Status epilepticus cause may predict likelihood of neurologic recovery but not short-term mortality

1. The underlying cause of status epilepticus is strongly associated with the likelihood of neurologic recovery, but does not independently predict short-term mortality.

2. Nonconvulsive status epilepticus with coma is the most powerful predictor of death and poor neurologic recovery, regardless of the underlying cause. 

Evidence Rating Level: 3 (Average)

Study Rundown: This two-center observational study evaluated whether status epilepticus (SE) etiology independently predicts mortality and neurologic recovery when classified using International League Against Epilepsy criteria and adjusted for confounders and withdrawal of life-sustaining treatment (WLST). Among 967 adult patients, in-hospital mortality was 7.9%, 30-day mortality was 13.9%, and 48.5% recovered to premorbid neurologic function. After multivariable adjustment, SE etiology was not independently associated with short-term mortality. However, etiology remained strongly associated with neurologic recovery: acute symptomatic SE and intracranial hemorrhage were linked to poorer recovery, while known epilepsy and remote symptomatic unprovoked SE were associated with better outcomes. Nonconvulsive SE with coma emerged as the strongest independent predictor of mortality and poor recovery across all etiologies. These findings suggest that SE type, rather than etiology alone, is the primary determinant of survival, while etiology remains important for functional prognosis.

Click to read the study in Neurology

Relevant Reading: Outcome predictors for status epilepticus: what really counts

In-Depth [observational study]: 

Status epilepticus (SE) is a neurologic emergency associated with substantial morbidity and mortality, and etiology has traditionally been viewed as a key determinant of outcome. However, prior studies evaluating the prognostic impact of SE etiology have been limited by non-standardized classifications, insufficient adjustment for confounders, and failure to account for withdrawal of life-sustaining treatment (WLST). This two-center observational study aimed to clarify the independent association between SE etiology, mortality, and neurologic recovery using the International League Against Epilepsy (ILAE) etiologic classification while accounting for major confounders and WLST.

The study included 967 adult patients with SE treated between 2015 and 2023 at two Swiss tertiary care centers. Etiologies were categorized according to ILAE criteria as acute symptomatic, remote symptomatic unprovoked, progressive central nervous system (CNS) disorders, epilepsy without additional triggers (with or without electroclinical syndromes), or cryptogenic. Clinical variables included age, SE type, Status Epilepticus Severity Score (STESS), Charlson Comorbidity Index (CCI), SE duration, treatment intensity, complications, and WLST. The primary outcome was in-hospital mortality. Secondary outcomes included 30-day mortality and recovery to premorbid neurologic function at hospital discharge. Associations were assessed using Poisson regression with robust error variance, adjusting for age, nonconvulsive status epilepticus (NCSE) with coma, comorbidity burden, and treatment center.

The median age of the cohort was 67 years, and 46.5% were female. Acute symptomatic SE was the most common etiology (34.2%), followed by remote symptomatic unprovoked SE (27.6%) and epilepsy without additional triggers (16.7%). SE was terminated in 95% of patients. Overall, in-hospital mortality was 7.9%, and 30-day mortality was 13.9%. Nearly half of patients (48.5%) recovered to their premorbid neurologic function at discharge.

In univariable analyses, mortality and SE refractoriness differed significantly across etiologic categories. However, after multivariable adjustment, no ILAE etiology group was independently associated with in-hospital mortality. Remote symptomatic unprovoked SE was associated with lower 30-day mortality, but this association was attenuated after correction for multiple comparisons. In contrast, etiology remained strongly associated with neurologic recovery. Acute symptomatic SE and intracranial hemorrhage were independently associated with a reduced likelihood of recovery to premorbid function, whereas known epilepsy and remote symptomatic unprovoked etiologies were associated with improved recovery.

Across all analyses, NCSE with coma emerged as the strongest and most consistent predictor of poor outcome. NCSE with coma was independently associated with higher in-hospital and 30-day mortality and with a markedly lower likelihood of neurologic recovery, regardless of etiology. Sensitivity analyses restricted to patients with refractory SE demonstrated that NCSE with coma remained the sole independent predictor of mortality, while etiologic associations with recovery were no longer observed. Exclusion of patients undergoing WLST did not materially change the results, suggesting that WLST did not significantly bias the observed associations.

In summary, this study demonstrates that while SE etiology provides important prognostic information regarding neurologic recovery, it does not independently predict short-term mortality after accounting for key confounders and WLST. Instead, SE type—particularly NCSE with coma—appears to be the dominant determinant of survival. These findings emphasize the critical importance of early recognition, continuous EEG monitoring, and prompt management of NCSE with coma in patients with SE.

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