Intensive Intracranial Pressure and Temperature Monitoring May Improve the Outcome of a Young Patient with Severe Cryptogenic New-onset Refractory Status Epilepticus: A Case Report

Abstract

As the name implies, new-onset refractory status epilepticus is a condition wherein a pediatric or a young adult patient with no previous history of epilepsy suddenly develops idiopathic, uninterrupted, and difficult-to-control seizure episodes. While different neurosurgical interventions in new-onset refractory status epilepticus have already been reported, they are primarily used for palliation and diagnostic purposes. Here we report a young comatose patient who significantly improved after being subjected to intensive intracranial pressure management. Our patient was a 20-year-old male construction worker who was transferred to our institution after he was managed for 13 days (X day [day of ictus] to X+12 days) at a local hospital as a case of refractory status epilepticus. Since the patient has non-convulsive status epilepticus induced by minor stimuli, despite continuous midazolam administration, a central venous catheter-based percutaneous thermoregulation system was inserted on the day of the transfer (X+13 days), which depressed the temperature to 37°C, effectively suppressing the electrographic seizure to some extent. Moreover, on X+15 days, an intracranial pressure sensor was implanted, and a ventriculostomy was done to control the increased intracranial pressure induced by uncontrolled seizures. Because the seizure episodes ceased on X+22 days, intracranial pressure monitoring was eventually terminated. Four days later (X+26 days), the patient's wakefulness improved from Glasgow Coma Scale score of 3 (E1V1M1) to8 (E4VTM4) and was transferred to a rehabilitation facility with a modified Rankin Score of 1. Aside from medical management, neurosurgical interventions should be considered if indicated to improve the survival of a condition with a grave prognosis, such as new-onset refractory status epilepticus.