Treatment of Refractory Status Epilepticus

When status epilepticus continues despite treatment with benzodiazepines and one antiepileptic drug, this condition considered as refractory and associated with high risk of permanent morbidity and even mortality; so, refractory status epilepticus (RSE) should be treated promptly. Early diagnosis and initiation of aggressive treatment leads to a better response and may improve outcomes; although aggressiveness of treatment of RSE should be tailored to the clinical situation. Generalized convulsive RSE should be treated aggressively to prevent major systemic and neurological injury with ongoing seizures. Conversely, non-convulsive RSE without significant impairment of consciousness can usually be treated more conservatively. Although well-defined studies are lacking, early induction of pharmacological coma under continuous EEG monitoring is recommenced in generalized convulsive RSE. Intravenous midazolam, propofol or barbiturates are most commonly used drugs. In unresponsive cases, other anesthetics, antiepileptic or immunomodulatory agents and non-pharmacological measures such hypothermia have been tried with mixed results. Well-designed multicenter prospective studies are needed to assess and introduce best practice guideline for RSE.