Post‐acute symptomatic seizure (PASS) clinic: A continuity of care model for patients impacted by continuous EEG monitoring

Punia, Vineet; Chandan, Pradeep; Fesler, Jessica R.; Newey, Christopher R.; Hantus, Stephen

doi:10.1002/epi4.12393

Cited by 12 publications

(5 citation statements)

References 32 publications

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“…The level of experience and expertise with ASM management may differ among various neurological care providers. Post‐acute symptomatic seizure (PASS) clinics served by epileptologists with a major clinical interest and practice focus in cEEG monitoring could bridge this gap in clinical care and scientific knowledge 48 …”

Section: Discussionmentioning

confidence: 99%

Long‐term continuation of anti‐seizure medications after acute stroke

Punia

Honomichl

Chandan

et al. 2021

Ann Clin Transl Neurol

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Objective To investigate the factors associated with the long‐term continuation of anti‐seizure medications (ASMs) in acute stroke patients. Methods We performed a retrospective cohort study of stroke patients with concern for acute symptomatic seizures (ASySs) during hospitalization who subsequently visited the poststroke clinic. All patients had continuous EEG (cEEG) monitoring. We generated a multivariable logistic regression model to analyze the factors associated with the primary outcome of continued ASM use after the first poststroke clinic visit. Results A total of 507 patients (43.4% ischemic stroke, 35.7% intracerebral hemorrhage, and 20.9% aneurysmal subarachnoid hemorrhage) were included. Among them, 99 (19.5%) suffered from ASySs, 110 (21.7%) had epileptiform abnormalities (EAs) on cEEG, and 339 (66.9%) had neither. Of the 294 (58%) patients started on ASMs, 171 (33.7%) were discharged on them, and 156 (30.3% of the study population; 53.1% of patients started on ASMs) continued ASMs beyond the first poststroke clinic visit [49.7 (±31.7) days after cEEG]. After adjusting for demographical, stroke‐ and hospitalization‐related variables, the only independent factors associated with the primary outcome were admission to the NICU [Odds ratio (OR) 0.37 (95% CI 0.15–0.9)], the presence of ASySs [OR 20.31(95% CI 9.45–48.43)], and EAs on cEEG [OR 2.26 (95% CI 1.14–4.58)]. Interpretation Almost a third of patients with poststroke ASySs concerns may continue ASMs for the long term, including more than half started on them acutely. Admission to the NICU may lower the odds, and ASySs (convulsive or electrographic) and EAs on cEEG significantly increase the odds of long‐term ASM use.

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Section: Discussionmentioning

confidence: 99%

Long‐term continuation of anti‐seizure medications after acute stroke

Punia

Honomichl

Chandan

et al. 2021

Ann Clin Transl Neurol

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“…The indication for an outpatient EEG in one‐thirds of the study population was to guide ASM management. Of note, 7 out of 8 patients who successfully discontinued ASMs were under the care of epileptologists, highlighting the importance of models of outpatient care like post‐acute symptomatic seizure (PASS) clinic reported by us recently 15 …”

Section: Discussionmentioning

confidence: 96%

Long‐term electro‐clinical profile of sudden cardiac arrest survivors

et al. 2021

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Objective Recent research has explored the use of continuous EEG (cEEG) monitoring for prognostication of spontaneous cardiac arrest (SCA). However, there is limited literature on the long‐term (post‐hospital discharge) electrographic findings among SCA survivors and their clinical correlates. Our study aims to fill this critical knowledge gap. Methods We retrospectively used our EEG database to identify adults (≥18 years) with SCA history who underwent an outpatient laboratory‐based EEG between 01/01/2011 and 12/31/2018. After electronic medical records (EMR) review, patients with epilepsy history and unclear/poorly documented SCA history were excluded. Outpatient EEGs were reviewed by authors. Acute EEG findings were extracted from the EEG database and EMR. In addition, we extracted data on acute and long‐term neuroimaging findings (CT/MRI), post‐SCA seizures, and anti‐seizure medications (ASM) status. Descriptive analysis and Fisher's exact test were performed. Results We included 32 SCA survivors (50% women; mean age = 52.1 ± 13.6 years) in the study. During a median clinical follow‐up of 28.2 months, 3 patients suffered only clinical seizures, 3 only chronic post‐hypoxic myoclonus, and 5 had both [11 (34.4%) in total]. Interictal epileptiform discharges (IEDs) were noted in one‐third of the patients, which localized to vertex and frontocentral regions in all but one patient. Five (15.6%) of them did not suffer a clinical seizure despite the presence of EAs. Patients who developed epilepsy were significantly more likely to have abnormal neuroimaging findings [10/11 (90.9%)] during the follow‐up compared to the rest of the patients [OR = 25 (95% CI 2.6–>100, P = .002)]. Half of the study cohort was taking ASM at the last follow‐up. Significance Our small study reveals a signature location of IEDs in SCA survivors. Neuroimaging abnormalities seem to be a better indicator of epilepsy development, while EEG may reveal markers of potential epileptogenicity in the absence of clinical seizures. Future, larger studies are needed to confirm our findings.

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“…Therefore, safely weaning ASMs in patients with a 20%–30% risk of spontaneous seizures requires a balancing act. Without evidence‐backed knowledge to manage these patients, post‐acute symptomatic seizure (PASS) clinics are proposed to provide uniform and systematic outpatient specialty care 29,30 …”

Section: Discussionmentioning

confidence: 99%

“…Without evidence-backed knowledge to manage these patients, post-acute symptomatic seizure (PASS) clinics are proposed to provide uniform and systematic outpatient specialty care. 29,30 The variability in available resources, health care systems, delivery mechanisms, and conventional local wisdom can influence clinical practice. Such factors possibly explain the difference in the management approach of respondents based on their country and cEEG availability.…”

Section: Possible Reasons and Impact Of Equipoisementioning

confidence: 99%

Immediate and long‐term management practices of acute symptomatic seizures and epileptiform abnormalities: A cross‐sectional international survey

Punia,

Daruvala,

Dhakar

et al. 2024

Epilepsia

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ObjectivesAcute symptomatic seizures (ASyS) and epileptiform abnormalities (EAs) on electroencephalography (EEG) are commonly encountered following acute brain injury. Their immediate and long‐term management remains poorly investigated. We conducted an international survey to understand their current management.MethodsThe cross‐sectional web‐based survey of 21 fixed‐response questions was based on a common clinical encounter: convulsive or suspected ASyS following an acute brain injury. Respondents selected the option that best matched their real‐world practice. Respondents completing the survey were compared with those who accessed but did not complete it.ResultsA total of 783 individuals (44 countries) accessed the survey; 502 completed it. Almost everyone used anti‐seizure medications (ASMs) for secondary prophylaxis after convulsive or electrographic ASyS (95.4% and 97.2%, respectively). ASM dose escalation after convulsive ASyS depends on continuous EEG (cEEG) findings: most often increased after electrographic seizures (78% of respondents), followed by lateralized periodic discharges (LPDs; 41%) and sporadic epileptiform discharges (sEDs; 17.5%). If cEEG is unrevealing, one in five respondents discontinue ASMs after a week. In the absence of convulsive and electrographic ASyS, a large proportion of respondents start ASMs due to LPD (66.7%) and sED (44%) on cEEG. At hospital discharge, most respondents (85%) continue ASM without dose change. The recommended duration of outpatient ASM use is as follows: 1–3 months (36%), 3–6 months (30%), 6–12 months (13%), >12 months (11%). Nearly one‐third of respondents utilized ancillary testing before outpatient ASM taper, most commonly (79%) a <2 h EEG. Approximately half of respondents had driving restrictions recommended for 6 months after discharge.SignificanceASM use for secondary prophylaxis after convulsive and electrographic ASyS is a universal practice and is continued upon discharge. Outpatient care, particularly the ASM duration, varies significantly. Wide practice heterogeneity in managing acute EAs reflects uncertainty about their significance and management. These results highlight the need for a structured outpatient follow‐up and optimized care pathway for patients with ASyS.

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Post‐acute symptomatic seizure (PASS) clinic: A continuity of care model for patients impacted by continuous EEG monitoring

Cited by 12 publications

References 32 publications

Long‐term continuation of anti‐seizure medications after acute stroke

Long‐term continuation of anti‐seizure medications after acute stroke

Long‐term electro‐clinical profile of sudden cardiac arrest survivors

Immediate and long‐term management practices of acute symptomatic seizures and epileptiform abnormalities: A cross‐sectional international survey

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