Stephan Rüegg studied medicine at the Universities of Fribourg and Berne
(Switzerland). He trained at the University Hospital of Basel (Internal Medicine,
Oncology, and Neurology) with approval of the specialty board neurology by the
Swiss Medical Board (FMH) in 2000. 2001-2003 he spent 18 months at the
University of Pennsylvania in Philadelphia as a postdoctoral fellow in the lab of
Prof. Marc Dichter and clinically with Prof. Jackie French and Brain Litt. On
return to Basel, he was appointed head of the EEG lab and epileptology as well as of the neurointensive care consult service in 2004. He became assistant professor in 2009 and associate professor in 2015. He was the President of the Swiss League Against Epilepsy 2016-2020. He is a Fellow of the European Academy of Neurology (EAN) and the American Epilepsy Society. Since 2022 he is co-chair of the management group of the Scientific Panel Epilepsy of the EAN. His research interests include the optimization of diagnosis and treatment of status epilepticus and its co-morbidities, the neurological prognostication of critically ill patients, like those with postanoxic encephalopathy. He focuses also on the improvement of care of autoimmune encephalitis and explores pharmaco-epidemiological aspects of epilepsy.

Status epilepticus (SE) is the most frequent neurological emergency requiring intensive care treatment. While diagnosis of motor forms is evident, the non-motor forms of SE (non-convulsive SE (NCSE)) pose much more diagnostic challenges given their protean symptoms. Regarding diagnosis of NCSE, the (continuous) EEG monitoring plays the major role. Following, an international team of experts revised the American Clinical Neurophysiology Society (ACNS) classification of EEG patterns in the intensive care unit (ICU), and fostered, among a multitude of adaptations, the concept of electroclinical SE. The ACNS classification, together with the so-called “Salzburg criteria” may help to better discriminate between SE and encephalopathy which represents still the most difficult task for even experienced ICU EEG readers.
Treatment of SE is divided into four stages depending on the respective response of the patient to specific treatment steps. Stage one is imminent SE and includes the pre-hospital and emergency room phase where benzodiazepines (BZD) are administered. The safety and efficacy of early and even pre-hospital treatment of SE with benzodiazepines have been corroborated in several trials. Stage two, established SE, is the phase where an intravenously antiseizure medication (ASM) is given after the BZD. The Established Status Epilepticus Treatment Trial (ESETT) showed equipoise with level I evidence of the three intravenously (i/v) administered antiseizure medications (ASMs) phenytoin, valproate, and levetiracetam regarding safety and efficacy. Lacosamide was non-inferior to fosphenytoin in non-motor SE in another prospective trial. In children, levetiracetam and fosphenytoin were equivalent regarding safety and efficacy in two large prospective randomized controlled trials. If the SE does not respond to a BZD and an i/v ASM, the patient has refractory SE ( stage three; RSE) which is treated with i/v anaesthetics, mainly midazolam or propofol or a combination of both of them. There is no new data about these or any other new compounds for RSE. When RSE persists despite adequate treatment, the patient enters stage four, super-refractory SE (SRSE). Here, too, all therapeutic approaches lack any evidence, and most data are derived from retrospective case series. Beyond the drugs already discussed earlier, the anaesthetic ketamine is often used, together with other non-phamaceutical treatments, like the ketogenic diet, stimulation devices like the vagus nerve stimulator and deep brain stimulation. A large trial evaluating hypothermia in convulsive SE/RSE/SRSE did not show efficacy in terms of a better outcome after 90 days. Rather worrying, several large retrospective studies pointed to worse outcomes in patients undergoing coma induction with anaesthetics and called for some more cautious and individualized therapy of SE in patients with RSE/SRSE. The discussion whether anaesthetics are friend or foe is not closed.

A recent study showed that applying machine learning methods to continuous EEG data can accurately predict the optimal time window to wean patients from anesthetics in almost real-time. This is an important step to improve patient safety, the more as an another study showed that patients with RSE/SRSE were extubated with marked delay despite successful weaning. Such analysis of big EEG data sets is currently under intense evaluation for predicting outcomes and for verifying appropriateness and futility of therapeutic measures administered to patients with SE.
Future treatment approaches of SE include the clinical testing of new compounds like the mid- chain fatty acids, anti-galanins, TRAP-gamma- and KEAP-1-inhibitors, mGLuR2-PAMs, anatgomirs usf., as well as the repurposing of medications already in use for other indications, like pentoxyfillin, verapamil, SSRI’s, amantadine, dexmedetomidine, usf.
Nevertheless: the best way to treat SE, and especially RSE/SRSE, is to prevent SE by optimizing therapy of epilepsy, reducing the incidence of severe brain injuries and illness, and the early diagnosis and resolute treatment of the early stages.