Unexpected Cardiac Damage Seen in Refractory Status Epilepticus

SAN DIEGO – Neurocardiogenic injury was surprisingly common in a series of patients treated for status epilepticus in a retrospective review conducted by investigators at the Mayo Clinic in Rochester, Minn.

Among 46 patients treated for 55 episodes of status epilepticus between 1999 and 2011, at least 8 (17%) experienced possible neurocardiogenic injury, Dr. Sara Hocker reported at the annual meeting of the American Neurological Association.

"I think we underestimate these cases because we don’t typically get troponin [levels] or echocardiograms in these patients," Dr. Hocker said in an interview at the meeting, where she presented the findings in poster form.

Patients included in the review were a mean age of 50 (within a standard deviation of 17.9 years) at the time of generalized convulsive or nonconvulsive status epilepticus. In 49 episodes, anesthetic coma was induced, and patients required anesthetic agents for an average 9.6 days.

At the onset of an episode, only 18 patients had troponin levels measured, with a mean of 0.1 and a standard deviation of 0.19 ng/mL.

Electrocardiogram findings at the onset of status epilepticus included ST elevation (7%), ST depression (5%), T wave inversion (5%), LVH (7%), and nonspecific ST changes (55%). Cardiac arrhythmias required intervention in more than 22% of cases, and included asystole (12%), ventricular tachycardia/fibrillation/flutter (8%), paroxysmal supraventricular tachycardia (2%), sinus bradycardia (46%), and sinus tachycardia (75%).

A non–ST elevation myocardial infarction was diagnosed in one patient, and pulmonary edema was present in more than one-third of patients.

Among 20 patients evaluated with echocardiography during status epilepticus, 8 had possible stress-induced cardiomyopathy that resolved following the episode.

"Neurologists and cardiologists are absolutely aware of catecholamine surge causing neurocardiogenic injury in massive neurologic insults like subarachnoid [hemorrhage] or acute hydrocephalus, or seizures," Dr. Hocker said.

"However, I think when we see patients with status, the majority of us, even neurointensivists, are surprised to see massive cardiogenic injury or any cardiogenic injury. It’s not the first thing we think of, and we don’t screen for it," she noted.

She said further review of the cases is underway to determine preexisting risk factors.

In the meantime, practice has changed at the Mayo Clinic to require echocardiograms in status epilepticus patients until more is known about neurocardiogenic injury in these patients.

"Is it worth it going forward to screen these patients carefully? Will it change outcomes? I don’t think we know enough at this point to say," Dr. Hocker said.

For institutions without easy access to echocardiograms in an intensive setting, bedside ultrasounds may be prudent "to decide whether to order a full echo or not," she advised.

Dr. Hocker reported no relevant disclosures related to her study.

SAN DIEGO – Neurocardiogenic injury was surprisingly common in a series of patients treated for status epilepticus in a retrospective review conducted by investigators at the Mayo Clinic in Rochester, Minn.

Among 46 patients treated for 55 episodes of status epilepticus between 1999 and 2011, at least 8 (17%) experienced possible neurocardiogenic injury, Dr. Sara Hocker reported at the annual meeting of the American Neurological Association.

"I think we underestimate these cases because we don’t typically get troponin [levels] or echocardiograms in these patients," Dr. Hocker said in an interview at the meeting, where she presented the findings in poster form.

Patients included in the review were a mean age of 50 (within a standard deviation of 17.9 years) at the time of generalized convulsive or nonconvulsive status epilepticus. In 49 episodes, anesthetic coma was induced, and patients required anesthetic agents for an average 9.6 days.

At the onset of an episode, only 18 patients had troponin levels measured, with a mean of 0.1 and a standard deviation of 0.19 ng/mL.

Electrocardiogram findings at the onset of status epilepticus included ST elevation (7%), ST depression (5%), T wave inversion (5%), LVH (7%), and nonspecific ST changes (55%). Cardiac arrhythmias required intervention in more than 22% of cases, and included asystole (12%), ventricular tachycardia/fibrillation/flutter (8%), paroxysmal supraventricular tachycardia (2%), sinus bradycardia (46%), and sinus tachycardia (75%).

A non–ST elevation myocardial infarction was diagnosed in one patient, and pulmonary edema was present in more than one-third of patients.

Among 20 patients evaluated with echocardiography during status epilepticus, 8 had possible stress-induced cardiomyopathy that resolved following the episode.

"Neurologists and cardiologists are absolutely aware of catecholamine surge causing neurocardiogenic injury in massive neurologic insults like subarachnoid [hemorrhage] or acute hydrocephalus, or seizures," Dr. Hocker said.

"However, I think when we see patients with status, the majority of us, even neurointensivists, are surprised to see massive cardiogenic injury or any cardiogenic injury. It’s not the first thing we think of, and we don’t screen for it," she noted.

She said further review of the cases is underway to determine preexisting risk factors.

In the meantime, practice has changed at the Mayo Clinic to require echocardiograms in status epilepticus patients until more is known about neurocardiogenic injury in these patients.

"Is it worth it going forward to screen these patients carefully? Will it change outcomes? I don’t think we know enough at this point to say," Dr. Hocker said.

For institutions without easy access to echocardiograms in an intensive setting, bedside ultrasounds may be prudent "to decide whether to order a full echo or not," she advised.

Dr. Hocker reported no relevant disclosures related to her study.

SAN DIEGO – Neurocardiogenic injury was surprisingly common in a series of patients treated for status epilepticus in a retrospective review conducted by investigators at the Mayo Clinic in Rochester, Minn.

Among 46 patients treated for 55 episodes of status epilepticus between 1999 and 2011, at least 8 (17%) experienced possible neurocardiogenic injury, Dr. Sara Hocker reported at the annual meeting of the American Neurological Association.

"I think we underestimate these cases because we don’t typically get troponin [levels] or echocardiograms in these patients," Dr. Hocker said in an interview at the meeting, where she presented the findings in poster form.

Patients included in the review were a mean age of 50 (within a standard deviation of 17.9 years) at the time of generalized convulsive or nonconvulsive status epilepticus. In 49 episodes, anesthetic coma was induced, and patients required anesthetic agents for an average 9.6 days.

At the onset of an episode, only 18 patients had troponin levels measured, with a mean of 0.1 and a standard deviation of 0.19 ng/mL.

Electrocardiogram findings at the onset of status epilepticus included ST elevation (7%), ST depression (5%), T wave inversion (5%), LVH (7%), and nonspecific ST changes (55%). Cardiac arrhythmias required intervention in more than 22% of cases, and included asystole (12%), ventricular tachycardia/fibrillation/flutter (8%), paroxysmal supraventricular tachycardia (2%), sinus bradycardia (46%), and sinus tachycardia (75%).

A non–ST elevation myocardial infarction was diagnosed in one patient, and pulmonary edema was present in more than one-third of patients.

Among 20 patients evaluated with echocardiography during status epilepticus, 8 had possible stress-induced cardiomyopathy that resolved following the episode.

"Neurologists and cardiologists are absolutely aware of catecholamine surge causing neurocardiogenic injury in massive neurologic insults like subarachnoid [hemorrhage] or acute hydrocephalus, or seizures," Dr. Hocker said.

"However, I think when we see patients with status, the majority of us, even neurointensivists, are surprised to see massive cardiogenic injury or any cardiogenic injury. It’s not the first thing we think of, and we don’t screen for it," she noted.

She said further review of the cases is underway to determine preexisting risk factors.

In the meantime, practice has changed at the Mayo Clinic to require echocardiograms in status epilepticus patients until more is known about neurocardiogenic injury in these patients.

"Is it worth it going forward to screen these patients carefully? Will it change outcomes? I don’t think we know enough at this point to say," Dr. Hocker said.

For institutions without easy access to echocardiograms in an intensive setting, bedside ultrasounds may be prudent "to decide whether to order a full echo or not," she advised.

Dr. Hocker reported no relevant disclosures related to her study.