Which clinical history findings are characteristic of status epilepticus (SE)?

Updated: Feb 13, 2018
  • Author: Julie L Roth, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Answer

Generalized convulsive status epilepticus (SE) is usually easy to diagnose, but an understanding of its evolution from overt convulsions through subtle SE is important. Patients may present with an undramatic clinical picture if they have subtle SE at the time of presentation.

Treiman and coworkers [48, 49, 50] described the clinical and electroencephalographic (EEG) changes accompanying generalized convulsive SE. The event usually begins with a series of generalized tonic, clonic, or tonic-clonic seizures that often are dramatic. Each seizure is discrete; the motor activity stops abruptly, coincident with the end of the electrographic seizure. Each convulsion is followed by gradual recovery, and then the next seizure occurs.

If the condition is not treated or is treated inadequately, SE persists, and the motor manifestations become less dramatic than before. Eventually, only subtle movements (eg, nystagmoid jerks of the eyes or twitching of the shoulder) may be seen—that is, subtle SE. If SE continues, all motor activity may stop, though EEG seizures persist (ie, electrical generalized convulsive SE).

The paradoxical evolution of apparent clinical improvement is important to understand. The clinician unfamiliar with this phenomenon may stop treatment because of the apparent improvement. Treatment should be continued until the EEG seizure activity has resolved completely.

In some patients, the underlying encephalopathic insult is so severe that only a few (or no) generalized convulsions occur before subtle convulsive activity develops. Finally, as the patient evolves from generalized tonic-clonic SE into subtle and then electrical generalized tonic-clonic SE, the manifestations become less intermittent and more continuous than before.

Persons accompanying the patient may be able to provide important information. A history of epilepsy frequently is elicited. Among patients with established epilepsy, noncompliance with medications is the rule rather than the exception. In roughly one third of cases, status epilepticus is the initial presentation of a seizure disorder.

In those without epilepsy, the history may suggest associated injuries, such as a fall or involvement in a motor vehicle accident. A history of systemic or CNS neoplasms, infections, metabolic disorders, toxic ingestions, alcohol cessation, and many other conditions may give clues to the precipitating cause of seizures.


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