regulations, strictly adhering to the local regulations regarding secondary usage of data collected for the routine clinical care.

Sample size

In the first prospective registry SENSE [51, 52], refractoriness rate reached 50%. Recent retrospective studies, single-center or population-based, showed a super-refractoriness rate from 3 to 10% [49, 67] using criteria defined above.

Thus, a cohort of approximately 3000 patients will be needed to reach a group size of 1500 patients in the refractory group and of about 150 patients in the super-refractory group.

For the refractory group, this group size is necessary to assess over 50 possible factors associated with outcome with a two-sided significance level of 5%, a power of 80% and an anticipated effect size of 10%.

For the super-refractory group, this group size will be needed to assess approximately 15 possible predictors of outcome with a two-sided significance level of 5%, a power of 80% and an anticipated effect size of 10%.

Data analysis

Calculations will be conducted according to incident patients (especially for mortality, where each patient cannot count for several exposures), and episodes (for example, regarding treatment impact, where several exposures of the same patient are potentially informative).

Continuous variables will be presented as mean and standard deviation in case of a normal distribution and as median and interquartile range with variables without normal distribution.

Interval-scaled and ordinal-scaled variables will be presented as median and interquartile range.

Categorical variables will be presented as frequency and percentages.

For continuous variables, comparisons between outcome categories will be analyzed using parametric tests for normally distributed variables and non-parametric tests for non-normally distributed variables. For categorical variables, comparisons will be performed using the Pearson’s Chi-squared test or Fisher’s exact test. Multivariable approaches will assess significance of variables of interest after multivariable analyses. Statistical analyses will be performed using the latest version of R (R Core Team).

Discussion

SENSE allowed to include over 1000 patients with SE from 8 centers. The study provided real-life data about SE and in particular refractory SE [54, 55].

It confirmed that a large proportion of first-line treatments was underdosed compared to the guidelines [54]. First-line treatment did not include benzodiazepines in 20% of all cases, 6% and 22% in CSE and non-CSE, respectively. These findings strongly suggest that IV ASMs are less efficacious than benzodiazepines as first-line treatment. Several predictors of SE cessation have been identified, such as a younger age, a lower mRS before SE onset, lower number of comorbidities, benzodiazepine as first-line treatment and a higher cumulative dose of ASMs within the first 30 min [53, 54]. Refractoriness occurred in 55% of patients and was associated with a higher baseline mRS and treatment deviation from guidelines, such as a lower bolus dose than recommended [54]. Unlike other studies, no difference was found comparing etiologies of refractory and non-refractory SE. Variables associated with good outcome in RSE were lower SE Severity Score (STESS) at SE onset, a shorter SE duration, a shorter length of stay and a lack of intubation. More than 70% of refractory SE were treated without airways protection and or mechanical ventilation. Limitations mentioned by the authors were the variability in recruitment of patients through the different centers, who could decrease the cohort homogeneity and potentially impacting on generalizability. Continuous EEGs were not available for most patients, even though it was recommended by several scientific societies [64, 68]. The focus of SENSE was RSE but only a few SRSE were recruited.

SENSE-II/AROUSE will provide high-quality data on SE of all types and severities. We have planned to collect continuous EEG data, if applicable, to alleviate the lack of knowledge about electrographic patterns of NCSE. We will focus on the functional outcome of SE but also on the refractoriness and super-refractoriness to identify potential predictors. Finally, due to lack of studies of third-line treatment and beyond, we plan to perform a comparative effectiveness study based on the collected data.

The evaluation of a large, heterogeneous patient group will hopefully help in clinical decision making in an area where data with higher level of evidence are still lacking.

Data Availability

Not applicable.

Abbreviations

ACNS:

American Clinical Neurophysiological Society

AES:

American Epilepsy Society

ASM:

Anti-seizure medication

CIVADs:

Continuous intravenous anesthetic drugs

CSE:

Convulsive status epilepticus (i.e., bilateral tonic clonic)

CT:

Computer tomography

EEG:

Electroencephalogram

EMSE:

Epidemiology-based mortality score in status epilepticus

ESETT:

Established status epilepticus treatment trial

FDG:

Fluorine-18 fluorodeoxyglucose

GDPR:

General Data Protection Regulation

IC:

Informed consent

ICC:

Ictal-interictal continuum

ICU:

Intensive care units

ILAE:

International League Against Epilepsy

IV:

Intravenous

MRI:

Magnetic resonance imaging

mRS:

Modified Rankin Scale

NCSE:

Nonconvulsive status epilepticus

NORSE:

New Onset Refractory Status Epilepticus

PET:

Positron emission tomography

REDCap:

Research Electronic Data Capture

RSE:

Refractory status epilepticus

SE:

Status epilepticus

SENSE:

Sustained effort network for treatment of status epilepticus

SENSE-II/AROUSE:

Sustained effort network for treatment of status epilepticus/European Academy of Neurology Registry on refractory Status Epilepticus

SRSE:

Super refractory status epilepticus

STESS:

Status epilepticus severity score

References

  1. Trinka E, Cock H, Hesdorffer D, Rossetti AO, Scheffer IE, Shinnar S, et al. A definition and classification of status epilepticus - report of the ILAE Task Force on classification of Status Epilepticus. Epilepsia. 2015. https://doi.org/10.1111/epi.13121.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Hirsch LJ, Fong MW, Leitinger M, LaRoche SM, Beniczky S, Abend NS, et al. American Clinical Neurophysiology Society’s standardized critical care EEG terminology: 2021 version. J Clin Neurophysiol. 2021;38:1–29.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Damien C, Cissé FA, Depondt C, Rikir E, Legros B, Gaspard N. Duration of nonconvulsive seizures in critically ill patients. Epilepsy Behav. 2021;124:108312.

    Article  PubMed  Google Scholar 

  4. Glauser T, Shinnar S, Gloss D, Alldredge B, Arya R, Bainbridge J, et al. Evidence-based Guideline: treatment of Convulsive Status Epilepticus in children and adults: report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16:48.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Shorvon S, Baulac M, Cross H, Trinka E, Walker M. The drug treatment of status epilepticus in Europe: Consensus document from a workshop at the first London colloquium on Status Epilepticus. Epilepsia. 2008;49:1277–85.

    Article  PubMed  Google Scholar 

  6. Shorvon S, Ferlisi M. The treatment of super-refractory status epilepticus: a critical review of available therapies and a clinical treatment protocol. Brain. 2011.

  7. Hirsch LJ, Gaspard N, van Baalen A, Nabbout R, Demeret S, Loddenkemper T, et al. Proposed consensus definitions for new-onset refractory status epilepticus (NORSE), febrile infection-related Epilepsy syndrome (FIRES), and related conditions. Epilepsia. 2018;59:739–44.

    Article  PubMed  Google Scholar 

  8. Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, et al. A comparison of four treatments for generalized convulsive Status Epilepticus. N Engl J Med. 1998;339:792–8.

    Article  CAS  PubMed  Google Scholar 

  9. Alldredge BK, Gelb AM, Isaacs SM, Corry MD, Allen F, Ulrich S, et al. A comparison of Lorazepam, diazepam, and Placebo for the treatment of out-of-hospital Status Epilepticus. N Engl J Med. 2001;345:631–7.

    Article  CAS  PubMed  Google Scholar 

  10. Silbergleit R, Durkalski V, Lowenstein D, Conwit R, Pancioli A, Palesch Y, et al. Intramuscular versus intravenous therapy for Prehospital Status Epilepticus. N Engl J Med. 2012;366:591–600.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Guterman EL, Sanford JK, Betjemann JP, Zhang L, Burke JF, Lowenstein DH, et al. Prehospital midazolam use and outcomes among patients with out-of-hospital status epilepticus. Neurology. 2020;95:e3203–12.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Gaínza-Lein M, Fernández IS, Ulate-Campos A, Loddenkemper T, Ostendorf AP. Timing in the treatment of status epilepticus: from basics to the clinic. Seizure. 2019;68:22–30.

    Article  PubMed  Google Scholar 

  13. Sathe AG, Underwood E, Coles LD, Elm JJ, Silbergleit R, Chamberlain JM, et al. Patterns of benzodiazepine underdosing in the established Status Epilepticus Treatment Trial. Epilepsia. 2021;62:795–806.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Sairanen JJ, Kantanen AM, Hyppölä HT, Kälviäinen RK. Status epilepticus: practice variation and adherence to treatment guideline in a large community hospital. J Neurol Sci. 2021;427.

  15. Kapur J, Elm J, Chamberlain JM, Barsan W, Cloyd J, Lowenstein D, et al. Randomized Trial of three anticonvulsant medications for Status Epilepticus. N Engl J Med. 2019;381:E211–6.

    Article  Google Scholar 

  16. Strzelczyk A, Zöllner JP, Willems LM, Jost J, Paule E, Schubert-Bast S, et al. Lacosamide in status epilepticus: systematic review of current evidence. Epilepsia. 2017;58:933–50.

    Article  CAS  PubMed  Google Scholar 

  17. Husain AM. Treatment of recurrent Electrographic Nonconvulsive seizures (TRENdS) study. Epilepsia. 2013;54:84–8.

    Article  CAS  PubMed  Google Scholar 

  18. Husain AM, Lee JW, Kolls BJ, Hirsch LJ, Halford JJ, Gupta PK, et al. Randomized trial of lacosamide versus fosphenytoin for nonconvulsive seizures. Ann Neurol. 2018;83:1174–85.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Aicua-Rapun I, André P, Rossetti AO, Decosterd LA, Buclin T, Novy J. Intravenous brivaracetam in status epilepticus: correlation between loading dose, plasma levels and clinical response. Epilepsy Res. 2019;149:88–91.

    Article  CAS  PubMed  Google Scholar 

  20. Strzelczyk A, Steinig I, Willems LM, Reif PS, Senft C, Voss M, et al. Treatment of refractory and super-refractory status epilepticus with brivaracetam: a cohort study from two German university hospitals. Epilepsy Behav. 2017;70:177–81. Pt A.

    Article  PubMed  Google Scholar 

  21. Kalss G, Rohracher A, Leitinger M, Pilz G, Novak HF, Neuray C, et al. Intravenous brivaracetam in status epilepticus: a retrospective single-center study. Epilepsia. 2018;59(Suppl 2):228–33.

    Article  CAS  PubMed  Google Scholar 

  22. Santamarina E, Parejo Carbonell B, Sala J, Gutiérrez-Viedma Á, Miró J, Asensio M, et al. Use of intravenous brivaracetam in status epilepticus: a multicenter registry. Epilepsia. 2019;60:1593–601.

    Article  CAS  PubMed  Google Scholar 

  23. Orlandi N, Bartolini E, Audenino D, Moja MC, Urso L, D’Orsi G, et al. Intravenous brivaracetam in status epilepticus: a multicentric retrospective study in Italy. Seizure. 2021;86:70–6.

    Article  PubMed  Google Scholar 

  24. Orlandi N, Giovannini G, Rossi J, Cioclu MC, Meletti S. Clinical outcomes and treatments effectiveness in status epilepticus resolved by antiepileptic Drugs: a five-year observational study. Epilepsia open. 2020;5:166–75.

    Article  PubMed  PubMed Central  Google Scholar 

  25. De Stefano P, Baumann SM, Grzonka P, Sarbu OE, De Marchis GM, Hunziker S, et al. Early timing of anesthesia in status epilepticus is associated with complete recovery: a 7-year retrospective two-center study. Epilepsia. 2023;64:1493–506.

    Article  PubMed  Google Scholar 

  26. Rossetti AO, Milligan TA, Vulliémoz S, Michaelides C, Bertschi M, Lee JW. A Randomized Trial for the treatment of Refractory Status Epilepticus. Neurocrit Care. 2011;14:4–10.

    Article  CAS  PubMed  Google Scholar 

  27. Chiu W-T, Campozano V, Schiefecker A, Rodriguez DR, Ferreira D, Headlee A, et al. Management of Refractory Status Epilepticus: An International COhort stuDy (MORSE CODe) analysis of patients managed in the ICU. Neurology. 2022. https://doi.org/10.1212/WNL.0000000000200818.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Bellante F, Legros B, Depondt C, Créteur J, Taccone FS, Gaspard N. Midazolam and thiopental for the treatment of refractory status epilepticus: a retrospective comparison of efficacy and safety. J Neurol. 2016;263:799–806.

    Article  CAS  PubMed  Google Scholar 

  29. Fernandez A, Lantigua H, Lesch C, Shao B, Foreman B, Schmidt JM, et al. High-dose midazolam infusion for refractory status epilepticus. Neurology. 2014;82:359–65.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Semmlack S, Tschudin-Sutter S, Widmer AF, Valença M, Rüegg S, Marsch S, et al. Independent impact of Infections on the course and outcome of status epilepticus: a 10-year cohort study. J Neurol. 2016;263:1303–13.

    Article  PubMed  Google Scholar 

  31. Sutter R, Marsch S, Fuhr P, Kaplan PW, Rüegg S. Anesthetic drugs in status epilepticus: Risk or rescue? 2014.

  32. Marchi NA, Novy J, Faouzi M, Stähli C, Burnand B, Rossetti AO. Status epilepticus: impact of therapeutic coma on outcome. Crit Care Med. 2015;43:1003–9.

    Article  PubMed  Google Scholar 

  33. Brigo F, Lattanzi S, Rohracher A, Russo E, Meletti S, Grillo E, et al. Perampanel in the treatment of status epilepticus: a systematic review of the literature. Epilepsy Behav. 2018;86:179–86.

    Article  PubMed  Google Scholar 

  34. Strzelczyk A, Knake S, Kälviäinen R, Santamarina E, Toledo M, Willig S, et al. Perampanel for treatment of status epilepticus in Austria, Finland, Germany, and Spain. Acta Neurol Scand. 2019;139:369–76.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Fechner A, Hubert K, Jahnke K, Knake S, Konczalla J, Menzler K, et al. Treatment of refractory and superrefractory status epilepticus with topiramate: a cohort study of 106 patients and a review of the literature. Epilepsia. 2019;60:2448–58.

    Article  CAS  PubMed  Google Scholar 

  36. Apostolakopoulou L, Bosque Varela P, Rossini F, O’Sullivan C, Löscher W, Kuchukhidze G et al. Intravenous topiramate for seizure emergencies - first in human case report. Epilepsy Behav. 2023;142.

  37. Nelson SE, Varelas PN. Status Epilepticus, Refractory Status Epilepticus, and Super-refractory Status Epilepticus. 2018.

  38. Stetefeld HR, Schaal A, Scheibe F, Nichtweiß J, Lehmann F, Müller M, et al. Isoflurane in (Super-) refractory status Epilepticus: a multicenter evaluation. Neurocrit Care. 2021;35:631–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Trinka E, Brigo F. Neurostimulation in the treatment of refractory and super-refractory status epilepticus. Epilepsy and Behavior. 2019;101.

  40. Trinka E, Brigo F. Neurostimulation in the treatment of refractory and super-refractory status epilepticus. Epilepsy Behav. 2019;101 Pt B.

  41. Wickström R, Taraschenko O, Dilena R, Payne ET, Specchio N, Nabbout R, et al. International consensus recommendations for management of new onset refractory status epilepticus (NORSE) including febrile infection-related Epilepsy syndrome (FIRES): Summary and clinical tools. Epilepsia. 2022. https://doi.org/10.1111/epi.17391.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Wickström R, Taraschenko O, Dilena RP ET, Specchio N, Nabbout R et al. International consensus recommendations for management of new onset refractory status epilepticus (NORSE) including febrile infection-related epilepsy syndrome (FIRES): Summary and clinical tools. Epilepsia. 2022;00:1–13.

  43. Holtkamp M, Masuhr F, Harms L, Einhäupl KM, Meierkord H, Buchheim K. The management of refractory generalised convulsive and complex partial status epilepticus in three European countries: a survey among epileptologists and critical care neurologists. J Neurol Neurosurg Psychiatry. 2003;74:1095–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Rossetti AO, Lowenstein DH. Management of refractory status epilepticus in adults: still more questions than answers. Lancet Neurol. 2011;10:922–30.

    Article  PubMed  PubMed Central  Google Scholar 

  45. An J, Jonnalagadda D, Moura V, Purdon PL, Brown EN, Westover MB. Variability in pharmacologically-induced coma for treatment of refractory status epilepticus. PLoS ONE. 2018;13.

  46. Fisch U, Jünger AL, Baumann SM, Semmlack S, De Marchis GM, Hunziker S, et al. Association between Induced Burst Suppression and clinical outcomes in patients with Refractory Status Epilepticus: a 9-Year Cohort Study. Neurology. 2023;100. https://doi.org/10.1212/WNL.0000000000207129.

  47. Shorvon S, Trinka E. Regulatory aspects of status epilepticus. Epilepsia. 2018;59(Suppl 2):128–34.

    Article  PubMed  Google Scholar 

  48. Dham BS, Hunter K, Rincon F. The epidemiology of status epilepticus in the United States. Neurocrit Care. 2014;20:476–83.

    Article  PubMed  Google Scholar 

  49. Kantanen AM, Sairanen J, Kälviäinen R. Incidence of the different stages of status epilepticus in Eastern Finland: a population-based study. Epilepsy Behav. 2019;101 Pt B.

  50. Leitinger M, Höller Y, Kalss G, Rohracher A, Novak HF, Höfler J, et al. Epidemiology-based mortality score in Status Epilepticus (EMSE). Neurocrit Care. 2015;22:273–82.

    Article  CAS  PubMed  Google Scholar 

  51. Kellinghaus C, Lang N, Rossetti AO, Rüegg S, Tilz C, Trinka E, et al. Making SENSE - sustained Effort Network for treatment of Status Epilepticus as a multicenter prospective registry. BMC Neurol. 2015;15:230.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Kellinghaus C, Rossetti AO, Trinka E, Lang N, Unterberger I, Rüegg S, et al. SENSE registry for status epilepticus. Epilepsia. 2018;59:150–4.

    Article  CAS  PubMed  Google Scholar 

  53. Kellinghaus C, Rossetti AO, Trinka E, Lang N, May TW, Unterberger I et al. Sustained Effort Network for treatment of Status Epilepticus (SENSE) – a multicenter prospective observational registry. Epilepsy Behav. 2019;101.

  54. Kellinghaus C, Rossetti AO, Trinka E, Lang N, May TW, Unterberger I, et al. Factors predicting cessation of status epilepticus in clinical practice: data from a prospective observational registry (SENSE). Ann Neurol. 2019;85:421–32.

    Article  CAS  PubMed  Google Scholar 

  55. Beuchat I, Rosenow F, Kellinghaus C, Trinka E, Unterberger I, Rüegg S, et al. Refractory status Epilepticus: risk factors and analysis of Intubation in the Multicenter SENSE Registry. Neurology. 2022. https://doi.org/10.1212/WNL.0000000000201099.

    Article  PubMed  Google Scholar 

  56. Trinka E, Leitinger M. Management of Status Epilepticus, Refractory Status Epilepticus, and super-refractory Status Epilepticus. Continuum (Minneap Minn). 2022;28:559–602.

    PubMed  Google Scholar 

  57. Lowenstein DH, Bleck T, Macdonald RL. It’s time to revise the definition of status epilepticus. Epilepsia. 1999;40:120–2.

    Article  CAS  PubMed  Google Scholar 

  58. Beniczky S, Hirsch LJ, Kaplan PW, Pressler R, Bauer G, Aurlien H, et al. Unified EEG terminology and criteria for nonconvulsive status epilepticus. Epilepsia. 2013. https://doi.org/10.1111/epi.12270.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Leitinger M, Trinka E, Gardella E, Rohracher A, Kalss G, Qerama E, et al. Diagnostic accuracy of the Salzburg EEG criteria for non-convulsive status epilepticus: a retrospective study. Lancet Neurol. 2016;15:1054–62.

    Article  PubMed  Google Scholar 

  60. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173:489–95.

    Article  PubMed  PubMed Central  Google Scholar 

  61. Van Swieten JC, Koudstaal PJ, Visser MC, Schouten H, Van Gijn J. Interobserver agreement for the assessment of handicap in Stroke patients. Stroke. 1988;19:604–7.

    Article  PubMed  Google Scholar 

  62. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.

    Article  CAS  PubMed  Google Scholar 

  63. Rossetti AO, Logroscino G, Bromfield EB. A clinical score for prognosis of status epilepticus in adults. 2006.

  64. Glauser T, Shinnar S, Gloss D, Alldredge B, Arya R, Bainbridge J, et al. Evidence-based Guideline: treatment of Convulsive Status Epilepticus in children and adults: report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16:48–61.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–81.

    Article  PubMed  Google Scholar 

  66. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95.

  67. Leitinger M, Trinka E, Giovannini G, Zimmermann G, Florea C, Rohracher A, et al. Epidemiology of status epilepticus in adults: a population-based study on incidence, causes, and outcomes. Epilepsia. 2019;60:53–62.

    Article  PubMed  Google Scholar 

  68. Claassen J, Taccone FS, Horn P, Holtkamp M, Stocchetti N, Oddo M. Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM. Intensive Care Med. 2013;39:1337–51.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

The study was not funded by any governmental, research or commercial entity. Resources were drawn from non-specific research funds of each institution. A grant for supporting the meeting costs will be applied for (European Cooperation in Science and Technology, COST) which will have no influence on research conduction, results and interpretation.

Author information

Authors and Affiliations

Authors

Contributions

CD made substantial contributions to the conception and design of the study, drafted the manuscript, developed the REDCap tools for data collection, obtained primary approval by the lead ethics committee,CK, FR, AS, RH, ML, ETr, SR, MD made substantial contributions to the conception and design of the study and critically revised this manuscript. PDS, RS, CB, ETa, LK, DS substantively revised this manuscript. NG made substantial contributions to the conception and design of the study, critically revised this manuscript, and coordinated the study. All authors approved the final version of this manuscript.

Corresponding author

Correspondence to Nicolas Gaspard.

Ethics declarations

Ethics approval and consent to participate

The study was registered at the Ethics Committee of Erasme Hospital (Committee Reference Number: 406; Protocol Number: CCB: B4062020000170; P2020/483).

The study was also registered in PRS with number NCT05839418.

In some countries, informed consent was waived due to the non-interventional character of this study. In some countries, informed consent is necessary purely due to the prospective nature of this study and due to data sharing regulations.

This study will be performed in line with the principles of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

Christoph Kellinghaus has received speaker’s honoraria from Angelini Pharma, Eisai, Jazz Pharmaceuticals, UCB, LivaNova. He has served on advisory boards for Angelini Pharma, Eisai and Marinus Pharma.

Adam Strzelczyk received personal fees and grants from Angelini Pharma, Biocodex, Desitin Arzneimittel, Eisai, Jazz (GW) Pharmaceuticals, Marinus Pharma, Precisis, Takeda, UCB (Zogenix) Pharma, and UNEEG medical. AS is editor-in-chied of Clinical Epileptology and editorial board member of Neurological Research and Practice.

Raoul Sutter received research grants from the Swiss National Foundation (No 320030_169379), the Research Fund of the University Basel, the Scientific Society Basel, and the Gottfried Julia Bangerter-Rhyner Foundation. He received personal grants from UCB-pharma and holds stocks from Novartis, Roche, Alcon, and Johnson & Johnson.

Leena Kämppi reports speaker’s honoraria from UCB, Merck and Eisai and personal grants from Michael Foundation, Finnish Neurological Society, Finnish Cultural Foundation and HUS Neurocenter.

Daniel Strbian serves in the advisory board for AstraZeneca, Alexion, Janssen, BMS, Orion, CLS Behring, Herantis Pharma and received unrestricted education grant from Boehringer Ingelheim.

Stephan Rüegg has received honoraria from serving on the scientific advisory boards of Arvelle/Angelini, Bial, Eisai, GW, and UCB-pharma, and from serving as a consultant for Arvelle/Angelini, Eisai, Pfizer, Novartis, Sandoz, and UCB-pharma. He has received speaker’s honoraria from Eisai and Novartis. He does not hold any stocks of any pharmaceutical industries or manufacturers of medical devices. He disclosed that he is co-editor-in-chief of Clinical Epileptology (01/01/2022; no payments).

Eugen Trinka reports paid consultancy from Arvelle, Argenx, Angelini, Clexio, UCB, Eisai, Epilog, Bial, Medtronic, Everpharma, Biogen, Takeda, Jazz, Liva-Nova, Newbridge, Sunovion, GW Pharmaceuticals/Jazz, Marinus; Research funding (directly, or to institution) from GSK, Biogen, Eisai, Novartis, Red Bull, Bayer, and UCB; Speaker’s honoraria from Arvelle, Angelini, GSK, GW Pharmaceuticals, Böhringer Ingelheim, Eisai, Epilog, Bial, Everpharma, UCB, Liva-Nova, Newbridge, Hikma, Novartis, and Sanofi. He is CEO of Neuroconsult Ges.m.b.H. Grants from Austrian Science Fund (FWF), Österreichische Nationalbank, and the European Union.

Nicolas Gaspard reports speaker’s honoraria from UCB Pharma and Angelini Pharma; paid consultancy from UCB Pharma and Marinus and research funding (directly, or to institution) from UCB and Angelini; grants from Belgian National Research Fund; Fonds Erasme pour la Recherche Médicale and INNOVIRIS; honoraria from MedLink Neurology.

Other authors declare that they have no competing interest.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Damien, C., Leitinger, M., Kellinghaus, C. et al. Sustained effort network for treatment of status epilepticus/European academy of neurology registry on adult refractory status epilepticus (SENSE-II/AROUSE). BMC Neurol 24, 19 (2024). https://doi.org/10.1186/s12883-023-03505-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12883-023-03505-y

Keywords