Tonicclonic status epilepticus

SIMON SHORVON, MATTHEW WALKER

Tonic-clonic status epilepticus can be defined as a condition in which prolonged or recurrent tonic-clonic seizures persist for 30 minutes or more.1 Most tonic-clonic seizures last less than two minutes; nevertheless many seizures that continue for less than 30 minutes self-terminate.2,3 Treatment of the premonitory stages is likely to be more successful than treatment in the later stages and so treatment should commence as soon as it is apparent that the seizure is persisting (a tonic-clonic seizure of more than five minutes duration) or there is a significant worsening of a patient's normal seizure pattern.

The annual incidence of tonic-clonic status epilepticus varies considerably from study to study depending on the population analysed; estimates have ranged from 4 to 28 cases per 100 000 persons (2000-14 000 new cases each year in the United Kingdom).4-7 It is most frequent in the young, in whom it also tends to be longer lasting. Status epilepticus is also commoner in epileptic patients with mental handicap, or with structural cerebral pathology (especially in the frontal lobes). In established epilepsy, status epilepticus can be precipitated by drug withdrawal, intercurrent illness, or metabolic disturbance, or the progression of the underlying disease, and is more common in symptomatic than in idiopathic epilepsy. About 5% of all epileptic adult clinic patients will have at least one episode of status epilepticus in the course of their epilepsy,1 and in children the proportion is higher (10-25%).1,8 Most status epilepticus episodes, however, do not develop in known epileptic patients, and in such cases are almost always due to acute cerebral disturbances; common causes are cerebral infection, trauma, cerebrovascular disease, cerebral tumour, acute toxic (usually alcohol related) or metabolic disturbance, or febrile illness (in children). Studies have shown status epilepticus to account for about 4% of admissions to neurological intensive care, and 5% of all visits to a university hospital casualty department.9 The mortality of status epilepticus is about 20%. Most patients die of the underlying condition, rather than the status epilepticus itself or its treatment.1,5,10 Permanent neurological and mental deterioration may result from status epilepticus, particularly in young children, the risks of morbidity being greatly increased the longer the duration of the status epilepticus episode.1 Furthermore status epilepticus can result in chronic epilepsy, and indeed 43% of those with acute symptomatic status epilepticus have a subsequent unprovoked seizure compared to 13% of those with acute symptomatic seizures. Tonic-clonic status epilepticus is only one of the forms of status epilepticus (Box 6.1), and indeed is not the most common. Nevertheless, unlike most other types, it is a medical emergency. Treatment is urgent because the longer seizures continue, the more difficult they

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