Diagnostic testing in nontrauma patients presenting to the emergency department with recurrent seizures: A systematic review

Abstract

Background: There is a lack of consensus regarding the role of investigations among patients presenting to the emergency department (ED) with recurrent seizures. The aim of this systematic review was to determine the frequency and utility of commonly requested investigations for nontrauma patients presenting to the ED with recurrent seizures. Methods:The MEDLINE, EMBASE, and Cochrane Library databases were searched (March 2021) for articles on this topic using search terms related to recurrent seizures, investigations, and the ED. The inclusion criteria required that articles include adult nontrauma patients presenting to the ED. Studies exclusively investigating firstepisode seizures, trauma patients, and status epilepticus were excluded. Eligible studies were assessed for bias using the Newcastle-Ottawa scale. Results of studies were presented using proportions.Results: There were six cohort studies included that contributed data from 36,595 patients. All six studies assessed at least one of our primary outcomes for computed tomography (CT) brain scans. The proportion of patients who underwent a head CT ranged from 13% to 42%. The rates of abnormal head CT findings ranged from 8% to 21%. One study reported on magnetic resonance imaging (MRI) and found it used infrequently in 0.79% of cases. The proportion and yield of nonneuroimaging investigations were not well evaluated in this patient population. Only one study reported on the utility of sodium levels or blood glucose results for this population and reported abnormalities in sodium levels for 19% of patients and abnormalities in glucose levels in 50% of patients. Conclusions:In this population, CT brain scans appeared to be performed uncommonly but with moderate rates of abnormal findings. In the absence of prolonged alteration of consciousness, a history of brain tumor, or positive neurologic findings, however, neuroimaging was of low yield. Given the heterogeneity and potential limitations of these studies, further research on this topic is required.

Pathology testing in non‐trauma patients presenting to the emergency department with recurrent seizures

“…In this study, electrolyte levels were abnormal in 19% of presentations and glucose levels were elevated in 50% of cases 14 . No previous study had reported on the incidence or influence of pathology investigations on patient management for this population 13 …”

“…Current seizure guidelines do not address the role of repeat pathology tests in atraumatic recurrent seizure patients presenting to the ED 9–12 . A recent systematic review concluded that only one previous study has assessed the yield of blood tests in this population 13 . In this study, electrolyte levels were abnormal in 19% of presentations and glucose levels were elevated in 50% of cases 14 .…”

Development of clinical prediction model to guide the use of CT head scans for non-traumatic Thai patient with seizure: A cross-sectional study

“…Requesting unnecessary tests has been associated with overcrowding, patient severity, and low physician experience [ 27 , 28 ]. Extensive research has consistently demonstrated a low yield of CT as a seizure work up tools and suggests a more conservative approach to the use of CT head scans based on clinical factors [ 5 , 8 , 29 ]. On the other hand, seizures represent clinically significant situations that require experienced assessment for accurate and timely patient guidance for further management.…”

“…Due to increased availability and fast scanning speeds, almost all patients with seizures or a history of symptom related seizures (uncontrolled body stiffening, limb jerking, or sensory aura) usually undergo a CT head scans as part of their workup [ 5 – 7 ]. Based on previous evidence, CT head scans have shown a low yield, ranging from 3.2% to 21.3% [ 8 ]. The proportion of management changes after investigation was even lower [ 8 ].…”

“…Based on previous evidence, CT head scans have shown a low yield, ranging from 3.2% to 21.3% [ 8 ]. The proportion of management changes after investigation was even lower [ 8 ]. Requesting unnecessary CT head scans can lead to excessive costs, burdens on healthcare workers and unnecessary radiation exposure for patient.…”