JAMA Neurol: refractory status epilepticus may lead to cerebral atrophy

Lead:

It has been shown that ultra-refractory status epilepticus can lead to neuronal death and reorganization, and there have been individual cases of brain atrophy
in such patients.
A recent study led by the Mayo Clinic reconfirmed this fact
by evaluating patients using MRI.

Researchers in the United States recently found that even if the seizures of ultra-refractory status epilepticus (SRSE) are controlled by anesthetic drugs, evidence
of brain atrophy can still be seen on MRI.
The study was published in the journal
JAMA Neurology.

"The cause of the gradual progression of brain atrophy remains unknown, but it may be due
to reversible cerebral edema, subclinical seizures that cannot be detected by EEG, direct effects of anesthetic drugs, or cessation of treatment.
" The team from the Mayo Clinic in the United States wrote
in the article.

The study reviewed a total of 19 SRSE patients with a mean age of 41 years
.
SRSE is defined as the persistence or recurrence
of status epilepticus over a period of one day or more after initial anesthetic medication.
Patients underwent an MRI scan within 2 weeks of the onset of SRSE and another scan within 6 months of resolution of SRSE, with an interval of at least 1 week between scans
.

The researchers measured the ventricle-brain parenchyma ratio (VBR) at the onset of the disease and at follow-up, dividing the total area of the brain by the area
of the lateral ventricles.
This data was determined
using the T2FLAIR sequence.

Determination of VBR value (located above the caudate nuclear head)

A female patient in her 20s developed SROSE
due to autoimmune encephalitis.

A: Initial MRI scan, completed 6 days after the onset of SRSE

B: Follow-up MRI scan, completed after 128 days, when the patient was treated with anesthesia for
76 days.

Follow-up scans showed diffuse cerebral atrophy, widening of the sulci, and enlargement
of the ventricular aperture.
The VBR value in this patient changed by 66.
2%.

A higher VBR value means more brain parenchymal loss
.
According to the authors, the median VBR values at the time of the initial scan and follow-up scan were 0.
06 and 0.
08, respectively, which corresponds to a 23.
3%
change in VBR values.

In the review, Andrew Cole from Massachusetts General Hospital points out that although this number may seem staggering, it does not mean that the patient's brain volume will be reduced by nearly 1/4
.
"An increase in VBR values could be the result of an increase in ventricular space, or a decrease in whole-brain volume, or a combination of
both.
" Cole also noted that the increase in ventricular area may be transient, possibly due to
changes in the dynamics of cerebrospinal fluid pressure.

The researchers also found that the degree of change in VBR was significantly positively correlated with the use of anesthetic drugs and length of hospital stay, but negatively correlated
with age.
In contrast, the investigators' assessment of patients' functional prognosis by modifying the Rankin score surprised both the investigators and the review authors
that there was no significant correlation between the change in VBR and the functional prognosis.
The researchers believe that this may suggest that brain atrophy itself does not determine poor recovery in patients, so it should not be used as the sole parameter for
revocation of life support measures.

The researchers concluded that further research should focus on which areas are more susceptible to influence, as well as assessing the relationship between brain atrophy and related clinical variables, and more importantly, the effects
of brain atrophy on long-term cognitive function in SRSE survivors.