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Table 1: Distribution of the Study subjects according to Age and gender

History of iron deficiency anaemia was observed in 5% cases, Stroke in 11%, space occupying lesion in 6%, CNS Malformation 6%, Immunization appropriate in 96%, milestones appropriate for age in 73% and delay in 27%. History of failure to thrive observed in 24% and vitamin/micronutrient deficiency was observed in 20%.

Table 2: Distribution of study subjects according to Past history

In present study prehospital resuscitation was done in 31% cases. Most common symptom was vomiting (35%) followed by fever with URI (22%) and ALOC (20%) while the commonest sign was pallor (70%) followed by abnormal skull shape in 19% and syndromic appearance (10%). Majority of patients had- CBG in the ranged from 120 to 200 mg/dl (50%) followed by from 54 to 120 mg/dl. Sodium, potassium and calcium were low in 18%, 21% and 33% of cases respectively. Ongoing NCSE was present in 66% patients and intracranial pressure in 36%, clinical meningeal signs in 31%, involuntary movements was seen in 38%, Cerebellar signs in 6%. Sensory system activity involved in all i.e. 100% cases of status epilepticus which may have an important role in both generation and inhibition of seizures.Urinary incontinence (Incontinence bowel/bladder) occurs in 38% child with status epilepticus

Table 3: Clinical examination profile of study population

In present study, most common etiology associated with status epilepticus in children was seizure disorder (44%), followed by acute CNS infection (34%), fever provoked seizures (24%) and Quadriplegia (19%).

Table 4: Etiology and diagnosis profile

Majority of children had abnormal epileptiform activity (73%) while 27% had normal EEG. Common EEG patterns noted were focal waveform abnormalities (17 %), periodic discharges (16 %), diffusely slow background activity (15 %) and low voltage recording (14 %).

Table 5: EEG of study population

Out of 20 children with abnormal neuroimaging, 7 children had refractory status epilepticus (RSE). Among the structural abnormality, most common was cystic encephalomalacia (6%), followed by porencephaly (4%), space occupying lesion-DNET (4%), polymicrogyria cortex (4%), and arachnoid cyst in temporal region (2%).

Table 6: Neuroimaging of children with status epilepticus

Maximum number of cases required 2 to 4 anti-epileptics drugs for the treatment of status epilepticus. 20% of cases required 4 to 6 anti-epileptics drugs.

Table 7: Anti-epileptics drugs (AEDs) required

Out of 100 cases, 76 cases (76%) recovered. Among those recovered, 6 cases (6%) recovered with new neurological sequalae; 13 cases (13%) died and 5 cases (5%) discharged against medical advice (AMA).

Table 8: Final outcome

The mortality associated with SE was greatest (46%) in children between 2 to 5 years of age followed by 5 to 10 years (28%), less than 2 years (20%) and in children between 10 to 12 years of age (6%). This age difference was statistically significant with p value of 0.039.

Table 9: Age Distribution and Final Outcome

DISCUSSION

Electrocorticography (ECoG) or intracranial EEG is useful for invasive recording of cortical electrical activitybyuseofelectrodesdirectlyonthesurfaceofbrain(subduralgridsorstrips) or deep inside the brain (depth electrodes).⁶ It helps to localize the epileptogenic zone and to map cortical functional areas in drug-resistant epilepsy. Traditional analog EEG machines are being replaced by digital EEG with simultaneous video recording. Surface scalp EEG recording can beconventional short-termrecording(30minutes) or long-term video EEG record (for witnessing and localizing seizureactivity). A convenient formulation of non-convulsive status epilepticus (NCSE) is the alteration of consciousness or behavior from baseline state for at least 30 minutes without convulsive movements, and the presence of one or more of the following epileptic form patterns:⁷

1. Repetitive focal or generalized epileptic form activity (spikes, sharp waves, spike-and-wave, sharp-and-slow wave complexes) or rhythmic theta or delta activity at more than two per second.
2. The above EEG patterns at less than one per second, but with improvement or resolution of epileptic activity and improvement in the clinical state following intravenous (IV) injection of a rapidly acting anti-epileptic drug (AED), such as a benzodiazepine.
3. A temporal evolution of epileptiform or rhythmic activity at more than 1 Hz with change in location or frequency over time.

EEG can help in diagnosis and management of epilepsy by assessing risk of recurrence after an unprovoked seizure, selection of antiepileptic treatment, likelihood of seizure relapse if medication is withdrawn, identification of epileptogenic region in epilepsy surgery candidates, investigation of cognitive decline, detection of non-convulsive status and monitoring in convulsive status.^6,7 Amonkar et al.,⁸ studied children aged 1 month to 16 years who presented with seizures were evaluated. EEG was performed during hospital stay in 59 (37.5%) patients and 28 (47.4%) patients had abnormal recordings. EEG abnormalities included focal waveform abnormalities (7), multifocal waveform abnormalities (4), diffusely slow background activity (7), periodic discharges (6) and low voltage recording (4). Similar findings were noted in present study. Narayanan and Murthy⁹ reported abnormal EEG in 56% patients, mostly nonspecific, either diffuse symmetric or focal theta or delta activity. None of the EEG showed spike or sharp wave activity and periodic discharges. There were no specific EEG features that could predict the recurrence seizures and SE. A study conducted by Singh and Suryavanshi ¹⁰ in 331 children with seizure revealed that in patients with generalized seizures 49% had abnormal EEG while 51% had normal EEG pattern whereas in patients with focal seizures 42% had normal EEG while 48% had abnormal EEG and there was no significant difference in EEG abnormalities in both groups. Alakkodan D¹¹ studied 218 children with first - time seizures. Abnormal neuro-radio imaging findings were gliosis in 46 - (21.10%), demyelination in 22 - (10.09%), hemorrhage in 20 (09.17%), brain atrophy in 8 - (3.66%), dysgenesis in 6 - (2.75%), infarction in 5 - (2.29%), and encephalomalacia in 4 (1.83%) children, abnormal EEG in 67/218 (30.73%) children. The abnormal recordings in EEG noted in this study were temporal shortwave discharges in 34 (15.59%), centrotemporal spikes in 19 (8.71%), occipital spikes/spike-waves in 17 (7.78%), generalized slowing in 17 (7.78%), focal slowing in 9 - (4.12%), frontal sharp wave discharge in 5 (2.29%), Neuroimaging of children with status epilepticus showed that out of 20 children with abnormal neuroimaging, 7 children had refractory status epilepticus (RSE). In Purusothaman and Kumar¹² study Structural abnormality was seen in 10 (18.5%) cases of them 7 children (12.2%) presented with refractory status epilepticus. The frequency of refractory seizures is low compared to other published reports the frequency varies from 25-50%.^13,14,15 Refractory seizures were observed more with structural abnormality. In current study, it was observed that among the structural abnormality, most common was cystic encephalomalacia seen in 30% cases followed by porencephaly 20%, space occupying lesion-DNET 20%, polymicrogyria cortex 20 and arachnoid cyst in temporal region seen in 10% cases. This is in accordance with the study done by Purusothaman and Kumar.¹²

Similarly, focal or unilateral SE, as well as lateralized periodic discharges detected by EEG are associated with focal diffusion restriction and increased T2 or FLAIR signal that may persists for days to weeks.^16,17

However, the EEG has a number of limitations. Electrical activity recorded by electrodes placed on the scalp or surface of the brain mostly reflects summation of excitatory and inhibitory postsynaptic potentials in apical dendrites of pyramidal neurons in the more superficial layers of the cortex. Spatial/temporal sampling in routine scalp EEG is incomplete, as significant amounts of cortex, particularly in basal and mesial areas of the hemispheres, are not covered by standard electrode placement. Limited and relatively short duration of routine interictal EEG recording are common reasons, why patients with epilepsy may not show interictal epileptiform discharge (IED) in the first EEG study.¹⁸ Proper prehospital therapy, early referral, proper care while transporting, anticipating risk factors involved, and protocol based approach uniformly at all hospital can reduce the mortality due to status epilepticus in children. Also considering the large number of referrals, upgradation of intensive care facilities even in tertiary care hospital is much sought to improve the overall outcome of SE.

CONCLUSION

In status epilepticus commonest type of seizure was a generalized tonic-clonic seizure. Seizure disorder, acute CNS infections, and febrile seizures were commonest etiological reasons. CSF analysis, Neuroimaging and EEG have the most important role in diagnosis of seizures. EEG can help in diagnosis and management of epilepsy by assessing risk of recurrence after an unprovoked seizure, selection of antiepileptic treatment, likelihood of seizure relapse if medication is withdrawn.

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