From the Guidelines
The management of focal nonconvulsive status epilepticus (NCSE) should prioritize the use of levetiracetam, fosphenytoin, or valproate as second-line therapy after benzodiazepines, as these medications can result in cessation of seizures in approximately half of all patients, thereby reducing morbidity and mortality. The treatment approach for focal NCSE involves initial therapy with intravenous benzodiazepines, but in the setting of benzodiazepine-resistant status epilepticus, the use of levetiracetam, fosphenytoin, or valproate is recommended, as stated in the clinical policy approved by the ACEP board of directors in 2024 1. This guideline emphasizes the importance of early treatment and cessation of status epilepticus to reduce morbidity and mortality.
Key considerations in the management of focal NCSE include:
- Prompt initiation of antiseizure medications to prevent prolonged seizure activity and its associated complications
- The choice of second-line therapy, such as levetiracetam, fosphenytoin, or valproate, which can be effective in approximately half of all patients, as noted in the 2024 clinical policy 1
- Continuous EEG monitoring for refractory cases to guide further treatment escalation
- Identification and addressing of underlying causes, such as metabolic disturbances, infections, stroke, or medication effects, to prevent recurrence and improve outcomes
The benefits of this approach, as highlighted in the 2024 clinical policy 1, include a reduction in morbidity and mortality, with limited harms primarily related to potential adverse drug reactions. By prioritizing the use of levetiracetam, fosphenytoin, or valproate as second-line therapy, clinicians can provide effective management for focal NCSE and improve patient outcomes.
From the Research
Management of Focal Nonconvulsive Status Epilepticus
- The management of focal nonconvulsive status epilepticus can be divided into several stages, including initial stabilization, seizure termination, and evaluation and treatment of the underlying cause 2.
- Diagnostic evaluation and seizure control should be achieved simultaneously to improve outcome 2.
- Seizure termination is achieved by pharmacotherapy, with benzodiazepines being the first line drugs for status epilepticus 2, 3.
- Commonly used drugs include lorazepam, diazepam, and midazolam 2, 3.
- In children without an IV access, buccal or nasal midazolam or rectal diazepam can be used 2.
- Phenytoin, valproate, levetiracetam, or lacosamide can be used as second line agents if seizures persist 4.
- Use of anaesthetic drugs should be delayed for as long as possible in patients with refractory focal SE 4.
- The available scientific evidence is insufficient to claim that pharmacological treatment of focal SE should be different from treatment for generalised SE 4.
Treatment Options
- Intravenous lorazepam and intramuscular midazolam appear as most effective treatments for early SE 5.
- In established SE, intravenous antiepileptic drugs such as valproate and levetiracetam can be used 5.
- Treatment options in refractory SE include intravenous anaesthetics, and in super-refractory SE, ketamine, magnesium, steroids, and other drugs have been used with variable outcomes 5.
Diagnosis and Treatment
- Nonconvulsive status epilepticus can be difficult to diagnose due to its protean manifestations, so a high index of suspicion is vital to prompt diagnosis and effective management 6.
- An electroencephalogram should be obtained immediately in anyone with unexplained alteration of behavior or mental status and after convulsive SE if the patient does not rapidly awaken 3.
- Delay in diagnosis of SE is associated with a worse outcome and a higher likelihood of poor response to treatment 3.