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Seizures in Critical Care

A Guide to Diagnosis and Therapeutics

Stocchetti, Nino MD

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doi: 10.1213/ANE.0b013e3181f43160
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Seizures are of interest for the specialist in intensive care medicine. Convulsive seizures and, in particular, convulsive status (“status epilepticus”) are well-known emergencies requiring prompt and aggressive therapy. Often, the treatment of a seizure itself can cause respiratory and hemodynamic depression and require admission to an intensive care unit (ICU). Moreover, the growth in specialized neuro-ICUs brings to the attention of the intensivist difficult cases of electrical disturbances in the brain that in the past were referred to neurologists. Finally, continuous electroencephalographic (EEG) monitoring has disclosed problems previously unsuspected (e.g., the occurrence of nonconvulsive epileptic activity in ICU patients).

In response to these new clinical challenges there are 2 risks: oversimplification or abdication. It would be easy to use simple algorithms for every seizure, myoclonus or suspect rhythmic movement, and to extend prophylactic antiepileptic drugs to many, if not all, at-risk patients. Alternatively, because of the complexity of the field, there is the temptation of abdicating in favor of other experts (e.g., neurologists with specific skills in interpreting EEGs).

Unfortunately, the ICU patient is quite different from the typical outpatient that the neurologist EEG specialist is used to managing. The ICU patient often experiences electrical disturbances of the brain as part of other organ failures (e.g., liver failure) or as part of complex brain injuries (e.g., traumatic contusions or venous cerebral thrombosis). It is therefore essential to include the interpretation of neurophysiologic changes (and the EEG) into the core competencies of a modern neuro-intensivist.

The intensive care specialist should know how to diagnose (and suspect, when convulsions are not evident) seizures, how to react promptly for stopping a convulsive status epilepticus, how to identify the likely causes of seizures, and how to plan a rational long-term treatment strategy. Moreover he or she should know the side effects of the proposed treatment, to balance expected benefits and potential risks to the patient. Finally, he or she should know when it is time to ask for more expert opinion (i.e., involving other specialists in the treatment process).

In the new edition of the book edited by Panayiotis Varelas entitled Seizures in Critical Care: A Guide to Diagnosis and Therapeutics, the contributing authors elegantly address these goals. In a compact format (approximately 400 pages), it provides essential information, illustrative cases, and sensible therapeutic suggestions. Every chapter includes an extensive overview of the current literature. The median number of references for each chapter is 106, with a range from 47 to 291. This amount of information, however, is not intimidating because the authors weigh the evidence and give practical hints based on their clinical experience.

The book begins with an overview of seizures in the ICU, including presentation and pathophysiology, and the second chapter illustrates continuous EEG and other monitoring systems. The subsequent chapters describe seizures (including specific features, causative mechanisms, and appropriate treatment) in stroke, traumatic brain injury, brain tumors, hypoxia-ischemia, and hepatic failure. Other causes of seizures, including electrolytes disturbances, alcohol, and drugs, are covered in separated chapters. Clinical cases are presented with computed tomographic scan or nuclear magnetic resonance images, documenting tissue damage, coupled with exemplificative EEG tracings (even if, in some cases, a microscope would be needed because of the fine print).

Finally, the last and most comprehensive chapter is devoted to the management of status epilepticus. As far as status epilepticus is concerned, the chapter is first class: clear, rational, and updated. Unfortunately, the final part of the chapter (e.g., the summary for treatment of critical care seizures in general) is less brilliantly written, with some overlap and redundancy.

Many issues concerning seizures in intensive care are not as yet fully settled. Mechanisms are not completely clear and therapies are sometimes ineffective, with many unanswered questions. For instance, although convulsive status epilepticus is linked to irreversible cellular damage, and as such justifies rapid and aggressive treatment, the extent of brain damage associated with nonconvulsive status is less clear. This book states right “upfront” what information is well documented and what is uncertain, assisting the clinician in the difficult choice of tailoring therapies while balancing side effects.

In summary, this is an extremely useful book for all those involved in neuro-intensive care. It can be a valuable companion for the neuro-intensivist and a good reference source for the general intensivist.

Nino Stocchetti, MD

Intensive Care Unit

Department of Neurosciences

Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico

University of Milan

Milan, Italy

[email protected]

© 2011 International Anesthesia Research Society