Most epilepsy patients experience brief recurrent solitary seizures. Serial seizures and prolonged seizures > 5 minutes are coupled with seizure emergencies and potentially lead to status epilepticus (SE). SE has a higher risk of poor outcome and merit more aggressive treatment approaches. Continuous EEG monitoring has unveiled a spectrum of epileptiform abnormalities involving an interictal-ictal continuum. Certain patterns are clearly ictal while PLEDs and other periodic patterns remain may reflect interictal, post-ictal, and transitional features often seen with SE. PLEDs noted in the ED (figure A) may translate to SE in the Neurological ICU (figure B). Working criteria to separate ongoing ictal and peri-ictal EEG are available1. It remains ill-defined to what extent individual or combinations of EEG patterns contribute to brain injury and which exist as epiphenomenon. Treatment approaches varies due to our lack of understanding regarding patterns that are clearly harmful to neuronal stabilization and recovery following clinical and EEG seizures and SE2. Focal SE may result in brain atrophy without a preceding structural cause. VNS implantation was performed in our patient with improvement. Drug reduction and transition to non-enzyme inducing medication with seizure reduction (0-2/month) was possible with ED visitation virtually eliminated.
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