Patients with new-onset focal seizures face delayed and missed diagnosis in emergent settings

By Frieda Wiley, PHARMD

credit: Scott Camazine / Science Source

Patients who have new-onset focal seizures often experience delayed diagnoses – a circumstance that contributes to worsened outcome, according to a recent study. Additionally, many of these patients initially present in the ED, with the outcomes hinging on the timeliness of the treatment they receive.

“Our study showed that a major cause of diagnostic delay in epilepsy is lack of recognition of nonmotor seizures in EDs, where a majority of patients with new-onset focal epilepsy present for initial evaluation of their symptoms,” said Jacqueline French, MD, professor at New York University Comprehensive Epilepsy Center and the study’s corresponding author. “Most striking was that people presenting to EDs with first lifetime motor seizures, such as bilateral tonic-clonic seizures, had a history of preceding nonmotor seizures that were unrecognized and therefore many patients who could have been diagnosed with epilepsy and started on treatment were not.”

Dr.  Jacqueline French

credit: SPL / Science Source

Epilepsy affects approximately 64 million people worldwide – more than half (60%) of whom have focal epilepsy. Seizures account for 1% of all ED visits and are the most common neurologic emergency. Data suggest that people who have focal epilepsy may experience seizures for months but choose to minimize their symptoms. By the time patients seek treatment, their condition has worsened, progressing to bilateral tonic-clonic convulsions.

However, a patient’s decision to postpone seeking treatment is not the only factor that hinders prompt diagnosis and treatment. Collecting an incomplete medical history when the patient presents to the ED can lead to missed diagnoses as well, said Dr. French. Even patients who seek timely diagnosis run the risk of being misdiagnosed, as the symptoms of focal epilepsy are often nonspecific and tend to mimic other conditions such as syncope and cardiac disorders, behavioral or psychiatric disorders, sleep disorders, and migraine-associated disorders. These factors often complicate the diagnosis and require expert consultation to sort out, which often further delays diagnosis and treatment.

The deleterious effects of delayed diagnoses extend beyond progression to bilateral tonic-clonic seizures for this patient population, said Rania El-Desoky, PharmD, BCPS, a postdoctoral academic fellow in the department of pharmacy practice and translational research at the University of Houston.

“In the ED, the health care team is comprised of nurses, providers, and pharmacists who play a vital role in recognizing, diagnosing, and treating a patient with focal seizures,” Dr. El-Desoky said in an interview. “A diagnostic delay or the seizure left untreated will likely contribute to the patient having worse outcomes, recurring episodes, decreased quality of life, and even progression to cause further complications and injuries to the patients due to uncontrolled seizure activity.”

Dr. French and colleagues enrolled 447 patients into their study who had new-onset focal epilepsy and were seen within 4 months following treatment initiation. Researchers incorporated seizure medical records and seizure diaries into their data collection. Based on symptomatology, seizures were classified as either subtle seizures (SS; primarily motor arrest or focal aware without motor; n = 246) or observable seizures (OS; primarily motor activity or verbal output, including generalized tonic-clonic seizures; n = 201). Both groups had similar baseline characteristics at the onset of epilepsy. Of the 132 patients who had SS and presented to the ED, 8 (6%) experienced their first subtle seizure episode. In the OS group, 147 presented to the ED, 134 (92%) of whom had their first-lifetime episode and 13 (9%) of whom had experienced multiple OS.

The study showed that antiepileptic therapy was not initiated in patients who had OS coupled with a history of numerous SS episodes more frequently than those who presented with a first-lifetime OS (93% vs. 43%). Both populations also had similar results for seizure identification as the chief complaint (85% vs. 87%). Results for whether the patient was admitted to the hospital or referred to a neurologist also mirrored both populations (87% vs. 79%).

Dr. French and Dr. El-Desoky share the opinion that the study highlights the need to improve recognition and treatment of epilepsy. Both stated the study provides value to the current literature, as it suggests that patients with a history of nonmotor seizures are less likely to be diagnosed with epilepsy upon presenting to the ED.

“This study supports the need for interventions that can help providers in recognizing and treating seizures in the ED, with a focus on nonmotor seizures,” said Dr. El-Desoky. “Providers should be educated to recognize that two or more events of unprovoked seizures more than 24 hours apart fits the definition of epilepsy and merits a referral to a neurologist or a neurologic consult in the inpatient setting.”

Dr. Rania El-Desoky

credit: Barbora Cvičková/Wikimedia/CC BY-SA 4.0

According to Dr. El-Desoky, potential limitations include the possibility of incomplete documentation of patient notes because of data collection from chart review and potential inclusion of patients with nonmotor seizures as EEG data and protocols to rule out such patients were not provided.

Dr. French noted that the patient population only included people who eventually sought treatment at a tertiary referral center and were enrolled in the study. For this reason, the results may not be generalizable because of socioeconomic, geographic, and insurance-related barriers to subspecialist evaluation. 

The study’s authors presented the details of their research at the American Academy of Neurology’s 2020 annual meeting, held virtually in May. The study was published online Aug. 18 in Academic Emergency Medicine.

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