紧急脑CT扫描在癫痫患者出现突破性癫痫发作的管理中的作用

摘要(中文译文)

背景与目的 全球急诊科就诊中约1-3%为急性癫痫发作。非增强计算机断层扫描（CT）神经影像在首次无诱因癫痫发作中的作用已被充分阐述。然而，现行指南对于已知癫痫病史、以突破性发作就诊的患者常规神经影像检查的实用性仅提供有限或非特异性建议。本研究评估了既往确诊癫痫的成人因突破性发作就诊于急诊科时，头颅CT影像的临床实用性。方法 我们对2019年至2023年的电子病历进行了回顾性审查。使用癫痫特异性诊断代码识别研究期间就诊于急诊科的患者。符合所有纳入标准的患者被选入进行CT影像结果和临床管理的审查。结果 共识别出207次癫痫相关急诊就诊。应用纳入和排除标准后，最终分析纳入121次就诊，涉及已知癫痫的成人因突破性发作就诊并接受了急诊非增强头颅CT检查。影像检查指征包括跌倒（47次，38.8%）、精神状态改变（24次，19.8%）、嗜睡（19次，15.7%）、癫痫反复发作（20次，16.5%）和头痛（11次，9.09%）。在接受影像检查的患者中，CT结果正常92例（76.0%），显示既往卒中11例（9.1%），术后改变9例（7.4%），小血管病5例（4.1%），陈旧性创伤2例（1.7%），以及结果不明确2例（1.7%）。与既往影像相比，无CT发现代表新发病理，且这些发现均未改变急性临床管理。结论 对突破性发作的癫痫患者进行急诊头颅CT的诊断阳性率较低。鉴于经济负担、辐射暴露和有限的临床影响，未来研究应侧重于制定循证影像指南，在维持患者安全的同时尽量减少不必要的CT使用。

Abstract

Background and purpose Approximately 1-3% of global emergency department (ED) visits are for acute seizures. The role of neuroimaging with non-contrast computed tomography (CT) has been well described for first-time unprovoked seizures. However, current guidelines provide limited or non-specific recommendations for the utility of routine neuroimaging in patients with a known history of epilepsy presenting with breakthrough seizures. This study evaluated the clinical utility of brain CT imaging in adults with a previously confirmed diagnosis of epilepsy who presented to the ED with breakthrough seizures. Methods We conducted a retrospective review of electronic medical records from 2019 to 2023. Seizure-specific diagnostic codes were used to identify patients who presented to the ED during the study period. Patients meeting all inclusion criteria were selected for review of CT imaging results and clinical management. Results A total of 207 seizure-related ED encounters were identified. After applying inclusion and exclusion criteria, 121 encounters involving adults with known epilepsy presenting with breakthrough seizures who underwent emergent non-contrast head CT were included in the final analysis. Indications for imaging included falls (47, 38.8%), altered mental status (24, 19.8%), lethargy (19, 15.7%), recurrent seizures (20, 16.5%), and headache (11, 9.09%). Among those imaged, CT findings were normal in 92 (76.0%), showed prior stroke in 11 (9.1%), postoperative changes in 9 (7.4%), small-vessel disease in 5 (4.1%), remote trauma in 2 (1.7%), and ambiguous findings in 2 (1.7%). No CT findings represented new pathology compared with prior imaging, and none of these findings altered acute clinical management. Conclusions The diagnostic yield of emergent brain CT in epilepsy patients with breakthrough seizures is low. Given the financial burden, exposure to radiation, and limited clinical impact, future studies should focus on developing evidence-based imaging guidelines that minimize unnecessary CT use while maintaining patient safety.

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