ECT's Role in the Treatment of Status Epilepticus: New Review From England

Out on Pubmed, from researchers in England, is this review:

Neuromodulation in Super-refractory Status Epilepticus.

Stavropoulos I, Pak HL, Valentin A.J Clin Neurophysiol. 2021 Jul 6. doi: 10.1097/WNP.0000000000000710. Online ahead of print.PMID: 34261110

The abstract is copied below:

Status epilepticus (SE) is a severe condition that needs immediate pharmacological treatment to tackle brain damage and related side effects. In approximately 20% of cases, the standard treatment for SE does not control seizures, and the condition evolves to refractory SE. If refractory status epilepticus lasts more than 24 hours despite the use of anesthetic treatment, the condition is redefined as super-refractory SE (srSE). sRSE is a destructive condition, potentially to cause severe brain damage. In this review, we discuss the clinical neuromodulation techniques for controlling srSE when conventional treatments have failed: electroconvulsive therapy, vagus nerve stimulation, transcranial magnetic stimulation, and deep brain stimulation. Data show that neuromodulation therapies can abort srSE in >80% of patients. However, no randomized, prospective, and controlled trials have been completed, and data are provided only by retrospective small case series and case reports with obvious inclination to publication bias. There is a need for further investigation into the use of neuromodulation techniques as an early treatment of srSE and to address whether an earlier intervention can prevent long-term complications.

And from the text:

Electroconvulsive therapy (Fig. 3) was applied to 25 patients. The number of ECT sessions and frequency of the treatment varied as seizure control was attempted. Some patients had only one stimulation session on a single day, whereas others received up to six stimulation sessions in one day. Regarding the frequency of these sessions, this also varied from two to five in a week. The number of seizures elicited by the ECT was highly dependent on each patient’s reaction to the treatment. Electroconvulsive therapy was considered as stopping srSE in 21 of the 25 reported cases. Complications observed were amnesia, cognitive impairment,  and vegetative status.

...Overall, neuromodulation techniques led to improvement of srSE in 47 of 52 patients. Five patients died without any improvement (4 ECT adn 1 VNS), one patient had an initial improvement but died when srSE recurred (VNS), and one patient died for multiorgan failure after srSE was resolved (ECT).
Three patients remained in vegetative state (two DBS and one ECT).

...Based on the efficacy and the safety of the reported cases of neuromodulation for srSE, we suggest that these techniques could be applied early in the course of srSE. Noninvasive techniques, such as ECT and rTMS, could be applied first, and the more invasive techniques of VNS and DBS later if no improvement in the srSE was observed. Unfortunately, there are no reported cases with the application of a second neuromodulation technique when the first failed, and thus, we do not know if there is possible benefit to try another type of neuromodulation after initial failure.

This is an excellent review of status epilepticus; the role of ECT is well described. With 25 patients from the literature, ECT is the best represented modality here. The authors' plea for earlier intervention is well taken.

This is a highly recommended read for anyone interested in the less common neuropsychiatric applications of ECT, ~20 minutes.