Clinical and electrographic stages

The pattern of seizures in tonic-clonic status epilepticus evolves over time. There is often a premonitory stage of minutes or hours, during which epileptic activity increases in frequency or severity from its habitual level. This clinical deterioration is an augury, often stereotypical, of impending status epilepticus, and urgent therapy may well prevent its full development. At the onset of status epilepticus, the attacks typically take the form of discrete grand mal seizures. As time passes, however, the convulsive motor activity often evolves, first to become continuous, and then clonic jerking becomes less pronounced and less severe, and finally ceases altogether. This is the stage of "subtle status epilepticus", by which time the patient will be deeply unconscious, and the prognosis is poor. These stages are not seen in all patients; they can be modified by concomitant medication, and there is often a varying time period between each stage. In parallel to this clinical evolution, a progressive change in the EEG has also been reported in animal models.11 The initial stage is that of discrete seizures; then there is waxing and waning of ictal discharges which progresses to continuous ictal discharges. The final stages are continuous ictal discharges punctuated by flat periods, and then periodic epileptiform discharges on a flat background. These electrographic and clinical stages importantly relate to underlying neuronal damage, and also to progressive difficulty in treating the status epilepticus (see below). The extent to which this EEG progression occurs in humans is less certain.11-12

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