An outcome audit at the epilepsy clinic: results from 1000 consecutive referrals

doi:10.1016/S1059-1311(05)80161-X

Seizure

Volume 3, Issue 1, March 1994, Pages 37-43

https://doi.org/10.1016/S1059-1311(05)80161-X Get rights and content

The clinical details, specialist investigation, pharmacological treatment and outcome in 1000 consecutive patients referred to the epilepsy clinic at the Western Infirmary in Glasgow were reviewed. Data were collected by detailed proforma at initial referral and from the clinical notes at audit. 524 (52%) of the patients were 30 years of age or younger. 527 (53%) were sent to the clinic by their general practitioner with the majority of the remainder being referred by another hospital consultant. 240 (24%) came from outwith greater Glasgow. In 253 (25%) patients a possible predisposing factor was identified, usually a major head injury or alcohol abuse. Sixty (6%) patients suffered from additional mental handicap. Focal spike and wave activity was identified in 26% of electroencephalograms. One or more abnormality was found in 33% of the 356 patients who underwent computerized tomographic brain scanning. In 13 (11%) of these, a tumour was demonstrated. On referral, 65% of patients were being treated with antiepileptic drugs; 58% were on monotherapy and 42% took more than one anticonvulsant. The figure at audit was 77% treated, with a higher proportion (68%) than at referral receiving monotherapy (P < 0.005). Sedative anticonvulsants, such as phenobarbitone and primidone, were withdrawn in 29% of cases. 50% of the 519 patients, for whom seizure frequency data were available for the years before referral and audit, were seizure-free and seizure numbers had been reduced by 50% or more in a further 23%. A poorer response to treatment was associated with mental handicap (P < 0.05), birth injury (P < 0.01), and partial or secondary generalized seizures (P < 0.005).

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There is limited data on the predictors of diagnostic yield in the routine outpatient EEG. The diagnostic yield can vary from 10% to 50% depending on cohort, clinical, and methodological factors [4–8]. A detailed understanding of predictors of the yield is likely to help us optimize the use of this common diagnostic test.
The routine outpatient electroencephalogram (EEG) is most often used in the diagnosis and classification of epilepsy. The diagnostic yield of outpatient EEGs is low and the clinical factors contributing to the EEG outcome have not been well established. In this study, we sought to determine the yield and the factors predicting the EEG outcome. We retrospectively analyzed 1092 routine adult EEGs that were performed in a tertiary referral center over a period of 1 year. Patient demographics, sources of referral, and indications for EEG were recorded. The majority of the referrals were from neurologists (54.7%), followed by the emergency department (15.4%). The indications for requesting an EEG included patients with a provisional or established diagnosis of epilepsy (56.3%), first seizure (10.7%), and seizure mimickers (29.1%). The majority (66.7%) of the EEGs were normal, whereas 13.2% demonstrated epileptiform discharges. At the time of recording, epileptic seizures occurred in 0.6% of the cases. With logistic regression analysis, three factors were found to be significantly associated with an abnormal (epileptiform) EEG: no antiepileptic drug therapy, the age of the patient, and indication for EEG (pre-test provisional diagnosis). Patients who are not on antiepileptic drug therapy and with a diagnosis of epilepsy or seizures are more likely to have epileptiform abnormalities in EEGs. Our findings suggest that careful selection of patients is likely to improve the diagnostic yield and cost-effectiveness of routine outpatient EEG.
A comparison of antiepileptic drug therapy in patients with severe intellectual disability and patients with normal intellect
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This study was not specifically designed to determine why differences exist but rather if they exist. However, given our finding of equal exposure to newer AEDs in the two groups, the differences in treatment observed here may be due to the fact that seizures in patients with ID may be more frequent or more severe, often associated with injuries, than those in patients with NI [30,31]. The main concern that motivated this study was the theoretical possibility that patients with ID might not be offered treatment with the newer AEDs.
We describe and compare the antiepileptic drug (AED) management in patients with severe intellectual disability (ID) and those with normal intellect (NI) and focal epilepsy at a tertiary epilepsy center. Fifty patients with ID were compared to a control group of 50 patients with NI; the majority of the patients in both groups had medically refractory epilepsy. Patients with ID were currently taking and had been previously exposed to a greater number of different AEDs. Despite the fact that both groups of patients had beene qually exposed to both old and newer AEDs, patients with ID were more likely to be taking at least one old AED and were more commonly treated with benzodiazepines (clobazam was the most commonly used drug in this group). This difference is likely related to greater seizure frequency and co-morbid behavioral disturbance in the ID group as no bias was identified against utilization of the newer AEDs in patients with ID.
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Hippocampal sclerosis (HS) is the most common pathology in mesial temporal lobe epilepsy (MTLE). There are a few reports concerning prognosis in patients with MTLE-HS treated medically. The study was carried out to determine the clinical risk factors affecting prognosis.
We enrolled 287 patients with MTLE-HS treated medically. Gender, age at onset of epilepsy, history of trauma, infection, febrile convulsion, status epilepticus, mental retardation, handedness, consanguinity, side of hippocampal sclerosis, additional extrahippocampal temporal lesion, aura, seizures types, antiepileptic drugs, psychiatric disturbances and seizure frequency were noted. All patients were divided into three groups. Group I: patients seizure-free during follow up, Group II: patients with improved seizure control whose seizure frequency had decreased >50% after the treatment, and Group III: patients with poor seizure control whose seizure frequency had no change or increased. Each clinical feature was also compared among three subgroups statistically.
Early age of seizure onset [Group II–III (p = 0.000) and Group I–III (p = 0.0004)], age of head trauma [Group II–III (p = 0.04)], the presence of mental retardation (p = 0.04) and female sex (p = 0.03) were risk factors for poor prognosis. However, the other parameters did not affect prognosis.
Recognizing bad prognostic features such as the presence of mental retardation, early age of seizure onset, age of head trauma and female gender may help physicians to identify risk groups with MTLE-HS and drug resistance seizures for epilepsy surgery.
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However, a small proportion of patients with MTS remained in remission, suggesting that some cases have a more benign form. Among the information that could be obtained early during the evaluation of patients we found that the presence of mental retardation and multiple seizure types were poor prognostic factors [14,25]. In conclusion the outcome for patients with epilepsy is variable; recognizing those who are at risk of developing intractable seizures an early stage would help in the management of refractory epilepsy.
To investigate the proportion of Chinese patients with intractable seizures and the risk factors leading to refractory epilepsy.
Consecutive patients over 14 years of age attending a Neurology clinic were evaluated. Patients with epilepsy were classified into two groups according to their seizure control: refractory or seizure-free. Epilepsy was classified as idiopathic as defined by age-related onset and typical electroclinical characteristics, symptomatic if secondary to a structural abnormality and cryptogenic if the cause was unknown. Age, sex, epilepsy syndrome classification, aetiology, presence of mental retardation and the number of drugs used were compared between patients with refractory epilepsy and those in remission.
Among 260 adolescent and adult patients with a mean age of 34 years (range 15–79), complete seizure control was achieved in 157 (60%) cases. Multivariate binomial logistic regression analysis showed that patients with mesial temporal sclerosis (OR = 7.6, 95% CI 3.53–16.4, p < 0.01) and the presence of mental retardation (OR = 9.39, 95% CI 3.98–22.12, p < 0.01) were more likely to develop pharmacoresistant epilepsy.
In adults the underlying aetiology is an important factor as to whether patients develop intractable seizures. Poor control was also associated with the presence of mesial temporal sclerosis and mental retardation.
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2005, Epilepsy and Behavior
This randomized, double-blind, placebo-controlled UK trial evaluated the effect of topiramate as add-on therapy on seizure frequency, seizure severity, and quality of life in patients with epilepsy and intellectual disability. There were three phases: 4 weeks baseline, 18 weeks titration to 200–400 mg topiramate/day (adults) or 5–9 mg/kg/day (children), 12 weeks maintenance. Recruitment was low (88/120); analyses were underpowered. Seizure frequency varied enormously (median 17.7, maximum 1706.2). There was no significant difference in reduction in mean total seizure frequency or number of responders between the groups. Topiramate reduced seizure frequency by >30% from baseline (placebo 1%); post hoc analyses showed a trend toward significance (R ratio, P = 0.052). There were no significant differences between the groups with respect to mean seizure severity or other outcome measures. Topiramate was generally well tolerated; body weight (P = 0.015) and systolic blood pressure (P = 0.043) were reduced. The study suggests that topiramate reduces seizure frequency in patients with epilepsy and intellectual disability without the added burden of behavior effects, and was potentially advantageous to physical well-being.
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Current evidence suggests that epilepsy outcome for people with a learning disability is poor, with the majority remaining refractory to treatment. There is very little evidence from randomised controlled trials in this population and despite the many uncontrolled variables it is suggested that an outcome audit may be one method of adding to the evidence base.
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The results of this audit suggest that the outcome for the majority of patients with learning disability and refractory epilepsy may be better than that has been previously reported.

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Original ArticleAn outcome audit at the epilepsy clinic: results from 1000 consecutive referrals

Lancet

Lancet

Lancet

Lancet

Lancet

Lancet

Commission on Classification and Terminology of the International League Against Epilepsy: proposal for revised classification of epilepsy and epileptic syndromes

Epilepsia

Drug treatment of epilepsy: outlines, criticism and perspectives

Drugs

A prospective study on sudden unexpected death in epilepsy

Annals of Neurology

An objective method for the assessment of psychological and social problems among epileptics

Epilepsia

Original Article
An outcome audit at the epilepsy clinic: results from 1000 consecutive referrals