Turning up the heat on the impact of febrile status epilepticus.

Commentary Febrile seizures are one of the more common conditions seen by child neurologists and were probably overtreated for many decades with medications such as phenobarbital. More recent years have seen child neurologists trained to reduce the amount of both treatments and diagnostic testing of children with febrile seizures, even when prolonged and classified as febrile status epilepticus (FSE) (1, 2). Concerning results from the FEBSTAT multicenter study may be moving the field back toward apprehension. Very recently published data would suggest HHV 6 and 7 may be more prevalent in FSE (3). This study now addresses the fear that FSE may lead to hippocampal sclerosis and mesial temporal lobe epilepsy. Dr. Shinnar and his multicenter FEBSTAT team report the increased likelihood of finding 1.5 Tesla MRI abnormalities generally within 1 week of the FSE episode. A large number—191 children—had imaging and were compared to a control group of 96 children with simple febrile seizures from the previously reported Columbia Febrile Seizure Study (4). The key findings were 1) 22/191 (11.5%) with FSE had T2 hyperintensities in the hippocampus versus 0% of the simple febrile seizure cohort and, 2) 20/191 (10.5%) with FSE had developmental abnormalities identified (often hippocampal malrotation) versus 2/96 (2.1%). Only two of the 17 " definite " cases of T2 hyperintensities had concurrent developmental abnormalities, but the concern is whether these children with hippocampal malrotation were potentially predisposed to FSE. With these small numbers, only a future study can answer that question. These results raise some concern about the potential impact of FSE. The methods section describes repeat MRI being obtained at 1 year; one can only suspect that the risk of T2 changes may be higher than the 1 in 10 seen within 1 week of the FSE. The authors also appropriately state that a more subtle injury may have occurred in those without obvious imaging abnormalities. Perhaps future evaluations using 3T or even 7T MRI could reveal an even higher incidence of MRI findings. If we assume that these changes are pathologic, is there a way we can translate these results to children in our practice to prevent them from occurring? It is known that aggressive anti-pyretics are not helpful (5). Anticonvulsants such as phenobar-bital may help but have significant potential adverse effects (6). A logical approach would be to have emergency benzo-diazepines (e.g., rectal diazepam) readily available to parents; however, 76% of these …