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Super-Refractory Status Epilepticus — SCE Neurology MCQ

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HardEpilepsy & Seizure DisordersSuper-Refractory Status EpilepticusSCE Neurology

A 55-year-old man with super-refractory status epilepticus (seizures persisting despite 24 hours of anaesthetic therapy) is in the ICU on propofol and midazolam infusions with burst-suppression on continuous EEG. Despite 72 hours of anaesthesia, seizures recur when the infusions are weaned. What treatment options should be considered for super-refractory SE?

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Correct answer: E — Consider ketamine infusion, immunotherapy (if autoimmune aetiology suspected), ketogenic diet, or hypothermia as adjunctive therapies

Super-refractory SE (seizures recurring despite 24+ hours of anaesthetic therapy, or recurring on weaning) has limited evidence-based treatments. Options include: (1) ketamine infusion (NMDA antagonist — synergistic with GABA-ergic agents), (2) immunotherapy if autoimmune aetiology is suspected (IV methylprednisolone, IVIg, PLEX), (3) ketogenic diet (effective in some cases of super-refractory SE), (4) therapeutic hypothermia (33–35°C), (5) additional IV AEDs (phenobarbital, lacosamide), (6) electroconvulsive therapy (case reports). Prognosis is poor but not universally fatal. A: Indefinite anaesthesia causes complications (myopathy, infections). C: Some patients recover. D: Craniotomy is not standard. E: Oral phenobarbital alone is insufficient.

Reference: Shorvon & Ferlisi Super-Refractory SE Review (2011); ABN SE Guidelines