The Impact of Clinical Seizure Characteristics on Recognition and Treatment of New‐onset Focal Epilepsy in Emergency Departments

Abstract

Objective Many people with new‐onset focal epilepsy initially seek evaluation in emergency departments (EDs), and treatment decisions in EDs can influence likelihood of seizure recurrence. Using data collected for the Human Epilepsy Project (HEP), we assessed the effect of clinical seizure characteristics on ED clinical management. Methods There were 447 participants with new‐onset focal epilepsy seen within 4 months of treatment initiation who were eligible and enrolled in HEP. Seizure calendars and medical records were collected. Based on clinical descriptions, seizures were categorized by semiology according to International League Against Epilepsy (ILAE) classifications as either focal nonmotor or focal motor seizures. Results Overall, 279 of 447(62%) of participants had presented to an ED prior to or at time of epilepsy diagnosis. A total of 132 of 246 (53%) with initial nonmotor seizures presented to an ED. Of these, eight (6%) presented with a first‐lifetime nonmotor seizure. The other 124 (94%) presented after multiple seizures: seven (5%) with multiple nonmotor seizures and 117 (89%) with a first‐lifetime motor seizure after having prior nonmotor seizures. A total of 147 of 201 (73%) participants with initial motor seizures presented to an ED. Of these, 134 (92%) presented with a first‐lifetime motor seizure and 13 (9%) with multiple motor seizures. There was no difference in the likelihood of antiseizure medication initiation between participants who had multiple prior nonmotor seizures followed by a motor seizure (thereby fulfilling the criterion for an epilepsy diagnosis) versus those presenting with a single lifetime motor seizure (39% vs. 43%). There was no difference in recognition of seizures as the presenting complaint (85% vs. 87%) or whether the participant was admitted or referred to a neurologist (87% vs. 79%). Conclusions This study contributes to evidence of underrecognition of nonmotor focal seizure semiologies in ED settings, which can support large‐scale interventions aimed at improving recognition, specialist consultation, and treatment in ED settings.

Missed, mistaken, stalled: Identifying components of delay to diagnosis in epilepsy

“…After assessment of full-text papers, we found 15 papers that met the criteria for inclusion, plus an additional two earlier papers from our own library (see Tables S1 and S2). [2][3][4][15][16][17][18][19][20][21][22][23][24][25][26][27][28] One paper was a registry study that used International Classification of Diseases (ICD) codes to identify patients and included individuals who obtained antiepileptic drugs (AEDs) before the epilepsy diagnosis was coded. 23 This study was included, as it met our criteria, and the numbers of treated and nontreated patients were noted.…”

“…After the removal of duplicates, a review of abstracts resulted in 54 potentially eligible studies. After assessment of full‐text papers, we found 15 papers that met the criteria for inclusion, plus an additional two earlier papers from our own library (see Tables and ) 2–4,15–28 . One paper was a registry study that used International Classification of Diseases (ICD) codes to identify patients and included individuals who obtained antiepileptic drugs (AEDs) before the epilepsy diagnosis was coded 23 .…”

Closing the Diagnostic Gap in Epilepsy: Recognizing More Than Just Motor Seizures

“…Pellinen et al examined the role of the latter through an analysis of the outcomes of emergency department (ED) visits in the same multicenter cohort of newly diagnosed focal epilepsy. 8 They found that the majority of those with nonmotor seizures presented to an ED after their first motor seizure, but that in those with prior nonmotor seizures, that history was elicited by the ED physician in only one-fifth of cases.…”

Missed Opportunities in New‐onset Seizures in the Emergency Department

“…Patients in whom no underlying reason for a first lifetime seizure is found may have had an isolated event or may develop recurring seizures and a diagnosis of epilepsy. The observational study by Pellinen et al 1 published in this issue of Academic Emergency Medicine serves to teach us about this latter cohort of patients using a database of those subsequently diagnosed with focal epilepsy after an initial ED visit.…”

“…Pellinen et al 1 use a registry of patients with newly diagnosed focal epilepsy to describe the characteristics of a subset who presented to an ED shortly prior to their diagnosis. The authors note that the first onset of epilepsy was nonmotor focal seizures in slightly more than half of the patients in the ED subset, but that they rarely came to the ED for these types of seizures.…”