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Neurol Clin Pract. Dec 2012; 2(4): 299–300.
PMCID: PMC3613205
What is the standard approach to assessment of an unprovoked seizure in an adult?
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Object name is CPJ200087FU2.jpgHONG KONG
Patrick Kwan, MD, PhDcorresponding author
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Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong.
corresponding authorCorresponding author.
Correspondence to:patrickkwan/at/cuhk.edu.hk
Disclosures: Dr. Kwan has acted as advisor/consultant to Eisai, GSK, Pfizer, and UCB Pharma; received research support from Eisai, Johnson & Johnson, Pfizer, and UCB Pharma; and lectured in speakers bureaus of Eisai and UCB Pharma. Go to Neurology.org/cp for full disclosures.
Since Hong Kong is highly urbanized and acute public hospitals have been established across the city, most patients with unprovoked seizures not already receiving antiepileptic drug (AED) therapy, particularly convulsive seizures, will be admitted as emergency for assessment. A thorough history is taken from the patient and any witnesses to the seizure. This includes the circumstance of the seizures, detailed symptoms and signs experienced by the patient and witnessed by others before, during, and after the seizure, any potential precipitating factors, history of previous seizures (that the patient might have overlooked), and history of previous brain insults that might have increased the risk of epilepsy later in life, including gestational and birth history, history of childhood febrile seizure, significant head trauma, any family history of epilepsy or seizures, comorbidities, current medications, drug and alcohol abuse, and social history including employment, driving, and living circumstances. A detailed physical and neurologic examination is performed.
Since Hong Kong is highly urbanized and acute public hospitals have been established across the city, most patients with unprovoked seizures not already receiving antiepileptic drug (AED) therapy, particularly convulsive seizures, will be admitted as emergency for assessment. A thorough history is taken from the patient and any witnesses to the seizure. This includes the circumstance of the seizures, detailed symptoms and signs experienced by the patient and witnessed by others before, during, and after the seizure, any potential precipitating factors, history of previous seizures (that the patient might have overlooked), and history of previous brain insults that might have increased the risk of epilepsy later in life, including gestational and birth history, history of childhood febrile seizure, significant head trauma, any family history of epilepsy or seizures, comorbidities, current medications, drug and alcohol abuse, and social history including employment, driving, and living circumstances. A detailed physical and neurologic examination is performed.
Tests will include complete blood count, renal and liver function tests, blood glucose, electrolytes, ECG, chest X-ray, interictal EEG, and an urgent plain CT brain scan. Further urgent testing will be guided by the clinical picture, e.g., lumbar puncture will be performed if CNS infection or inflammation is suspected, and urine toxicology if drug intoxication is suspected. If CT brain is normal and an underlying structural abnormality remains suspected (e.g., focal seizures), a brain MRI will be arranged, which is usually performed in outpatient. With a developed economy and universal health coverage, there is clinical impression that the etiologies of single unprovoked seizures in Hong Kong are similar to those encountered in other high-income countries.
Because of the limited number of designated neurology beds, patients are often admitted to the general medical wards, where referrals to neurologists are made. Neurology care is available in most acute hospitals. The assessment approach is generally not affected by who is covering the treatment costs because most patients with seizures/epilepsy will seek neurologist assessment in the public health system, which charges nominal consultation and prescription fees. For local residents with financial difficulties, these fees can be waived after means testing. Nor are decisions affected by how medical facilities and professionals are reimbursed because they are paid at fixed salaries under the public health system.
The decision to start or withhold treatment after a single unprovoked seizure will be thoroughly discussed with the patient and family. Treatment is generally not initiated (and not preferred by patients) after a single unprovoked seizure, unless there is a high risk of recurrence and significant psychosocial consequence from a further seizure. Not infrequently a patient would opt to receive traditional Chinese medicine treatment (outside the public hospital setting) instead of or in addition to conventional Western medicine. The patient may sometimes be commenced on treatment by emergency or general physicians (internists) before obtaining neurology opinion based on the clinical judgment of individual cases (e.g., a patient having prolonged or multiple seizures).
If it is decided to start treatment, an appropriate AED will be chosen based on seizure type and other factors such as gender, comorbidities, concomitant medications, and patient preference. Under the public health system's drug formulary, one of the older AEDs (carbamazepine, phenobarbital, phenytoin, valproic acid) should be given as the first AED. However, a newer AED can be used at the clinician's discretion with justification. There is a system-wide policy of screening for HLA-B*15:02 before initiating carbamazepine, which must be avoided if the patient tests positive unless the clinical benefits are judged to weigh the greatly increased risk of carbamazepine-induced Stevens Johnson syndrome in these individuals.
After the initial assessment, the patient will be monitored at the hospital's outpatient clinics. There is no major variability in management approach throughout Hong Kong, which is a highly urbanized, compact city. However, because under the public health system, a patient is generally admitted and followed up at the nearest hospital, there are variabilities in the availability of specialist expertise (general neurologists, neurologists with special interest/training in epilepsy), investigation techniques (MRI, long-term video EEG monitoring), drugs (usually the most newly approved), and epilepsy surgery and dietary therapies. These variabilities are partly reduced by cross-referral among the hospitals.
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