Is electroconvulsive therapy (ECT) effective for treating supra-refractory status epilepticus?

Electroconvulsive Therapy for Supra-Refractory Status Epilepticus

Electroconvulsive therapy (ECT) should be considered as a treatment option for supra-refractory status epilepticus (SRSE) when standard pharmacological interventions have failed, with approximately 71% of patients showing clinical improvement according to recent evidence. 1

Definition and Treatment Hierarchy

Supra-refractory status epilepticus (SRSE) is defined as status epilepticus that continues or recurs despite 24 hours of general anesthesia treatment. The treatment algorithm typically follows:

1. First-line: Benzodiazepines
2. Second-line: Antiepileptic medications (phenytoin, fosphenytoin, valproate, levetiracetam) 2
3. Third-line: Anesthetic agents (propofol, barbiturates)
4. Fourth-line: ECT and other interventions when all standard pharmacological options are exhausted

Evidence for ECT in SRSE

The most recent and comprehensive evidence comes from a 2024 scoping review that found:

• 71% of patients (20 out of 28) showed clinical improvement with ECT for SRSE
• 7% (2 patients) experienced complete seizure cessation
• ECT was typically administered within 3-70 days (mean 20 days) after SE onset
• Number of ECT sessions ranged from 1-12 per patient 1

Individual case reports and small series have demonstrated successful termination of SRSE with ECT after weeks of failed pharmacological management 3, 4, 5. However, not all cases respond to ECT, as demonstrated in a 2023 case report 6.

ECT Protocol for SRSE

When implementing ECT for SRSE, the following protocol is recommended:

• Setting: Inpatient setting with specialized ECT area 2
• Team: Psychiatrist, anesthesiologist experienced in ECT, and nursing staff 2
• Electrode placement: Bilateral electrode placement is preferred for SRSE 3
• Intensity: High-intensity protocol may be required (up to 200% stimulation energy) 3
• Frequency: Daily treatments initially, potentially multiple treatments per day 3, 4
• Monitoring: EEG monitoring to assess seizure activity and duration 2

Potential Adverse Effects

Adverse effects that should be monitored include:

• Memory impairment and cognitive effects (most common concern)
• Headache, nausea, vomiting, muscle aches
• Confusion and agitation
• Tardive seizures (rare but serious)
• Prolonged seizures (>180 seconds) 2

Most side effects are transient and do not persist beyond the day of treatment 2.

Practical Considerations

• Complete physical examination and appropriate laboratory investigations are required before initiating ECT 2
• Informed consent must be obtained from the patient's legal representative 2
• Concurrent medications may need adjustment, as some can interfere with ECT efficacy:
  • Benzodiazepines may increase seizure threshold
  • Lithium concurrent with ECT may cause acute brain syndrome
  • Theophylline may prolong seizure duration 2

Limitations of Current Evidence

The evidence for ECT in SRSE is limited by:

• Small sample sizes in available studies
• Retrospective nature of most reports
• Lack of controlled trials
• Potential publication bias favoring successful cases 1

Despite these limitations, ECT represents a viable option for SRSE when standard treatments have failed, with a reasonable chance of clinical improvement based on the available evidence.