Refractory and Super-Refractory Status Epilepticus Therapeutic Options and Prognosis

Management of SE, one of the most common neurologic emergencies with a potential impact on morbidity and mortality, should consider that the underlying biologic background represents the main prognostic variable; hence the importance of identifying the underlying etiology. A swift application of a treatment protocol, initially including adequate doses of a benzodiazepine followed by an IV ASM, reduces the risk of RSE development. If RSE arises, it seems reasonable to readily use therapeutic coma-induction with general anesthetics in generalized convulsive and NCSE in coma, while further non-sedating ASM attempts may be warranted in patients with focal forms lacking profound consciousness impairment. Patients with SR SE should benefit from attempts with ketogenic diet and/or ketamine, and for those having NORSE/FIRES immunologic treatments should be administered early after excluding an underlying infection. Finally, the intensity of pharmacologic treatment of SE arising after cardiac arrest should always be tuned by the results of multi- modal prognostication.