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An Excitatory Path to Unconsciousness: Nonconvulsive Status Epilepticus

States of unconsciousness can result from metabolic derangement, drug intoxication, or structural brain diseases such as stroke, infection, or trauma. When a patient is demonstrating aberrant motor activity, a generalized seizure is readily suspected as the cause of unconsciousness. If the seizure is prolonged or followed by subsequent seizures without a return to baseline neurologic status, the pathology is defined as generalized convulsive status epilepticus (GCSE). It must be recognized that an unconscious patient manifesting no behavioral features of a seizure may nonetheless still be in status epilepticus: nonconvulsive status epilepticus (NCSE) is a significantly underrecognized diagnosis in unconscious patients. The concept of an excitatory pathway to unconsciousness is one that is not routinely experienced by anesthesiologists, as most commonly used anesthetic agents are central nervous system depressants that potentiate the inhibitory neurotransmitter g-amino butyric acid (GABA). Seizure activity, in contrast, leads to unconsciousness by overexcitation of cerebral activity with corresponding increases in concentrations of monoamines in the brain. The dysregulation of neural signals— whether by aberrant suppression (anesthesia) or stimulation (seizure)— disrupts the temporal integration that is necessary for normal cognition.