An Overview of Status Epilepticus

This serious complication of epilepsy requires urgent treatment

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Status epilepticus is a dangerous situation historically defined as a seizure or a cluster of seizures lasting longer than 30 minutes without improvement in consciousness. When seizures do not improve, on their own or with medication, they can cause brain damage or even death. Therefore, this 30-minute definition is not used in clinical practice; instead, any continuous seizure lasting five minutes or more, or two or more successive seizures without recovery of consciousness is considered status, requiring immediate treatment with anti-seizure medications. However, there are times when someone with status epilepticus may not improve despite treatment.

Symptoms

In general, seizures tend to last from a few seconds to a few minutes, depending on the type of seizure. However, prolonged seizures can occur—and are always an emergency.

The symptoms of status epilepticus may be easy to recognize in some situations, but not others. Some cases of status epilepticus can be subtle, especially in people who are severely ill.

There are many types of seizures. The convulsive ones, which are characterized by shaking or jerking, are usually obvious. Some are non-convulsive, though, and impair the person's consciousness without any shaking or obvious physical symptoms.

Young babies or children with developmental problems may have seizures characterized by loss of muscle tone, which may go unnoticed. Additionally, people who are extremely sick and who already have a low degree of alertness may also experience seizures that are not obvious.

Symptoms of status epilepticus are generally the same as those for epilepsy. The differences lie in their duration and the fact that the seizures can happen repeatedly without the person regaining consciousness.

Symptoms of status epilepticus may include:

  • Persistent shaking or jerking of the body lasting for longer than five minutes
  • Falling to the ground and remaining unresponsive
  • Lack of alertness for longer than five minutes
  • Prolonged staring spells
  • Decreased muscle tone for longer than five minutes
  • Repetitive facial movements, sounds, or gestures (generally with a lack of awareness) that last longer than five minutes

Serious Symptoms

Get emergency medical help when:

  • Seizure symptoms last for longer than five minutes
  • Someone loses consciousness and doesn't wake up
  • Someone has repeated seizures without waking up in between

Causes

Some triggers and conditions make status epilepticus more likely, but sometimes it can occur without a known reason.

Possible triggers include:

  • Epilepsy syndromes: People who suffer from severe seizure disorders, such as Rasmussen's syndrome, Rett syndrome, Lennox-Gastaut syndrome, and Dravet syndrome are more prone to status epilepticus. Episodes are more likely to occur during illness, infection, or when medications are skipped. They can occur without a trigger.
  • Cerebral damage: People who have had extensive damage to the cerebral cortex, the region of the brain most likely to produce seizures, are more likely to experience status epilepticus than people who have small areas of limited brain damage. Hypoxia (low oxygen) prior to birth, cerebral palsy, head trauma, and severe blood loss can cause substantial cerebral damage that can raise the likelihood of status epilepticus, even years after the condition is resolved.
  • Brain tumor: Tumors and cancer in the brain can produce seizures and may cause status epilepticus, particularly if they are large or numerous.
  • Electrolyte abnormalities: Blood loss, dehydration, malnutrition, drug overdose, and medications can all cause electrolyte imbalances that may trigger seizures and status epilepticus.
  • Drug or alcohol overdose or withdrawal: Alcohol and drugs such as cocaine, methamphetamine, and heroin can produce brief seizures or status epilepticus. Drug or alcohol withdrawal after heavy or prolonged use can be just as dangerous, causing seizures during the withdrawal period and up to several days thereafter.
  • Encephalitis: An infection of the brain, while not common, can cause severe, prolonged status epilepticus.

Prevalence and Risk Factors

Status epilepticus occurs in 50,000 to 150,000 people in the United States each year. It's more likely in children under 10, adults over 50, and those with febrile (fever-related) seizures.

Studies note that between 30 percent and 44 percent of status epilepticus cases are in people previously diagnosed with epilepsy. In children, nearly 70 percent of cases are in those with diagnosed epilepsy, and skipping medication was believed to be a major cause.

Research shows that black people are significantly more likely than those of other races to experience status epilepticus. Researchers suspect this is due, at least in part, to socioeconomic factors that may influence the ability to access treatment.

Death from status epilepticus is more common in men than in women, and it grows more common with age. Children under 10 have the best outcomes, with deaths in less than 3 percent of cases. That goes up to 30 percent for adults.

Diagnosis

Status epilepticus can be diagnosed by clinical observation, but most often an electroencephalogram (EEG), brain imaging, or lumbar puncture is needed to verify the diagnosis.

  • EEG: Because the clinical symptoms of status epilepticus and several other conditions may be similar, an EEG is usually needed to distinguish between seizures and patterns that are consistent with conditions such as stroke and encephalopathy.
  • Brain imaging: A brain computed tomography (CT) or magnetic resonance imaging (MRI) scan may be needed to determine the cause of the seizures and to identify conditions such as a stroke, brain tumor, or inflammation in the brain.
  • Lumbar puncture: If there is a possible infection, it can be diagnosed using a lumbar puncture, which is a procedure that draws fluid that surrounds the brain and spinal cord for testing.

Diagnosing status epilepticus and identifying the cause is important because status epilepticus requires different treatment than the other conditions that have similar symptoms.

Treatment

Status epilepticus is a medical emergency. It can cause death due to physical injury, choking, or as a result of the seizure itself. The episode may cause lasting brain damage, which can result in worsening seizures, increased predisposition to status epilepticus, and cognitive decline.

If you or your child is prone to this condition, your doctor will give you a prescription for an injectable anti-convulsant. For a baby, you may be given a form that's delivered in the rectum.

The American Epilepsy Society has made recommendations for the treatment of status epilepticus

First-line medications for status epilepticus include:

  • IM (intramuscular) midazolam
  • Intravenous (IV) lorazepam
  • IV diazepam
  • Rectal diazepam
  • Intranasal midazolam
  • Buccal midazolam

If the initial drug doesn't work, emergency medical staff may use a second drug, such as:

  • IV valproic acid
  • IV fosphenytoin
  • IV levetiracetam
  • IV phenobarbital

These medications act quickly, and their effects do not typically last for longer than a few hours. They can cause worsening of symptoms for people who do not have epilepsy. For example, lorazepam can make encephalopathy worse.

When status epilepticus is triggered by medical problems, it is important to treat these conditions once the seizures are controlled.

Treatment approaches for related conditions may include:

  • Treatment of infections
  • Correcting electrolyte and metabolic problems
  • Steroid treatment to reduce swelling caused by tumors
  • Surgery to remove a tumor

A Word From Verywell

If you or your child has experienced status epilepticus, you're well aware of how frightening it can be. It is important to recognize the symptoms that occur right before the seizure and to take medication to try to prevent it. Have a convenient method of calling for emergency medical help so that you can receive proper treatment as soon as possible. With the right treatment, seizures can be controlled, the episodes of status epilepticus can be reduced, and the triggering cause(s) can be addressed.

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