When and How to Treat Status Epilepticus: The Tortoise or the Hare?

Status epilepticus (SE) is a collective term that is used to describe a variety of subtypes. Forgetting this point can be perilous, even resulting in exposing patients to unnecessary harms. This review revisits the foundations of many of our current treatment guidelines, providing context to the ever-growing options in the treatment of SE. It aims to highlight the uncertainties that clinicians and EEGers face when treating SE. Several promising future approaches are raised. These bring hope of transitioning to therapies that are based on correcting maladaptive neuronal responses that are personally tailored using real time measures. All types of SE should be diagnosed as soon as possible, and treatment should be started expeditiously. For convulsive SE, treatment should be aggressive with full doses and cessation of seizures should be confirmed with EEG if patients are not returning to normal rapidly. For most other types of SE, the perennial debate about the tortoise or the hare continues: When should we be more measured and conservative and when should we rapidly escalate therapies to a combination of highly sedating agents?