Acil Servise Nöbet Şikayeti ile Başvuran Olguların Görüntüleme Bulgularının Analizi
Özet
Objective: In this study, our aim was to evaluate the imaging findings of patients admitted to the emergency department with seizures during the period of January 2009 – July 2017.
Material and method:1002 patients with an admission diagnosis of seizure during the period of January 2009 – July 2017 were included in this study. After the evaluation of medical records, 202 of them were excluded due to a final diagnosis of syncope or inability to differentiate syncope from seizure. Features including age, gender, established diagnosis of epilepsy, new-onset seizure and coexisting disease (neoplastic and non-neoplastic) were determined for all patients. The patients were analyzed in two groups: new-onset seizure cases and cases with a history of epilepsy. Both groups were further stratified according presence or absence of a medical history; patients with medical history were classified into neoplastic and non-neoplastic groups; neoplastic ones were categorized into intracranial and extracranial neoplasms, intracranial neoplasia into primary central nervous system (CNS) neoplasia and metastasis, and primary CNS neoplasias into glioblastoma and other intracranial neoplasms. Patients with non–neoplastic medical disease history were stratified according to involvement of CNS. Patients with disorders involving the CNS were classified as vascular and non-vascular pathologies. Patients with history of epilepsy were divided into two groups: primary/idopathic and secondary symptomatic epilepsies. History of trauma was specifically noted in patients with history of epilepsy and primary/idiopathic seizures. Imaging techniques (CT and MRI) obtained during the admission were reviewed. Positive finding on CT and MRI was considered as new pathology (diagnostic) or as a finding that would change therapy and/or follow-up plan (prognostic). The distribution of imaging findings across clinical categories was then assessed and odds ratios in patients with epilepsy and new onset seizures were calculated. The diagnostic yield of imaging, especially for pathologies that were not evident on CT but apparent on MRI was also evaluated. For patients with multiple admissions, separate odds ratios were determined for initial admission and repeated scans.
Results: The average age of the patients was 46.7±19.7 years. Among 800 patients, 458 (57.3%) were male and 342 (42.7%) were female. 38.9% (n=311) of patients were admitted to the hospital with new-onset seizure, while 61.1% (n=489) already had a seizure history. 40.5% of the patients suffering from their first seizure were found to have a positive medical history. The location of neoplasms in the group of new-onset seizures was extracranial in 74% and intracranial in 26 %. The most common extracranial neoplasm was primary lung cancer. However, among primary intracranial neoplasms glioblastoma was the most common (33.3%), followed by meningioma and low grade glial tumors. Cerebrovascular accident (CVA) was the most common cause of non-neoplastic disorders affecting CNS with a rate of 26.5%, intracranial aneurysms were the next common cause and was observed in 14.7% of cases. The incidence of abnormal imaging findings was significantly high in the following cases: new-onset seizure history (p<0.001), neoplasm, extracranial neoplasm, especially when there is a history of non-metastatic lung cancer, other extracranial neoplasm presence except for lung cancer (p<0.001), intracranial neoplasm (p=0.001) except for glioblastoma and newly diagnosed non-neoplastic disease (p=0.011).
57.7% of patients with epilepsy had primary epilepsy and 42.3% had secondary symptomatic epilepsy. 58 of patients with primary epilepsy (11.9 % of all epilepsies) had a trauma accompanying the seizure while being admitted to the hospital. 23.5% of patients with secondary symptomatic epilepsy had a history of neoplastic disease, while 18.8 % of them had non-neoplastic disease history. All neoplasms were intracranial in patients with secondary symptomatic epilepsy. 65.2% of these tumors were primary CNS tumors and 34.8% of them were intracranial metastasis of extra-CNS tumors. The rate of primary intracranial neoplasms was as follows: 29.7% glioblastomas, 18.9% meningioma, 16.2% oligodendroglioma. CVA (15.2%) was the most common cause of non-neoplastic disease in secondary symptomatic epilepsy patients, followed by previous epilepsy surgery (12%) and AVM (12%). The incidence of positive imaging findings among secondary symptomatic epilepsy patients was high in the presence of neoplasm (p=0.023) and glioblastoma (p=0.030). The incidence of positive imaging findings in patients with history of primary epilepsy was low (p<0.001).
75% of patients with negative CT and positive MRI findings had anew onset seizure, while, 25% of them were in the group of patients with epilepsy history. A great majority of findings on MRI were arterial ischemia, meningits-encephalitis and venous ischemia in this group of patients. 46.7% of patients admitted to the hospital multiple times had primary epilepsy, while 53.3% of them had secondary epilepsy. None of the patients admitted on multiple occasions had any pathology on CT or MRI. There was also no significant increase in the incidence of positive findings in the secondary symptomatic epilepsy group, as well.
While the sensitivity of CT in new onset seizure with the history of neoplastic (extracranial and intracranial) disease was 65-80% depending on the size of lesion and the patophysiology of co-existing non-neoplastic pathology, it was lower than 35% in both vascular and non-vascular pathologies in non-neoplastic group. The sensitivity of CT in secondary symptomatic epilepsy patients with neoplasm (intracranial and extracranial) was 75-100%, while it was between 35-65% in patients without neoplasm and higher than in patients with new onset seizure.
Conclusion: In conclusion, the incidence of positive finding on imaging that will change the diagnostic, therapeutic or follow-up process is higher in the group of patients with new onset seizure. The yield of CT was high in both new onset seizure and secondary symptomatic epilepsy patients, and also in patients with history of an underlying disease. If there is a history of non-neoplastic, especially vascular pathology associated disease in the newly diagnosed and secondary symptomatic epilepsy patients using MRI together with CT during admission or follow-up will be helpful for diagnostic, therapeutic and follow-up processes. Patients presenting to emergency department with seizure and with primary epilepsy history do not show an increase in the incidence of positive findings on imaging. The presence of trauma history in the patients with primary epilepsy increase the incidence of positive finding on imaging, but without statistical significance.
