A practical approach to in-hospital management of new-onset refractory status epilepticus/febrile infection related epilepsy syndrome
New-onset refractory status epilepticus (NORSE) is “a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurological disorder, with new onset of refractory status epilepticus without a clear acute or active structural, toxic, or metab...
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| Format: | Article |
| Language: | English |
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Frontiers Media S.A.
2023-05-01
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| Series: | Frontiers in Neurology |
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| Online Access: | https://www.frontiersin.org/articles/10.3389/fneur.2023.1150496/full |
| _version_ | 1826984643230957568 |
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| author | Zubeda Sheikh Zubeda Sheikh Lawrence J. Hirsch |
| author_facet | Zubeda Sheikh Zubeda Sheikh Lawrence J. Hirsch |
| author_sort | Zubeda Sheikh |
| collection | DOAJ |
| description | New-onset refractory status epilepticus (NORSE) is “a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurological disorder, with new onset of refractory status epilepticus without a clear acute or active structural, toxic, or metabolic cause.” Febrile infection related epilepsy syndrome (FIRES) is “a subcategory of NORSE that requires a prior febrile infection, with fever starting between 2 weeks and 24 h before the onset of refractory status epilepticus, with or without fever at the onset of status epilepticus.” These apply to all ages. Extensive testing of blood and CSF for infectious, rheumatologic, and metabolic conditions, neuroimaging, EEG, autoimmune/paraneoplastic antibody evaluations, malignancy screen, genetic testing, and CSF metagenomics may reveal the etiology in some patients, while a significant proportion of patients’ disease remains unexplained, known as NORSE of unknown etiology or cryptogenic NORSE. Seizures are refractory and usually super-refractory (i.e., persist despite 24 h of anesthesia), requiring a prolonged intensive care unit stay, often (but not always) with fair to poor outcomes. Management of seizures in the initial 24–48 h should be like any case of refractory status epilepticus. However, based on the published consensus recommendations, the first-line immunotherapy should begin within 72 h using steroids, intravenous immunoglobulins, or plasmapheresis. If there is no improvement, the ketogenic diet and second-line immunotherapy should start within seven days. Rituximab is recommended as the second-line treatment if there is a strong suggestion or proof of an antibody-mediated disease, while anakinra or tocilizumab are recommended for cryptogenic cases. Intensive motor and cognitive rehab are usually necessary after a prolonged hospital stay. Many patients will have pharmacoresistant epilepsy at discharge, and some may need continued immunologic treatments and an epilepsy surgery evaluation. Extensive research is in progress now via multinational consortia relating to the specific type(s) of inflammation involved, whether age and prior febrile illness affect this, and whether measuring and following serum and/or CSF cytokines can help determine the best treatment. |
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| issn | 1664-2295 |
| language | English |
| last_indexed | 2025-02-18T06:56:55Z |
| publishDate | 2023-05-01 |
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| series | Frontiers in Neurology |
| spelling | doaj.art-714a122ad67b415db7edb13f413f02342024-11-08T15:23:10ZengFrontiers Media S.A.Frontiers in Neurology1664-22952023-05-011410.3389/fneur.2023.11504961150496A practical approach to in-hospital management of new-onset refractory status epilepticus/febrile infection related epilepsy syndromeZubeda Sheikh0Zubeda Sheikh1Lawrence J. Hirsch2Department of Neurology, West Virginia University School of Medicine, Morgantown, WV, United StatesEpilepsy Division, Department of Neurology, Yale School of Medicine, New Haven, CT, United StatesEpilepsy Division, Department of Neurology, Yale School of Medicine, New Haven, CT, United StatesNew-onset refractory status epilepticus (NORSE) is “a clinical presentation, not a specific diagnosis, in a patient without active epilepsy or other preexisting relevant neurological disorder, with new onset of refractory status epilepticus without a clear acute or active structural, toxic, or metabolic cause.” Febrile infection related epilepsy syndrome (FIRES) is “a subcategory of NORSE that requires a prior febrile infection, with fever starting between 2 weeks and 24 h before the onset of refractory status epilepticus, with or without fever at the onset of status epilepticus.” These apply to all ages. Extensive testing of blood and CSF for infectious, rheumatologic, and metabolic conditions, neuroimaging, EEG, autoimmune/paraneoplastic antibody evaluations, malignancy screen, genetic testing, and CSF metagenomics may reveal the etiology in some patients, while a significant proportion of patients’ disease remains unexplained, known as NORSE of unknown etiology or cryptogenic NORSE. Seizures are refractory and usually super-refractory (i.e., persist despite 24 h of anesthesia), requiring a prolonged intensive care unit stay, often (but not always) with fair to poor outcomes. Management of seizures in the initial 24–48 h should be like any case of refractory status epilepticus. However, based on the published consensus recommendations, the first-line immunotherapy should begin within 72 h using steroids, intravenous immunoglobulins, or plasmapheresis. If there is no improvement, the ketogenic diet and second-line immunotherapy should start within seven days. Rituximab is recommended as the second-line treatment if there is a strong suggestion or proof of an antibody-mediated disease, while anakinra or tocilizumab are recommended for cryptogenic cases. Intensive motor and cognitive rehab are usually necessary after a prolonged hospital stay. Many patients will have pharmacoresistant epilepsy at discharge, and some may need continued immunologic treatments and an epilepsy surgery evaluation. Extensive research is in progress now via multinational consortia relating to the specific type(s) of inflammation involved, whether age and prior febrile illness affect this, and whether measuring and following serum and/or CSF cytokines can help determine the best treatment.https://www.frontiersin.org/articles/10.3389/fneur.2023.1150496/fullnew-onset refractory status epilepticusfebrile infection related epilepsy syndromeanakinratocilizumabrituximabsuper-refractory status epilepticus |
| spellingShingle | Zubeda Sheikh Zubeda Sheikh Lawrence J. Hirsch A practical approach to in-hospital management of new-onset refractory status epilepticus/febrile infection related epilepsy syndrome Frontiers in Neurology new-onset refractory status epilepticus febrile infection related epilepsy syndrome anakinra tocilizumab rituximab super-refractory status epilepticus |
| title | A practical approach to in-hospital management of new-onset refractory status epilepticus/febrile infection related epilepsy syndrome |
| title_full | A practical approach to in-hospital management of new-onset refractory status epilepticus/febrile infection related epilepsy syndrome |
| title_fullStr | A practical approach to in-hospital management of new-onset refractory status epilepticus/febrile infection related epilepsy syndrome |
| title_full_unstemmed | A practical approach to in-hospital management of new-onset refractory status epilepticus/febrile infection related epilepsy syndrome |
| title_short | A practical approach to in-hospital management of new-onset refractory status epilepticus/febrile infection related epilepsy syndrome |
| title_sort | practical approach to in hospital management of new onset refractory status epilepticus febrile infection related epilepsy syndrome |
| topic | new-onset refractory status epilepticus febrile infection related epilepsy syndrome anakinra tocilizumab rituximab super-refractory status epilepticus |
| url | https://www.frontiersin.org/articles/10.3389/fneur.2023.1150496/full |
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