Department of Emergency Medicine, Lewis Katz School of Medicine, 1314 West Ontario Street, Philadelphia, PA 19140, United States of America.
Am J Emerg Med. 2020 Feb;38(2):288-291. doi: 10.1016/j.ajem.2019.05.004. Epub 2019 May 4.
Studies have shown the value of CT brain imaging in adults with first-time seizures, but there are no recommendations regarding emergent brain CTs in persons with an established seizure disorders. Our study aimed to derive a clinical decision instrument (CDI) to determine which patients with status epilepticus (SE) require emergent brain imaging.
This was a retrospective chart review of patients who presented to our emergency department with SE between 2010 and 2018. Patients with first-time seizures were excluded. A priori, we defined high risk criteria for emergent imaging as well as positive findings on brain CT. High risk criteria included known malignancy, trauma, and immunosuppression. Positive CT scans included findings such as intracranial hemorrhage (ICH) and mass.
We identified 214 patients who met inclusion criteria Of the 181 patients without high risk criteria, 3% had positive CT scans. Of the 33 patients with high risk criteria, 10% had positive CT scans. The sensitivity, specificity, PPV, and NPV for our initial CDI were 38%, 85%, 9%, and 97%. Adding the criterion of prior ICH would have lowered our miss rate to 0.6%. Modifying our CDI to 1) History of ICH, 2) Malignancy, 3) Immunosuppression, and 4) Trauma would result in a CDI with sensitivity, specificity, PPV, and NPV of 87.5%, 87.4%, 21.2%, and 99.5%.
By using four criteria to identify high risk patients, we can defer CT scanning in the vast majority of patients with SE and known seizure disorders. This CDI should be prospectively validated before adoption.
研究表明 CT 脑成像对首次发作的成人癫痫有价值，但对于已确诊的癫痫患者，尚未有关于急诊脑部 CT 的建议。我们的研究旨在制定一种临床决策工具（CDI）来确定哪些癫痫持续状态（SE）患者需要紧急脑部成像。
这是一项回顾性病历回顾研究，纳入了 2010 年至 2018 年间因 SE 就诊于我们急诊科的患者。排除了首次发作的癫痫患者。我们预先定义了急诊成像的高风险标准，以及脑 CT 的阳性发现。高风险标准包括已知的恶性肿瘤、创伤和免疫抑制。阳性 CT 扫描包括颅内出血（ICH）和肿块等发现。
我们确定了 214 名符合纳入标准的患者。在 181 名无高风险标准的患者中，3%的患者 CT 扫描阳性。在 33 名有高风险标准的患者中，10%的患者 CT 扫描阳性。我们初始 CDI 的敏感性、特异性、阳性预测值和阴性预测值分别为 38%、85%、9%和 97%。如果增加 ICH 病史的标准，我们的漏诊率将降至 0.6%。将我们的 CDI 改为 1）ICH 病史，2）恶性肿瘤，3）免疫抑制，4）创伤，将得到一种 CDI，其敏感性、特异性、阳性预测值和阴性预测值分别为 87.5%、87.4%、21.2%和 99.5%。
通过使用四项标准来识别高风险患者，我们可以在绝大多数有 SE 和已知癫痫病史的患者中延迟 CT 扫描。在采用之前，应该对该 CDI 进行前瞻性验证。
