⚡ Non-Convulsive Status Epilepticus (NCSE) is an underdiagnosed cause of coma and confusion at all ages. A left cortical irritative focus → eyes deviate to the right (± flickering eye movements), and vice versa. Always think of NCSE in otherwise unexplained altered consciousness.

🩺 Initial NCSE Management
➡️ ABC approach, give high-flow O₂, check glucose ➡️ Consider urgent CT scan to rule out stroke / SOL ➡️ EEG is confirmatory but often unavailable – treat empirically if suspicion is high ➡️ Lorazepam 1 mg IV (may repeat once if no effect) ➡️ Long-term anticonvulsants (IV Phenytoin / IV Levetiracetam) ➡️ If no clear cause (e.g. stroke), consider LP and further investigations ➡️ Always exclude differentials: encephalitis, meningitis, SOL

🩺 Initial NCSE Management

➡️ ABC approach, give high-flow O₂, check glucose
➡️ Consider urgent CT scan to rule out stroke / SOL
➡️ EEG is confirmatory but often unavailable – treat empirically if suspicion is high
➡️ Lorazepam 1 mg IV (may repeat once if no effect)
➡️ Long-term anticonvulsants (IV Phenytoin / IV Levetiracetam)
➡️ If no clear cause (e.g. stroke), consider LP and further investigations
➡️ Always exclude differentials: encephalitis, meningitis, SOL

📖 About

NCSE = persistent alteration in consciousness or behaviour with continuous epileptiform EEG activity, but without major motor convulsions.
Often presents as coma, stupor, or delirium – easily missed in elderly or critically ill patients.
A treatable cause of otherwise unexplained altered mental status.

🧬 Aetiology

Can affect all age groups – children, adults, and the elderly.
Triggers include: structural brain lesions (stroke, tumour), metabolic disturbance, CNS infection, medication withdrawal (esp. benzodiazepines), or known epilepsy.

📌 Types

Absence status
Simple / complex partial status
Subtle status epilepticus (often in ICU patients)

⚠️ Clinical Features

💭 Confusion, stupor, or reduced responsiveness lasting hours–days
👁️ Eye deviation (contralateral to cortical irritative focus)
👀 Flickering eye movements or nystagmus
🧓 Common in elderly – unexplained confusion or hypoactive delirium
🩸 May follow benzodiazepine withdrawal or occur in patients with epilepsy history
❗ Think of NCSE in coma with subtle movements but no tonic–clonic activity

🔍 Investigations

Bloods: FBC, U&E, Ca, Mg, LFTs, lactate, VBG
CT Brain: Exclude tumour, stroke, haemorrhage, abscess, encephalitis
MRI Brain: More sensitive, but often impractical acutely
Lumbar Puncture: If infection suspected (after imaging)
EEG: Diagnostic – shows continuous epileptiform discharges (spike–slow wave) but may be hard to obtain acutely

💊 Management

🎯 Treat empirically if strong suspicion (do not delay for EEG)
Exclude other coma causes (hypoglycaemia, opioid overdose)
Lorazepam 1 mg IV, repeat once if needed
Long-term therapy: IV Phenytoin or IV Levetiracetam
If infection possible: Start broad-spectrum antibiotics (e.g. Cefotaxime) + antivirals (Aciclovir)
Supportive care: airway protection, seizure precautions, ICU if refractory

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Non Convulsive Status Epilepticus