1
|
Smith MD, Sampson CS, Wall SP, Diercks DB, Diercks DB, Anderson JD, Byyny R, Carpenter CR, Friedman BW, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Mattu A, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Thompson JT, Tomaszewski CA, Trent SA, Valente JH, Westafer LM, Wall SP, Yu Y, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Seizures: Approved by the ACEP Board of Directors, April 17, 2024. Ann Emerg Med 2024; 84:e1-e12. [PMID: 38906639 DOI: 10.1016/j.annemergmed.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024]
|
2
|
Pellinen J, Foster EC, Wilmshurst JM, Zuberi SM, French J. Improving epilepsy diagnosis across the lifespan: approaches and innovations. Lancet Neurol 2024; 23:511-521. [PMID: 38631767 DOI: 10.1016/s1474-4422(24)00079-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 02/11/2024] [Accepted: 02/16/2024] [Indexed: 04/19/2024]
Abstract
Epilepsy diagnosis is often delayed or inaccurate, exposing people to ongoing seizures and their substantial consequences until effective treatment is initiated. Important factors contributing to this problem include delayed recognition of seizure symptoms by patients and eyewitnesses; cultural, geographical, and financial barriers to seeking health care; and missed or delayed diagnosis by health-care providers. Epilepsy diagnosis involves several steps. The first step is recognition of epileptic seizures; next is classification of epilepsy type and whether an epilepsy syndrome is present; finally, the underlying epilepsy-associated comorbidities and potential causes must be identified, which differ across the lifespan. Clinical history, elicited from patients and eyewitnesses, is a fundamental component of the diagnostic pathway. Recent technological advances, including smartphone videography and genetic testing, are increasingly used in routine practice. Innovations in technology, such as artificial intelligence, could provide new possibilities for directly and indirectly detecting epilepsy and might make valuable contributions to diagnostic algorithms in the future.
Collapse
Affiliation(s)
- Jacob Pellinen
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Emma C Foster
- Department of Neurosciences, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Jo M Wilmshurst
- Red Cross War Memorial Children's Hospital and University of Cape Town Neuroscience Institute, Cape Town, South Africa
| | - Sameer M Zuberi
- Royal Hospital for Children and University of Glasgow School of Health & Wellbeing, Glasgow, UK
| | - Jacqueline French
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, USA
| |
Collapse
|
3
|
Jandhyala N, Ferrer M, Pellinen J, Greenwood HT, Dlugos DJ, Park KL, Thio LL, French J. Unrecognized Focal Nonmotor Seizures in Adolescents Presenting to Emergency Departments. Neurology 2024; 102:e209389. [PMID: 38691824 PMCID: PMC11404317 DOI: 10.1212/wnl.0000000000209389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Many adolescents with undiagnosed focal epilepsy seek evaluation in emergency departments (EDs). Accurate history-taking is essential to prompt diagnosis and treatment. In this study, we investigated ED recognition of motor vs nonmotor seizures and its effect on management and treatment of focal epilepsy in adolescents. METHODS This was a retrospective analysis of enrollment data from the Human Epilepsy Project (HEP), an international multi-institutional study that collected data from 34 sites between 2012 and 2017. Participants were 12 years or older, neurotypical, and within 4 months of treatment initiation for focal epilepsy. We used HEP enrollment medical records to review participants' initial diagnosis and management. RESULTS A total of 83 adolescents were enrolled between 12 and 18 years. Fifty-eight (70%) presented to an ED before diagnosis of epilepsy. Although most ED presentations were for motor seizures (n = 52; 90%), many patients had a history of nonmotor seizures (20/52 or 38%). Adolescents with initial nonmotor seizures were less likely to present to EDs (26/44 or 59% vs 32/39 or 82%, p = 0.02), and nonmotor seizures were less likely to be correctly identified (2/6 or 33% vs 42/52 or 81%, p = 0.008). A history of initial nonmotor seizures was not recognized in any adolescent who presented for a first-lifetime motor seizure. As a result, initiation of treatment and admission from the ED was not more likely for these adolescents who met the definition of epilepsy compared with those with no seizure history. This lack of nonmotor seizure history recognition in the ED was greater than that observed in the adult group (0% vs 23%, p = 0.03) and occurred in both pediatric and nonpediatric ED settings. DISCUSSION Our study supports growing evidence that nonmotor seizures are often undiagnosed, with many individuals coming to attention only after conversion to motor seizures. We found this treatment gap is exacerbated in the adolescent population. Our study highlights a critical need for physicians to inquire about the symptoms of nonmotor seizures, even when the presenting seizure is motor. Future interventions should focus on improving nonmotor seizure recognition for this population in EDs.
Collapse
Affiliation(s)
- Nora Jandhyala
- From the Department of Neurology (N.J.), NYU Langone Health, New York; Departments of Pediatrics and Neurology (M.F.) and Neurology (H.T.G., J.F.), NYU Grossman School of Medicine, New York, NY; Departments of Neurology (J.P.) and Pediatrics and Neurology (K.L.P.), University of Colorado School of Medicine, Aurora; Department of Neurology (D.J.D.), Children's' Hospital of Philadelphia, PA; and Department of Neurology (L.L.T.), Washington University in St. Louis, MO
| | - Monica Ferrer
- From the Department of Neurology (N.J.), NYU Langone Health, New York; Departments of Pediatrics and Neurology (M.F.) and Neurology (H.T.G., J.F.), NYU Grossman School of Medicine, New York, NY; Departments of Neurology (J.P.) and Pediatrics and Neurology (K.L.P.), University of Colorado School of Medicine, Aurora; Department of Neurology (D.J.D.), Children's' Hospital of Philadelphia, PA; and Department of Neurology (L.L.T.), Washington University in St. Louis, MO
| | - Jacob Pellinen
- From the Department of Neurology (N.J.), NYU Langone Health, New York; Departments of Pediatrics and Neurology (M.F.) and Neurology (H.T.G., J.F.), NYU Grossman School of Medicine, New York, NY; Departments of Neurology (J.P.) and Pediatrics and Neurology (K.L.P.), University of Colorado School of Medicine, Aurora; Department of Neurology (D.J.D.), Children's' Hospital of Philadelphia, PA; and Department of Neurology (L.L.T.), Washington University in St. Louis, MO
| | - Hadley T Greenwood
- From the Department of Neurology (N.J.), NYU Langone Health, New York; Departments of Pediatrics and Neurology (M.F.) and Neurology (H.T.G., J.F.), NYU Grossman School of Medicine, New York, NY; Departments of Neurology (J.P.) and Pediatrics and Neurology (K.L.P.), University of Colorado School of Medicine, Aurora; Department of Neurology (D.J.D.), Children's' Hospital of Philadelphia, PA; and Department of Neurology (L.L.T.), Washington University in St. Louis, MO
| | - Dennis J Dlugos
- From the Department of Neurology (N.J.), NYU Langone Health, New York; Departments of Pediatrics and Neurology (M.F.) and Neurology (H.T.G., J.F.), NYU Grossman School of Medicine, New York, NY; Departments of Neurology (J.P.) and Pediatrics and Neurology (K.L.P.), University of Colorado School of Medicine, Aurora; Department of Neurology (D.J.D.), Children's' Hospital of Philadelphia, PA; and Department of Neurology (L.L.T.), Washington University in St. Louis, MO
| | - Kristen L Park
- From the Department of Neurology (N.J.), NYU Langone Health, New York; Departments of Pediatrics and Neurology (M.F.) and Neurology (H.T.G., J.F.), NYU Grossman School of Medicine, New York, NY; Departments of Neurology (J.P.) and Pediatrics and Neurology (K.L.P.), University of Colorado School of Medicine, Aurora; Department of Neurology (D.J.D.), Children's' Hospital of Philadelphia, PA; and Department of Neurology (L.L.T.), Washington University in St. Louis, MO
| | - Liu Lin Thio
- From the Department of Neurology (N.J.), NYU Langone Health, New York; Departments of Pediatrics and Neurology (M.F.) and Neurology (H.T.G., J.F.), NYU Grossman School of Medicine, New York, NY; Departments of Neurology (J.P.) and Pediatrics and Neurology (K.L.P.), University of Colorado School of Medicine, Aurora; Department of Neurology (D.J.D.), Children's' Hospital of Philadelphia, PA; and Department of Neurology (L.L.T.), Washington University in St. Louis, MO
| | - Jacqueline French
- From the Department of Neurology (N.J.), NYU Langone Health, New York; Departments of Pediatrics and Neurology (M.F.) and Neurology (H.T.G., J.F.), NYU Grossman School of Medicine, New York, NY; Departments of Neurology (J.P.) and Pediatrics and Neurology (K.L.P.), University of Colorado School of Medicine, Aurora; Department of Neurology (D.J.D.), Children's' Hospital of Philadelphia, PA; and Department of Neurology (L.L.T.), Washington University in St. Louis, MO
| |
Collapse
|
4
|
Ando T, Fujikawa H. A Case of Focal Seizures Presented With Recurrent Sweating and Chills. Cureus 2024; 16:e53139. [PMID: 38420087 PMCID: PMC10900175 DOI: 10.7759/cureus.53139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Focal seizures, characterized by excessive electrical excitation in a brain region, present diagnostic challenges due to diverse manifestations, particularly with non-motor symptoms. Here, we present a 69-year-old Japanese woman experiencing unexplained recurrent episodes of sweating, chills, and shivering. Despite exhaustive investigations that identified no abnormalities, her symptoms remained unalleviated by symptomatic treatments. The episodic nature of her presentations subsequently prompted a clinical suspicion of seizures, leading to further neurological evaluations. Magnetic resonance imaging (MRI) of the brain and electroencephalography (EEG) revealed chronic ischemic changes in the cerebral white matter and intermittent sharp and slow wave bursts in the frontal regions. These findings led to a diagnosis of focal seizures manifesting as autonomic symptoms. The patient's symptoms were successfully treated with carbamazepine. This case illustrates the importance of considering non-motor focal seizures in patients with episodic symptoms, even when routine tests show no abnormalities.
Collapse
Affiliation(s)
- Takayuki Ando
- Center for General Medicine Education, School of Medicine, Keio University, Tokyo, JPN
| | - Hirohisa Fujikawa
- Department of Internal Medicine, Suwa Central Hospital, Nagano, JPN
- Center for General Medicine Education, School of Medicine, Keio University, Tokyo, JPN
| |
Collapse
|
5
|
Pellinen J, Pardoe H, Sillau S, Barnard S, French J, Knowlton R, Lowenstein D, Cascino GD, Glynn S, Jackson G, Szaflarski J, Morrison C, Meador KJ, Kuzniecky R. Later onset focal epilepsy with roots in childhood: Evidence from early learning difficulty and brain volumes in the Human Epilepsy Project. Epilepsia 2023; 64:2761-2770. [PMID: 37517050 DOI: 10.1111/epi.17727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/26/2023] [Accepted: 07/26/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE Visual assessment of magnetic resonance imaging (MRI) from the Human Epilepsy Project 1 (HEP1) found 18% of participants had atrophic brain changes relative to age without known etiology. Here, we identify the underlying factors related to brain volume differences in people with focal epilepsy enrolled in HEP1. METHODS Enrollment data for participants with complete records and brain MRIs were analyzed, including 391 participants aged 12-60 years. HEP1 excluded developmental or cognitive delay with intelligence quotient <70, and participants reported any formal learning disability diagnoses, repeated grades, and remediation. Prediagnostic seizures were quantified by semiology, frequency, and duration. T1-weighted brain MRIs were analyzed using Sequence Adaptive Multimodal Segmentation (FreeSurfer v7.2), from which a brain tissue volume to intracranial volume ratio was derived and compared to clinically relevant participant characteristics. RESULTS Brain tissue volume changes observable on visual analyses were quantified, and a brain tissue volume to intracranial volume ratio was derived to compare with clinically relevant variables. Learning difficulties were associated with decreased brain tissue volume to intracranial volume, with a ratio reduction of .005 for each learning difficulty reported (95% confidence interval [CI] = -.007 to -.002, p = .0003). Each 10-year increase in age at MRI was associated with a ratio reduction of .006 (95% CI = -.007 to -.005, p < .0001). For male participants, the ratio was .011 less than for female participants (95% CI = -.014 to -.007, p < .0001). There were no effects from seizures, employment, education, seizure semiology, or temporal lobe electroencephalographic abnormalities. SIGNIFICANCE This study shows lower brain tissue volume to intracranial volume in people with newly treated focal epilepsy and learning difficulties, suggesting developmental factors are an important marker of brain pathology related to neuroanatomical changes in focal epilepsy. Like the general population, there were also independent associations between brain volume, age, and sex in the study population.
Collapse
Affiliation(s)
- Jacob Pellinen
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Heath Pardoe
- Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Stefan Sillau
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Jacqueline French
- New York University Comprehensive Epilepsy Center, New York, New York, USA
| | - Robert Knowlton
- University of California, San Francisco, San Francisco, California, USA
| | - Daniel Lowenstein
- University of California, San Francisco, San Francisco, California, USA
| | | | - Simon Glynn
- University of Michigan, Ann Arbor, Michigan, USA
| | - Graeme Jackson
- Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | | | - Chris Morrison
- New York University Comprehensive Epilepsy Center, New York, New York, USA
| | - Kimford J Meador
- Stanford University Neuroscience Health Center, Palo Alto, California, USA
| | | |
Collapse
|
6
|
On epilepsy perception: Unravelling gaps and issues. Epilepsy Behav 2022; 137:108952. [PMID: 36306590 DOI: 10.1016/j.yebeh.2022.108952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/09/2022] [Accepted: 10/10/2022] [Indexed: 01/05/2023]
Abstract
Epilepsy is one of the most common neurological diseases, but it can sometimes be under-reported or have a time delay in diagnosis. This data is not surprising if we consider that a person often seeks medical attention only after presenting a generalized tonic-clonic seizure. Epilepsy diagnostic delay is caused by several factors: under-reporting by patients, under-diagnosed epileptic manifestations by inexperienced clinicians, and lack of time in the emergency setting. The consequences of this delay are increased accidents, a high rate of premature mortality, and economic expanses for the healthcare system. Moreover, people with epilepsy have a higher probability of comorbidities than the general population, such as mood disorders or cognitive problems. Along with recurrent seizures, these comorbid diseases promote isolation and stigmatization of people with epilepsy, who suffer from discrimination at school, in the workplace, and even in social relationships. Public awareness of epilepsy and its comorbidities is necessary to prevent diagnostic delays and overcome social and professional iniquities for people with epilepsy.
Collapse
|
7
|
Pellinen J. Treatment gaps in epilepsy. FRONTIERS IN EPIDEMIOLOGY 2022; 2:976039. [PMID: 38455298 PMCID: PMC10910960 DOI: 10.3389/fepid.2022.976039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/18/2022] [Indexed: 03/09/2024]
Abstract
Over 50 million people around the world have epilepsy, and yet, epilepsy recognition and access to care are ongoing issues. Nearly 80% of people with epilepsy live in low-and middle-income countries and face the greatest barriers to quality care. However, there are substantial disparities in care within different communities in high-income countries as well. Across the world, under-recognition of seizures continues to be an issue, leading to diagnostic and treatment delays. This stems from issues surrounding stigma, public education, basic access to care, as well as healthcare worker education. In different regions, people may face language barriers, economic barriers, and technological barriers to timely diagnosis and treatment. Even once diagnosed, people with epilepsy often face gaps in optimal seizure control with the use of antiseizure medications. Additionally, nearly one-third of people with epilepsy may be candidates for epilepsy surgery, and many either do not have access to surgical centers or are not referred for surgical evaluation. Even those who do often experience delays in care. The purpose of this review is to highlight barriers to care for people with epilepsy, including issues surrounding seizure recognition, diagnosis of epilepsy, and the initiation and optimization of treatment.
Collapse
|
8
|
An aqueous extract of Khaya senegalensis (Desv.) A. Juss. (Meliaceae) prevents seizures and reduces anxiety in kainate-treated rats: modulation of GABA neurotransmission, oxidative stress, and neuronal loss in the hippocampus. Heliyon 2022; 8:e09549. [PMID: 35663738 PMCID: PMC9160348 DOI: 10.1016/j.heliyon.2022.e09549] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/28/2022] [Accepted: 05/23/2022] [Indexed: 11/22/2022] Open
Abstract
Ethnopharmacological relevance Temporal lobe epilepsy is the most common form of drug-resistant epilepsy. Therefore, medicinal plants provide an alternative source for the discovery of new antiepileptic drugs. Aim of the study This study was aimed at investigating the antiepileptic- and anxiolytic-like effects of an aqueous extract of Khaya senegalensis (K. senegalensis) in kainate-treated rats. Methods Seventy-two rats received a single dose of kainate (12 mg/kg) intraperitoneally. Those that exhibited two hours of status epilepticus were selected and monitored for the first spontaneous seizure. Then, animals that developed seizures were divided into 6 groups of 8 rats each and treated twice daily for 14 days as follows: negative control group received per os (p.o.) distilled water (10 ml/kg); two positive control groups received either sodium valproate (300 mg/kg, p.o.) or phenobarbital (20 mg/kg, p.o.); and three test groups received different doses of the extract (50, 100, and 200 mg/kg, p.o.). In addition, a group of 8 normal rats (normal control group) received distilled water (10 ml/kg, p.o.). During the treatment period, the animals were video-monitored 12 h/day for behavioral seizures. At the end of the treatment period, animals were subjected to elevated plus-maze and open field tests. Thereafter, rats were euthanized for the analysis of γ-aminobutyric acid (GABA) concentration, oxidative stress status, and neuronal loss in the hippocampus. Results The aqueous extract of K. senegalensis significantly reduced spontaneous recurrent seizures (generalized tonic-clonic seizures) and anxiety-like behavior compared to the negative control group. These effects were more marked than those of sodium valproate or phenobarbital. Furthermore, the extract significantly increased GABA concentration, alleviated oxidative stress, and mitigated neuronal loss in the dentate gyrus of the hippocampus. Conclusion These findings suggest that the aqueous extract of K. senegalensis possesses antiepileptic- and anxiolytic-like effects. These effects were greater than those of sodium valproate or phenobarbital, standard antiepileptic drugs. Furthermore, these effects are accompanied by neuromodulatory and antioxidant activities that may be related to their behavioral effects. These data justify further studies to identify the bioactive molecules present in the extract for possible future therapeutic development and to unravel their mechanisms of action.
Collapse
|
9
|
Pellinen J, Snyder E, Knupp KG. The language of seizure identification: A qualitative investigation. Epilepsy Behav 2022; 126:108484. [PMID: 34915429 DOI: 10.1016/j.yebeh.2021.108484] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/08/2021] [Accepted: 11/28/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Clinical history taking is often the most important factor in seizure recognition and the diagnosis of epilepsy. Apart from subspecialist evaluation, patients frequently present for initial evaluation of seizures in emergency departments, urgent care clinics, and primary care clinics. We utilized qualitative methods to assess the current approaches and language used by both subspecialist and non-specialist physicians when interviewing adult patients with suspected seizures to create a clinical tool to aid in seizure diagnosis. METHODS We carried out semi- structured interviews with 10 physicians spanning a range of specialties, practice locations, and clinical experience. This included epilepsy specialists and non-specialists in fields where evaluation of new-onset seizures is common: emergency medicine, internal medicine, and family medicine. Thematic analysis was used to develop a "Seizure Identifier" questionnaire, which was subsequently reviewed by five independent experts for content and face validity. RESULTS Our analysis revealed that across specialties and practice settings, physicians have a structured approach in evaluating patients who present with suspected seizures. Five key characteristics important for identifying seizures emerged across interviews: sudden-onset unprovoked symptoms, short-lasting symptoms, strange or difficult-to-describe symptoms, highly stereotyped symptoms, and postictal symptoms. After independent review, these were translated into an eight-question "Seizure Identifier" tool. SIGNIFICANCE This study highlights important concepts for clinical practice regarding seizure identification. Using themes from our analysis, we were able to create a tool that may aid non-specialists in the approach to history taking for adult patients who present with suspected seizures and may help improve time to subspecialist evaluation. Importantly, this tool can be tested in future research for improving seizure recognition and improving timely epilepsy diagnosis.
Collapse
Affiliation(s)
- Jacob Pellinen
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Ellen Snyder
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kelly G Knupp
- Departments of Pediatrics and Neurology, University of Colorado School of Medicine, Aurora, CO, USA; University of Colorado School of Medicine, Department of Neurology, Aurora, CO, USA
| |
Collapse
|
10
|
Steriade C. Closing the Diagnostic Gap in Epilepsy: Recognizing More Than Just Motor Seizures. Epilepsy Curr 2021; 21:173-174. [PMID: 34867097 PMCID: PMC8609599 DOI: 10.1177/1535759721994807] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
[Box: see text]
Collapse
|
11
|
Pellinen J, French J, Knupp KG. Diagnostic Delay in Epilepsy: the Scope of the Problem. Curr Neurol Neurosci Rep 2021; 21:71. [PMID: 34817723 DOI: 10.1007/s11910-021-01161-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Diagnostic delay is an increasingly recognized issue in epilepsy. At the same time, there is a clear disparity between public awareness of epilepsy and that of other public health issues. A contributing factor for this seems to be a lack of studies testing interventions designed to improve seizure recognition. In this review, we summarize the main findings from recent studies investigating diagnostic delay in epilepsy, highlighting causes, consequences, and potential interventions in future research that may improve quality of care in this population. RECENT FINDINGS Building on prior evidence, diagnostic delay in patients with new-onset focal epilepsy has been identified as an important problem for patients with epilepsy. Such delay in diagnosis can lead to delayed treatment and potentially preventable morbidity and mortality including motor vehicle accidents. Nonmotor seizure semiology appears to be a major contributor for delay; such seizures are largely unrecognized when patients present to emergency departments for care. Improving recognition and diagnosis of recurrent nonmotor seizures in emergency departments represents a significant opportunity for improving time to diagnosis, particularly when patients present following a first lifetime motor seizure and meet diagnostic criteria for epilepsy. Diagnostic delay in epilepsy is a significant public health issue and recent studies have highlighted potential areas for intervention.
Collapse
Affiliation(s)
- Jacob Pellinen
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Jaqueline French
- Comprehensive Epilepsy Center, New York University School of Medicine, New York, NY, USA
| | - Kelly G Knupp
- Departments of Pediatrics and Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
12
|
Alessi N, Perucca P, McIntosh AM. Missed, mistaken, stalled: Identifying components of delay to diagnosis in epilepsy. Epilepsia 2021; 62:1494-1504. [PMID: 34013535 DOI: 10.1111/epi.16929] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/16/2021] [Accepted: 04/30/2021] [Indexed: 11/27/2022]
Abstract
A substantial proportion of individuals with newly diagnosed epilepsy report prior seizures, suggesting a missed opportunity for early epilepsy care and management. Consideration of the causes and outcomes of diagnostic delay is needed to address this issue. We aimed to review the literature pertaining to delay to diagnosis of epilepsy, describing the components, characteristics, and risk factors for delay. We undertook a systematic search of the literature for full-length original research papers with a focus on diagnostic delay or seizures before diagnosis, published 1998-2020. Findings were collated, and a narrative review was undertaken. Seventeen papers met the inclusion criteria. Studies utilized two measures of diagnostic delay: seizures before diagnosis and/or a study-defined time between first seizure and presentation/diagnosis. The proportion of patients with diagnostic delay ranged from 16% to 77%; 75% of studies reported 38% or more to be affected. Delays of 1 year or more were reported in 13%-16% of patients. Seizures prior to diagnosis were predominantly nonconvulsive, and usually more than one seizure was reported. Prior seizures were often missed or mistaken for symptoms of other conditions. Key delays in the progression to specialist review and diagnosis were (1) "decision delay" (the patient's decision to seek/not seek medical review), (2) "referral delay" (delay by primary care/emergency physician referring to specialist), and (3) "attendance delay" (delay in attending specialist review). There were few data available relevant to risk factors and virtually none relevant to outcomes of diagnostic delay. This review found that diagnostic delay consists of several components, and progression to diagnosis can stall at several points. There is limited information relating to most aspects of delay apart from prevalence and seizure types. Risk factors and outcomes may differ according to delay characteristics and for each of the key delays, and recommendations for future research include examining each before consideration of interventions is made.
Collapse
Affiliation(s)
- Natasha Alessi
- Department of Medicine (Austin Health), Epilepsy Research Centre, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, Melbourne Brain Centre, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Piero Perucca
- Department of Medicine (Austin Health), Epilepsy Research Centre, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, Melbourne Brain Centre, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Neurology, Comprehensive Epilepsy Program, Austin Health, Melbourne, Victoria, Australia.,Department of Neurology, Alfred Health, Melbourne, Victoria, Australia.,Central Clinical School, Department of Neuroscience, Monash University, Melbourne, Victoria, Australia
| | - Anne M McIntosh
- Department of Medicine (Austin Health), Epilepsy Research Centre, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, Melbourne Brain Centre, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Neurology, Comprehensive Epilepsy Program, Austin Health, Melbourne, Victoria, Australia
| |
Collapse
|
13
|
Zehtabchi S, Silbergleit R. Missed Opportunities in New-onset Seizures in the Emergency Department. Acad Emerg Med 2021; 28:477-479. [PMID: 33184915 DOI: 10.1111/acem.14173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/05/2020] [Indexed: 11/30/2022]
|