What is the management approach for status epilepticus in a patient with a history of focal epilepsy originating in the temporal lobe, as well as psychogenic non-epileptic seizures (PNES) and psychogenic seizures?

From the Guidelines

The management of status epilepticus in a patient with temporal lobe epilepsy and a history of psychogenic events should prioritize valproate as a second-line therapy due to its efficacy and safety profile, as demonstrated in the most recent and highest quality study 1. The approach to managing status epilepticus in such patients involves a stepwise protocol, starting with ensuring patient safety and confirming true status epilepticus through clinical presentation and emergent EEG, if available. Initial treatment should involve administering a benzodiazepine, such as intravenous lorazepam 4mg (or 0.1mg/kg) given over 2 minutes, which can be repeated once after 5-10 minutes if seizures persist. If seizures continue, proceeding to second-line therapy with valproate 40mg/kg IV (maximum 3000mg) is recommended, given its comparable efficacy to fosphenytoin and levetiracetam, as shown in the ESETT study 1, with a cessation of status epilepticus and improvement in the level of consciousness at 60 minutes achieved in 46% of patients receiving valproate. For refractory status epilepticus, initiating continuous EEG monitoring and administering either midazolam, propofol, or ketamine is necessary. Throughout treatment, it is crucial to maintain vigilance for psychogenic components, as these patients may have mixed presentations. After stabilization, optimizing the patient's regular antiepileptic regimen, focusing on medications effective for temporal lobe seizures, and arranging psychiatric consultation for management of underlying psychological factors contributing to PNES are essential steps. Key considerations in the management include:

• Prompt recognition and treatment of status epilepticus
• Distinguishing true epileptic activity from psychogenic non-epileptic seizures (PNES)
• Use of valproate as a second-line therapy due to its efficacy and safety profile
• Continuous EEG monitoring in refractory cases
• Vigilance for psychogenic components and mixed presentations
• Optimization of the antiepileptic regimen and psychiatric consultation for PNES management.

From the FDA Drug Label

The treatment of status, however, requires far more than the administration of an anticonvulsant agent. It involves observation and management of all parameters critical to maintaining vital function and the capacity to provide support of those functions as required. Because status epilepticus may result from a correctable acute cause such as hypoglycemia, hyponatremia, or other metabolic or toxic derangement, such an abnormality must be immediately sought and corrected. Furthermore, patients who are susceptible to further seizure episodes should receive adequate maintenance antiepileptic therapy For the treatment of status epilepticus, the usual recommended dose of lorazepam injection is 4 mg given slowly (2 mg/min) for patients 18 years and older. If seizures cease, no additional lorazepam injection is required. If seizures continue or recur after a 10- to 15-minute observation period, an additional 4 mg intravenous dose may be slowly administered

The management approach for status epilepticus in a patient with a history of focal epilepsy originating in the temporal lobe, as well as psychogenic non-epileptic seizures (PNES) and psychogenic seizures, involves:

• Observation and management of all parameters critical to maintaining vital function
• Identification and correction of any correctable acute cause, such as hypoglycemia or hyponatremia
• Administration of lorazepam injection at a dose of 4 mg given slowly (2 mg/min) for patients 18 years and older
• Additional doses of lorazepam may be administered if seizures continue or recur after a 10- to 15-minute observation period
• Maintenance antiepileptic therapy should be provided to patients susceptible to further seizure episodes 2, 2, 2.

From the Research

Management Approach for Status Epilepticus

The management approach for status epilepticus in a patient with a history of focal epilepsy originating in the temporal lobe, as well as psychogenic non-epileptic seizures (PNES) and psychogenic seizures, involves several key considerations:

• The treatment approach varies based on the time and the treatment stage of status epilepticus, with benzodiazepines considered the first-line therapy during the emergent treatment phase 3.
• Antiseizure medicines such as phenytoin, valproic acid, and levetiracetam are recommended during the urgent treatment phase, with individualized therapy chosen based on patient characteristics 3.
• For refractory status epilepticus, general anesthesia with IV midazolam, propofol, pentobarbital, or thiopental could be applied, as well as the use of ketamine, megadose phenobarbital therapy, and multiple combinations of various AEDs including high doses of oral AEDs 4.

Focal Epilepsy Considerations

In patients with focal epilepsy, the diagnosis and classification of seizures are crucial to ensure optimal care:

• Focal seizures are defined as those that originate within networks limited to one hemisphere, and are primarily subdivided into focal aware, focal impaired awareness, and focal to bilateral tonic-clonic seizures 5.
• Focal epilepsies account for most epilepsy cases both in children and adults, and are often acquired in adults, caused by a structural lesion or other factors such as stroke, infection, or traumatic brain injury 5, 6.
• EEG and MRI continue to serve as the main diagnostic tools for the diagnosis of focal epilepsy, with the various forms of focal epilepsy generating seizure presentations that are dependent on the anatomic structures involved in the seizure 6.

Psychogenic Non-Epileptic Seizures (PNES) Considerations

In patients with PNES, it is essential to differentiate between epileptic and non-epileptic seizures:

• The diagnosis of PNES can be challenging, and requires a comprehensive evaluation, including video-EEG monitoring and psychological assessment 4.
• The treatment approach for PNES typically involves psychological therapy, such as cognitive-behavioral therapy, and may also include medication for underlying psychiatric conditions 4.