Drislane Frank W, Lopez Maria R, Blum Andrew S, Schomer Donald L
Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
J Clin Neurophysiol. 2008 Aug;25(4):181-6. doi: 10.1097/WNP.0b013e31817be70e.
Status epilepticus (SE) is not rare in critically ill intensive care unit (ICU) patients, but its diagnosis is often delayed or missed, in part because it is mistaken for other causes of altered mental status. Even once diagnosed, SE in the ICU can be refractory to treatment. We sought to determine the causes, clinical features, and difficulties in diagnosis of SE in the ICU, and the effects of antiepileptic drugs (AEDs) on its course. We reviewed the course of ICU patients with both clinical and EEG evidence of SE, attempting to determine which patients are at risk for unsuspected SE, what was the typical delay in diagnosis, and whether AED treatment made a difference in their clinical courses. By clinical and EEG evidence, 91 ICU patients with SE were identified, all with abnormal mental status: 74 were comatose. Vascular disease (in 24) and anoxia (22) were the most common causes; most had multiple medical problems. Although 76 patients had clinically evident seizures earlier (and 56, clinical SE) only 20 were thought to be in SE at the time of the diagnostic EEG. There was a median delay of 48 hours from clinical deterioration until diagnosis in patients with earlier clinical seizures and 72 hours without seizures. Among the 68 nonanoxic patients treated with AEDs, 38 (56%) seemed to improve in alertness, including 25 who were comatose. Although patients who were stuporous or confused (vs. comatose) improved more often on AEDs, they were less often realized to be in SE before the EEG. Patients with earlier seizures were also more likely to improve, but no more likely to be diagnosed before the EEG. Patients who responded to AEDs were more likely to survive. ICU patients with altered mental status and EEG evidence of SE often have severe medical and surgical illnesses, refractory SE, and a high mortality. The delay to diagnosis is substantial, but a significant subset of patients improves on AEDs once SE is discovered. This diagnosis should be sought more often in ICU patients with abnormal mental status, especially after clinical seizures or SE without full recovery.
癫痫持续状态（SE）在重症监护病房（ICU）的重症患者中并不罕见，但其诊断常常延迟或漏诊，部分原因是它被误诊为其他导致精神状态改变的病因。即便一旦确诊，ICU中的SE对治疗也可能无效。我们试图确定ICU中SE的病因、临床特征、诊断难点以及抗癫痫药物（AEDs）对其病程的影响。我们回顾了有临床和脑电图证据证实为SE的ICU患者的病程，试图确定哪些患者有未被怀疑的SE风险、诊断的典型延迟时间以及AED治疗是否对其临床病程有影响。根据临床和脑电图证据，确定了91例患有SE的ICU患者，他们均有精神状态异常：74例昏迷。血管疾病（24例）和缺氧（22例）是最常见的病因；大多数患者有多种医疗问题。尽管76例患者 earlier（此处原文有误，推测为earlier）有临床明显的癫痫发作（56例为临床SE），但在诊断性脑电图检查时只有20例被认为处于SE状态。有早期临床癫痫发作的患者从临床病情恶化到诊断的中位延迟时间为48小时，无癫痫发作的患者为72小时。在68例接受AED治疗的非缺氧患者中，38例（56%）的警觉性似乎有所改善，其中包括25例昏迷患者。尽管昏睡或意识模糊（与昏迷相比）的患者使用AEDs后改善更为常见，但在脑电图检查前他们较少被意识到处于SE状态。有早期癫痫发作的患者也更有可能改善，但在脑电图检查前被诊断的可能性并不更高。对AEDs有反应的患者存活的可能性更大。有精神状态改变且有脑电图证据证实为SE的ICU患者通常患有严重的内科和外科疾病，SE难治，死亡率高。诊断延迟时间很长，但一旦发现SE，相当一部分患者使用AEDs后会有所改善。对于精神状态异常的ICU患者，尤其是在临床癫痫发作或SE后未完全恢复的情况下，应更频繁地进行此项诊断。
