The patient's right arm flexion/extension movements stop within a minute of lorazepam administration. Because he actually had some fluctuating alertness overnight that hadn't raised any red flags earlier, you decide to go ahead and connect him to cEEG.
Over the next hour, his mentation improves to baseline. He is amnestic to this event. He denies having ever had other events like this. You breathe a sigh of relief. Because he does have an elevated risk for seizures in light of his acute IPH this admission, you load him with IV levetiracetam 3g and start maintenance 1g bid. All in a day's work.
Later in the afternoon, when you're in the cafeteria getting a late lunch, you get an urgent page from the epilepsy fellow. The epilepsy fellow tells you that the patient just went into focal status epilepticus. He sends you a screenshot of the EEG in the secure chat. You finish your last bite of your chicken wrap and run back up the stairs to see the patient.
(Sinha 2010)
Not necessarily, actually. Yes, it's not great to hear that the patient is in status epilepticus. However, the important addition there is that he's in focal status. Not all focal status is created equally. The key additional piece of information you really need to know to figure out your plan is the patient's current mental status.
If the patient's mentation is totally preserved and he's just talking to you as his arm is convulsing away, great. Focal motor status epilepticus with preserved awareness is also known as epilepsia partialis continua (EPC). EPC can be notoriously difficult to treat, and will actually end up being fine so long as you don't overdo it with sedating medications; you don't want to give him a reason to get intubated. Of course, you should ensure that the patient is very carefully monitored in this acute phase, as his mentation may very well decline, which would then necessitate more aggressive management.
If the patient's mentation is clearly acutely impaired in association with this focal status, then we should treat this as we would any other typical generalized convulsive status epilepticus, going through the usual algorithm with benzodiazepines followed by levetiracetam vs. fosphenytoin vs. valproic acid followed by intubation and propofol.
Unfortunately, there are times when the patient's mentation is stably poor throughout the admission, and it's not clear whether it's been further impaired by the focal status. It can be helpful to contextualize this development in terms of the patient's current and overall clinical course, their baseline neurologic status, their ongoing comorbidities and how they'd affect and be affected by status management, and their goals of care. It's common in these situations to have to err on the side of initial aggressive management (treated as we would with generalized convulsive status), and then using their response in the coming days to guide continued management, whether it's high doses of sedatives or continued multi-ASM uptitration.
Copyright © 2024-2026 Andrew M. Nguyen, M.D. For educational use only.
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