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How urgent is the treatment of nonconvulsive status epilepticus?

Status epilepticus may be classified for practical purposes into convulsive status epilepticus, which must be rapidly stopped to prevent death or neurologic sequelae, and nonconvulsive status epilepticus (NCSE), which is usually characterized by some degree of clouding of consciousness. This latter condition constitutes a diagnosis challenge, because it often goes unrecognized or is mistaken for behavioral or psychiatric disturbances. Emergency EEG is the key feature for diagnosis. NCSE are classically divided on the basis of the ictal EEG into absence status (AS), with predominantly symmetrical synchronous ictal discharges and complex partial status epilepticus (CPSE), with continuous or rapidly recurring complex partial seizures that may involve temporal and/or extratemporal regions (Shorvon, 1994). NCSE should obviously be rapidly treated because of the acute neurologic impairment of the patients, because of the attendant morbidity including physical injury, and because it may evolve on to generalized convulsions. There is reasonable concern about possible long-term effects, but longterm permanent neurologic damage from NCSE occurring in ambulatory patients has not yet been firmly documented as a mandate for aggressive treatment (Drislane, 1999). Despite its high recurrence rate, typical AS occurring in idiopathic generalized epilepsies almost always present a rapid and spectacular response to intravenous benzodiazepines. Anecdotal case reports in which AS lasted as long as weeks or even months recovered without any sequelae. Despite the lack of long-term follow-up studies, there is no scientific evidence that typical AS has any effect either on cognitive functions, or on the natural history of the underlying epileptic syndrome (Drislane, 1999). The influence of atypical AS on the cognitive prognosis in cryptogenic or symptomatic generalized epilepsies is not as clear. In most instances, AS does not appear to have any significant effect. This is, however, a subject of debate.