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2011/04/14 EBM-seizure

2011/04/14 EBM-seizure. R3 吳竣維 Supervisor 詹逸凌 主任. 若符合下列情況應做腦部電腦斷層. 新出現的神經學異常 持續意識障礙 頭部外傷 第一次癲癇發作 凝血功能異常 愛滋病患者或者免疫功能不足患者 腦膜炎徵象 酒精成癮患者 癲癇發作型態改變. Q1: Is Brain CT providing information to change acute management in pts with seizure attack?. Harden CL, Huff JS, Schwartz TH, et al.

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2011/04/14 EBM-seizure

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  1. 2011/04/14 EBM-seizure R3 吳竣維 Supervisor 詹逸凌 主任

  2. 若符合下列情況應做腦部電腦斷層 • 新出現的神經學異常 • 持續意識障礙 • 頭部外傷 • 第一次癲癇發作 • 凝血功能異常 • 愛滋病患者或者免疫功能不足患者 • 腦膜炎徵象 • 酒精成癮患者 • 癲癇發作型態改變

  3. Q1: Is Brain CT providing information to change acute management in pts with seizure attack?

  4. Harden CL, Huff JS, Schwartz TH, et al.

  5. THE EVIDENCE PYRAMID Meta - analysis Randomized Controlled Double Blind Studies Randomized Controlled Studies Cohort studies Case Control Studies Case series/ Reports Meta-analysisForest plot Ideas, Editorials, Opinions Animal research In vitro (test tube) research Hierarchy of evidence that arranges study designs by their susceptibility to bias.

  6. Objective • To reassess the value of neuroimaging forseizure pts in ED • As a screening procedure to provide information to change acute management • To reassess clinical/historical features associated with abnormal neuroimaging

  7. Methods • Ovid Medline: relevant articles published, 1966~2004/11 • key words: diagnostic imaging, neuroimaging, seizures, epilepsy, EMS, emergencies, craniocerebral trauma, neurocysticercosis, HIV, status epilepticus • Initial reports: 73+19=92  Inclusion: 15 • exclusion: review articles without primary data, case reports, articles without emergent neuroimaging evaluation of seizure

  8. Q1: Likelihood that a neuroimaging study will change acute management for adult ED pts with a first seizure? Q2: Pediatric ED pts with a first seizure? Q3: Chronic seizure? Q4: Special population? Q5: Factors associated with abnormal neuroimaging studies for ED seizure pts?

  9. Q1: Likelihood that a neuroimaging study will change acute management for adult ED pts with a first seizure? • abnormal CT scans: 34~56% • change of acute management: 9~17% • traumatic brain injury, SDH, ICH/SAH, CVA, tumor, brain abscesses

  10. Including prompting hospital admission, changed management beyond further OBS?

  11. Conclusion  An emergency CT in adults with first seizure is possibly useful for acute management of the patient (Class III). • Recommendation  An emergency CT may be considered in adults with first seizure (Level C).

  12. Q2: Pediatric ED pts with a first seizure? • simple febrile seizure excluded • complex febrile seizures: included • abnormal CT scans: 0 ~ 21% • change of acute management: 3~8% • cerebral hemorrhages, tumors, cysticercosis, obstructive hydrocephalus

  13. Conclusion  An emergency CT in children with a first seizure is possibly useful for acute management of the patient (Class III). • Recommendation  An emergency CT may be considered in children with a first seizure (Level C).

  14. Q3: Chronic seizure? • abnormal CT in chronic / first: not different • Pts with chronic seizures with abnormal CT: 7~21% • changing management in ED for pts with chronic seizures: not available • cerebral hemorrhages, shunt malfunctions

  15. Conclusion  The evidence is inadequate to support or refute the usefulness of emergency CT in persons with chronic seizures. • Recommendation  There is no recommendation regarding an emergency CT in persons with chronic seizures (Level U).

  16. Predictors of abnormal findings of computed tomography of the head in pediatric patients presenting with seizures Warden et al. Ann Emerg Med 1997; 29:518

  17. Objective: To predict abnormal brain CT by characteristics of pediatric ED pts with seizure • Methods: retrospective, 01/01/92 ~ 12/31/94, children with seizures s/p brain CT, bivariate analysis, OR (95% CI) • Results: most significantly associated with abnormal CT: (1)≦6 m/o, (2) CHI, (3) shunt revision within 6 wks, (4) NCD, (5) malignancy

  18. Normal brain CT in the following condition • No high-risk (malignancy, NCD, recent CHI, or recent CSF shunt revision), • >6 m/o • Seizure ≤15 mins • No new-onset focal neurologic deficit • Conclusion: • Absence of defined high-risk factors predicted normal brain CT findings. • 41% of brain CT could have been deferred

  19. Q4: Special population(<6m/o, AIDS, children + immediate posttraumatic seizures) ? • ＜6 m/o + seizure: significant abnormal CT (55%),  changed management • Aicardi syndrome, Miller-Diecker syndrome, tuberous sclerosis, an infarct, a depressed skull fracture • AIDS + first seizure: high rates of abnormal CT (96%) • mass lesions, CNS toxoplasmosis, PML, atrophy

  20. Children + immediate posttraumatic seizure: low rate of abnormal CT (16%) • Brain CT not useful for change acute management?, no recommendation?

  21. Conclusions  An emergency CT in ＜6 m/ochildren and in AIDSpts is possibly useful for acute management (Class III). • Recommendations  An emergency CT may be considered in ＜6 m/o childrenand in patients with AIDS (Level C).

  22. Q5: Factors associated with abnormal neuroimaging in ED seizure pts? • 9 studies • 5: All age with NE: a focal abnormality • 3: pre-existing factor (<6 m/o, CHI, recent shunt revision, malignancy, or neurocutaneous disorder) • 2: focal seizure onset • 1: cysticercosis, mental change, >65 y/o, >15 mins

  23. Conclusion  The clinical/historical features of an abnormal NE, a predisposing Hx, or a focal seizure onset are probably predictive of an abnormal CT for in ED seizure pts (Class II). • Recommendation  An emergency CT should be considered in ED seizure pts who have an abnormal NE, predisposing Hx, or focal seizure onset (Level B).

  24. Conclusions • Adult/pediatric ED pts with a first seizure  brain CT • ED pts with chronic seizure  no emergent brain CT • <6 m/o or AIDS with seizure  brain CT • abnormal NE, a predisposing Hx, a focal seizure onset  abnormal CT

  25. 若符合下列情況應做腦部電腦斷層 • 新出現的神經學異常 • 持續意識障礙 • 頭部外傷 • 第一次癲癇發作 • 凝血功能異常 • 愛滋病患者或者免疫功能不足患者 • 腦膜炎徵象 • 酒精成癮患者 • 癲癇發作型態改變 • 年齡小於六個月 • 近期做CSF shunt 手術 • 惡性腫瘤 • neurocutaneous disorder

  26. Thanks for your attention!!

  27. Age

  28. Q2: Is AED better than BZD in pts with alcohol withdrawal seizure?

  29. PICO • P: patients with alcohol withdrawal seizure • I: Antiepileptic drugs (AED) • C: BZD • O: seizure

  30. Anticonvulsants for alcohol withdrawal Silvia Minozzi1 , Laura Amato1, Simona Vecchi1, Marina Davoli1 Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD005064. DOI: 10.1002/14651858.CD005064.pub3.

  31. THE EVIDENCE PYRAMID Meta - analysis Randomized Controlled Double Blind Studies Randomized Controlled Studies Cohort studies Case Control Studies Case series/ Reports Meta-analysisForest plot Ideas, Editorials, Opinions Animal research In vitro (test tube) research Hierarchy of evidence that arranges study designs by their susceptibility to bias.

  32. Objectives • To evaluate the effect/safetyof AED to alcohol withdrawalseizure

  33. Search strategy • Cochrane Drugs and Alcohol Group’ Register of Trials (December 2009) • PubMed (January 1966- December 2009) • EMBASE (January 1988- December 2009) • CINAHL (January 1982- December 2009) • EconLIT (1969 to December 2009) • Inclusion: 56 studies, 4076 participants.

  34. Selection criteria • Randomized controlled trials (RCTs) • Controlled clinical trials (CCTs) • Types of comparisons • AED v.s. placebo; • AED v.s. other drugs (major: BZD); • different AEDs between themselves; • AEDS + other drugs v.s. other drugs • AED 1 + other drugs v.s. AED 2

  35. Efficacy outcomes • Alcohol withdrawal seizures • Alcohol withdrawal delirium • Alcohol withdrawal symptoms as measured by prespecified scales (as the CIWA-Ar score) • Global improvement of overall alcohol withdrawal syndrome • Safety outcomes: Adverse events, Severe, life-threatening adverse events • Acceptability outcomes: Dropout • Secondary outcomes • Additional medication needed • Length of stay in intensive therapy • Mortality • Quality of life

  36. Data collection and analysis • Two authors independently screened and extracted data from studies. • Relative risk (RR) • The MD or the SMD with 95%CI • Chi-squared (Q) test ( P<.05)

  37. Result (1)- Alcohol withdrawal seizures • AED v.s. placebo, 9 studies, 883 participants • RR 0.61 (0.31 to 1.20), not statistically significant

  38. AED v.s. any Other (major: BZD), 12 studies, 880 participants • RR 0.58 (0.22 to 1.58), not statistically significant

  39. Result (2) • AED v.s. placebo: no statistically significant differences for the six outcomes • AED v.s. other drug: favor AED only in the comparison carbamazepine v.s. BZD (oxazepam / lorazepam) for alcohol withdrawal symptoms (CIWA-Ar score), none of the other comparisons reached statistical significance. • different AED: no statistically significant difference • AED + other drugs v.s. other drugs: favor paraldehyde + chloral hydrate v.s. chlordiazepoxide, for the severe-life threatening side effects, RR 0.12 (0.03 to 0.44)

  40. Conclusion • No sufficient evidence in favor of AED to treat AWS seizure

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