Status Epilepticus Treatment Algorithm

Status Epilepticus AlgorithmI


Uptodate Status Epilepticus Algorithm in PDF

New definition of STATUS EPILEPTICUS (Status Epilepticus: Current Treatment Strategies, by Ed Manno, published in Neurohospitalist 2015)

Status epilepticus (SE) can be defined as a seizure of sufficient duration to overcome the inherent cellular mechanisms designed to terminate the seizure. SE becomes a self-sustaining process.

Initial League against Epilepsy originally defined SE as 30 mins of sustained seizure activity or 2 or more seizures during this time period without full recovery of the patient.

Pathologically, hippocampal neurons begin to die after 30 mins of sustained seizure activity.

Newer operational definitions have suggested that seizures lasting longer than 5 mins are unlikely to discontinue spontaneously and should be treated.


There is an initiation and maintenance phase. SE is initiated through excessive excitatory stimulation but is maintained through lack of GABA-mediated neuronal suppression.

Failure to suppress initial excitatory focus may be due to development of changing GABA isoforms. With sustained seizure, hippocampal GABA A isoforms with different pharmacological properties may develop. This explains the resistance to benzodiazepines that develops during SE over time.

SE may also be sustained through excitatory NMDA’mediated neuronal stimulations. NMDA antagonists have been suggested as a possible pharmacologic strategy.

Intraventricular Antibiotics for Ventriculitis

Prepare the following:

1.  Three 3-way stopcocks

2.  One sterile saline flush (preservative-free)

3.  2-4 10cc syringes

4.  sterile gloves, sterile towels

5.  gauze with betadine

6.  cap, gown, mask

7.  antibiotic in 2cc syringe

Put drape underneath shunt access port.  Clean shunt access port with betadine thoroughly, paint line and port with betadine.  Prepare sterile field (won’t be completely sterile), put on gown, mask and sterile gloves.  Prepare stopcock, flush, empty syringe and antibiotic – connect in series as shown in photograph.  Maintain one hand as sterile and another hand as “dirty.”  Lock CSF drain to patient.  Connect free end of stopcock to shunt access port.  and open empty syringe (distal port) to patient.  Withdraw CSF into empty syringes – draw fluid slowly, to max of 20 cc. (volume equal to or slightly more than amount of antibiotic and sterile flush to be infused).  Close empty syringe (now filled with CSF) to patient.  Open antibiotic port (proximal port) to patient and push antibiotic slowly.  Close antibiotic port and open sterile flush port (middle port) to patient.  Flush enough saline to push antibiotic in tubing into patient, and then push an extra 1-2 ml more.  Close sterile flush port and disconnect intraventricular infusion set up from shunt access port.  Maintain EVD clamped x 1 hour.


Empiric treatment:

Vancomycin 15mgkg q8-12h (max 2g) plus one of the following

  1. ceftazidime 2g IV q8h
  2. cefepime 2g IV q8h
  3. meropenem 2g IV q8h

Gram positive:

  • Vancomycin for MRSA
  • Nafcillin or Oxacillin for MSSA
  • Add rifampin if refractory
  • Linezolid 600mg IV q12h if VRE or vancomycin allergy

Duration of treatment:

  1. normal CSF and CONS (+) – possible contaminatin, replace shunt on day 3 if cultures negative
  2. if CONS(+) and abnormal CSF – ABx while device in plus 1 week; document sterile CSF prior to shunt placement
  3. if virulent organism then >10d for staph or 14-21d for GNB; document sterile CSF x 10d prior to shunt
  4. if device cannot be removed, cont ABx until 7-10d after sterile CSF


  • best experience with gentamicin and vancomycin
  • may use colistin for MDROs (i.e. acinetobacter)
  • no PCN or cephalosporins (neurotoxic!)
  • goal is INHIB QUOTIENT of <10-20  … INHIB QUOTIENT is trough of CSF ABx / MIC

CHOICES: vanc 5-20mg/d; gent 4-8mg/d; ampho 0.1-1mg/d


  • IDSA recommends cefazolin but UPTODATE prefer vancomycin over cefazolin (pred CONS)
  • vancomycin 15mgkg (<2g) IV 2h prior (since vanc requires 60 minute infusion)
  • if al, then cefazolin 1-2g IV 1h prior



Intraventricular application of antibiotics to reach effective concentrations within the CNScapture


Very comprehensive review of intra-CSF antibiotics was published May, 2018 – author went over 200 articles on this topic – by Mrowczynski, et al published in Clinical Neurology and Neurosurgery.  See reference #3 below.  A short summary is provided here.

  1. Vancomycin
    • studies on intrathecal vancomycin for prophylaxis – potential use, 10mg/day x <10d
    • dosage ranges from 0.075 to 50mg/day, most common doses used 5-20mg/day
    • adverse effect: nerve root irritation in 1 case
  2. Teicoplanin
    • most commonly used for gram positive infections
    • most common doses used 5-20 mg/day, treatment duration 7-30 days
    • no significant side effects
  3. Daptomycin
    • useful for methicillin and vancomycin resistant strains
    • most common doses 2.5-10mg/day, treatment duration 1-4 weeks
    • adverse effect: transient pyrexia in 1 case, generally well tolerated
  4. Gentamicin
    • most common doses used 1-10mg/day, treatment duration 3-35 days
    • adverse effect: meningeal inflammation in 2 cases, mostly no significant side effects
  5. Amikacin
    • used at 4-50mg/day over 3 days to 6 months, ave duration 2 weeks
    • side effects:  hearing loss in 4 cases, tonic-clonic seizures in 1 case, vomiting in  1 case, back pain in 1 case
  6. Tobramycin
    • most often administered at 5-20mg/day x 2 infusions to every day for 40 days
    • no significant side effects
  7. Netilmicin
    • only 1 recent case report – 1mg to 150mg/day, no significant side effects
  8. Streptomycin
    • dosage varied from 2-100mg
    • associated with significant side effects – convulsions, apnea, coma, shock, pallor, vomiting, death
  9. Kanamycin
    • discontinued
    • used previously at dose of 5mg/day
  10. Penicillins
    • intrathecal therapy abandoned – multiple cases of severe seizures
  11. Lincomycin
    • older antibiotic used for gram positive infections
    • dose used 2mg/day x 5-9 days
  12. Cephalosporins
    • most common dosages used were between 25-100mg/d
    • note:  significant risk of seizures
  13. Erythromycin
    • varied from 3mg/day to 25mg/day, no significant side effects
  14. Polymyxin B
    • useful for multidrug resistant bacteria
    • most common dosages ranged from 2000 to 100,000 units x 5dto 4 weeks
    • one case described severeside effects: meningealirritation, decreased reflexes, but most reports noted no toxicity
  15. Colistin (Polymyxin E)
    • useful for resistant gram negative infections
    • predominantly used to treat acinetobacter baumanii infections at doses from 12,500 IU to 500,000 IU per day
    • Most common dose 125,000 IU
    • does not commonly cause toxicity, limited cases of chemical meningitis, nephrotoxicity, seizures and cauda equina syndrome noted
  16. Chloramphenicol
    • doses varied from 0.1mg to 50mg/day
    • no side effects noted
    • use can lead to aplastic anemia (intravenous) thus has been all but abandoned
  17. Rifampin
    • used at 2-5mg/day x 7-50 days
    • some patients have developed jaundice
  18. Isoniazid
    • dose range from 5-100mg/day, usually 3x per week
    • increased risk of significant side effects: hemiplegia, quadriplegia, convulsions, partial optic atrophy, hydrocephalus


Case report: successful use of intrathecal tigecycline after failed intravenous carbapenem antibiotic therapy of drug resistant Klebsiella ventriculitis.

Dose: 5mg/day, tigecycline diluted in saline up to a volume of 4ml; similar amount of CSF removed, and drug injected through EVD in 2 minutes; drain closed x 2 hours after dose; administered x total of 11d.

Pharma: 2 hours after dosing, levels peaked between 178.9 and 310.1 ug/mL, staying at 35.4-41.3 ug/mL at 6hours (which was 15-20 above MIC); after 24h, dose not detectable in CSF.

*reported doses in the literature = 1-10mg q12-24h; when los doses used, (+) CSF cultures persisted; IDSA recommends adjusting levels to 15-20x above MIC.


Nau, R., F. Sorgel, and H. Eiffert. “Penetration Of Drugs Through The Blood-Cerebrospinal Fluid/Blood-Brain Barrier For Treatment Of Central Nervous System Infections”. Clinical Microbiology Reviews 23.4 (2010): 858-883.

Mrowczynski, O., Langan, S. and Rizk, E. (2018). Intra-cerebrospinal fluid antibiotics to treat central nervous system infections: A review and update. Clinical Neurology and Neurosurgery, 170, pp.140-158.

Soto-Hernández, J., Soto-Ramírez, A., Pérez-Neri, I., Angeles-Morales, V., Cárdenas, G., & Barradas, V. (2019). Multidrug-resistant Klebsiella oxytoca ventriculitis, successfully treated with intraventricular tigecycline: A case report. Clinical Neurology And Neurosurgery, 188, 105592. doi: 10.1016/j.clineuro.2019.105592


10 basal cisterns and fissures



HIJDRA Illustration in Powerpoint



  1. Grade each of the 10 basal cisterns and fissures separately on a scale according to the amount of extravasated blood:
    1. No blood = 0
    2. Small amount = 1
    3. Moderately filled = 2
    4. Completely filled = 3
  2. Grade clots that expanded the original size of a cistern or fissure as 3
  3. Calculate total amount of subarachnoid blood [sum score] by adding the 10 scores;  range = 0-30
  4. Use average score for inadequately visualized cisterns or fissures
  5. Grade the amount of blood in the four ventricles
    1. No blood = 0
    2. Sedimentation in posterior part = 1
    3. Partly filled = 2
    4. Completely filled = 3
  6. Calculate total amount of intraventricular blood [sum score] by adding the 4 scores; range = 0-12


Utility of Hijdra Score:

In one study, Hijdra sum score and history of smoking was noted to be the strongest predictors of cerrebral vasospasm on angiography.  This score was noted to be superior to the modified Fisher score as a tool to predict vasospasm after SAH.

Combined history of smoking and HSS >23 had positive and negative predictive values of 37 and 88%, respectively, for prediction of cerebral vasospasm after aneurysmal hemorrhage.


Dupont, Stefan A. et al. “Prediction Of Angiographic Vasospasm After Aneurysmal Subarachnoid Hemorrhage: Value Of The Hijdra Sum Scoring System”. Neurocritical Care 11.2 (2009): 172-176. Web.

Hijdra, A. et al. “Grading The Amount Of Blood On Computed Tomograms After Subarachnoid Hemorrhage”. Stroke 21.8 (1990): 1156-1161. Web.