What are the guidelines for neurostorming (Status Epilepticus) management?

From the Guidelines

Neurostorming guidelines prioritize the urgent control of seizures with medications such as valproate, levetiracetam, or phenobarbital, in addition to phenytoin/fosphenytoin, to prevent secondary brain injury and improve patient outcomes. The management of status epilepticus, a critical component of neurostorming, involves a systematic approach to seizure control. According to the study by Misra et al 1, IV valproate has been shown to be at least as effective as phenytoin for refractory status epilepticus, with potentially fewer adverse effects. The recommended protocol for neurostorming includes:

• Assessing and managing airway, breathing, and circulation (ABCs)
• Administering medications such as lorazepam, levetiracetam, or phenobarbital to control seizures
• Maintaining adequate cerebral perfusion pressure (>60 mmHg)
• Avoiding hypoxemia and preventing further seizures
• Considering advanced therapies such as barbiturate coma, therapeutic hypothermia, or decompressive craniectomy for refractory cases

Key considerations in neurostorming include:

• Early recognition and treatment of status epilepticus
• Aggressive management of elevated intracranial pressure (ICP)
• Maintenance of adequate cerebral perfusion pressure
• Prevention of secondary brain injury

The most recent and highest quality study on neurostorming guidelines is not explicitly provided, but the study by Misra et al 1 provides strong evidence for the use of valproate in the management of status epilepticus. Additionally, the studies by Agarwal et al and Gilad et al, as cited in the evidence 1, support the use of valproate as an effective and safe treatment option for refractory status epilepticus. The guidelines for pediatric patients receiving chimeric antigen receptor T cell therapy 1 also provide valuable insights into the management of status epilepticus, but may not be directly applicable to adult patients. Overall, the goal of neurostorming is to prevent secondary brain injury and improve patient outcomes by aggressively managing seizures and maintaining optimal cerebral perfusion pressure.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Neurostorming Guidelines

There are no specific guidelines for neurostorming provided in the given studies. However, the studies provide information on the management of cerebral perfusion pressure and intracranial pressure in patients with traumatic brain injury.

Management of Cerebral Perfusion Pressure

• The management of cerebral perfusion pressure is crucial in patients with severe head injury, as it represents the pressure gradient acting across the cerebrovascular bed and contributes to the hydrostatic pressure within the intracerebral vessels 2.
• The border between adequate and inadequate cerebral perfusion pressure should be assessed individually and continuously, as it may fluctuate in time 2.
• A treatment plan that includes rapid identification of intracranial hemorrhage, rapid evacuation of extra-axial blood, treatment of intracranial hypertension, and promotion of cerebral and systemic perfusion is likely to provide the best outcome for all patients 2.

Reduction of Intracranial Pressure

• Hypertonic saline and mannitol are effective in reducing intracranial pressure after severe traumatic brain injury 3, 4, 5.
• Hypertonic saline appears to be superior to mannitol in reduction of the combined burden of intracranial hypertension and associated hypoperfusion in severe TBI patients 3.
• Decompressive craniectomy can effectively decrease intracranial pressure and increase cerebral perfusion pressure in patients with TBI and refractory elevated intracranial pressure 6.

Comparison of Hypertonic Saline and Mannitol

• The comparison of hypertonic saline and mannitol indicated that they are close in improving functional outcome, reducing intracranial pressure, and reducing mortality 5.
• However, hypertonic saline was more effective than mannitol in intracranial pressure management, with a pooled relative risk of successful ICP control of 1.06 (95% CI: 1.00 to 1.13, p = 0.044) 5.