Unmasking the Causes of Pediatric Refractory Status Epilepticus: Insights from Three Challenging Cases

Abstract

Status epilepticus (SE) refers to a neurological emergency where the condition can escalate even after treatment to refractory status epilepticus (RSE) with a high rate of both morbidity and mortality. According to the International League Against Epilepsy, seizures going beyond 5 minutes (t1) are more likely to persist, and those going beyond 30 minutes (t2) lead to irreversible neuronal injury. Case 1 was tuberculous meningoencephalitis with hydrocephalus, necessitating ventriculoperitoneal shunting. Case 2 was on the topic of highly resistant bacterial neonatal meningitis caused by Elizabethkingia meningoseptica. Case 3 was a study report on mtDNA depletion syndrome, which is a form of Alpers-Huttenlocher syndrome. Continuous midazolam infusion along with ventilatory support was the only way through which all the cases could be controlled from further seizure activity. This study aims to investigate the causes of pediatric refractory status epilepticus and provide clinical insights through the presentation of three challenging cases. This case series highlights that acute symptomatic etiologies, such as infections and metabolic disorders, are the main reasons behind pediatric RSE. It also emphasizes the importance of early neuroimaging, accelerated etiological diagnosis, and protocol-based EEG-guided anesthesia for achieving good neurological outcomes.