Treating status epilepticus in clinical practice - A multi-national survey in Germany, Austria and Switzerland

Leona Möller^1*Urs Fisch^2,3Lena Habermehl^1,4Clara Jünemann¹

• ¹Department of Neurology, Epilepsy Center Hessen, Philipps University Marburg, Marburg, Germany
• ²Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, United States
• ³Department of Neurology, University Hospital Basel, Basel, Switzerland
• ⁴Epilepsy Center, Neurological Institute, University Hospitals Cleveland Medical Center, Cleveland, United States

Background: Status epilepticus (SE) is a life-threatening neurological emergency, and exhibits significant variability in clinical management despite established guidelines. This study evaluates current practices across German speaking countries. Methods: A web-based survey (December 2023-May 2024) assessed SE treatment strategies among 83 neurologists and neurointensivists from Germany, Austria, and Switzerland. Cases were presented to analyze diagnostic and therapeutic preferences. Results: The preferred benzodiazepine for first line treatment was lorazepam, chosen by 71.6% of the respondents. In the case of established SE, 35.4% chose levetiracetam as the preferred ASM. Propofol in combination with sufentanil/ fentanyl was the preferred anesthetic of choice in 65.4% of respondents. For super-refractory status epilepticus (SRSE), 41.5% prefer to add further ASM, with valproic acid (67.1%) and lacosamide (64.5%) being the most frequently selected. Only 31.8% reported that their emergency services have a standard operating procedure (SOP) for SE treatment, and the choice of the preferred benzodiazepine varied in the preclinical setting, with midazolam being the most commonly used. • First-line therapy: Lorazepam (71.6% in-hospital), midazolam (50% prehospital). • Second-line therapy: Levetiracetam (35.4%) and lacosamide (13.4%) were the most common choices. • Refractory SE: Propofol with opioids (65.4%) were preferred for anesthesia • Prehospital care: 31.8% of emergency services lacked standardized protocols; midazolam dosing varied widely (2–10 mg). Diagnostics: Laboratory testing was universal (96.9%), but MR-imaging (10%) and clinical use of prognostic scores (6.2%) were underutilized. Conclusion: This survey highlights the variability in clinical practice for managing status epilepticus in German-speaking countries. Persistent heterogeneity in SE management underscores the need for standardized protocols, particularly in prehospital care and refractory SE therapy.