These clinics not only get patients a faster diagnosis but help them avoid subsequent emergency presentations.
Speedy attendance at a first seizure clinic reduces hospital and emergency presentations down the line, a new Australian study has found.
The large data-linkage cohort study, published in JAMA Neurology, analysed nearly 9400 patients booked into two first seizure clinics – at Royal Melbourne and The Alfred hospitals – between 2007 and 2018.
Those who attended the clinic were almost 30% less likely to present at an emergency department, and about 20% less likely to present at a hospital, for any reason than those who skipped or cancelled or who attended delayed appointments.
Senior author Dr Emma Foster, co-head of The Alfred’s first seizure clinic, said seeing a specialist early and getting advice appeared to improve outcomes, though the data wasn’t detailed enough to reveal exactly why.
“We found that if you’re not able to get in to your first seizure clinic within two weeks of being referred [assuming referral happens soon after the seizure], the risk of coming back to hospital for any reason or for a seizure-related reason is much higher,” Dr Foster told TMR. “That risk jumps again between two to four weeks after referral, and then again four weeks onwards.
“So the quicker you get in, the better your chance at not returning to hospital.”
The study also found that specifically seizure-related presentations were higher among first seizure clinic attendees; but this seeming paradox was most likely explained by correct identification of a seizure due to prior clinic attendance.
First seizure clinics are an Australian invention and now also exist in the US, UK and Canada.
The clinics, of which Australia has a handful, aim to shorten the time to diagnosis and treatment using the right imaging and specialised history-taking to differentiate epilepsy from other conditions that mimic it.
“This is a really important paper and it goes a long way to showing the benefit of rapid subspecialist care,” said Dr David Vaughan, who leads The Austin’s first seizure clinic in Melbourne, one of the first in the country, and was not involved in the study.
“A first seizure or seizure-like event can be a really terrible experience and people are often unsure about what’s happened and why, and what it means for their lives,” he told TMR.
After the usual initial hospital episode, he said, the clinic was “the first chance that people have to talk with a specialist about what’s happened. It’s a really important role. It’s firstly getting the diagnosis right but also explaining what the treatment options are and how to manage safely the issues around driving and workplace safety and other activities.”
Dr Vaughan also works on the Australian Epilepsy Project, one of whose goals is to try to improve the quality of diagnosis at the early stage.
The Austin and The Alfred’s FSCs offer video telehealth and see patients from across the country.
Clinics may vary slightly, but Dr Foster said the ideal process (which differed from reality thanks to under-resourcing) began with an EEG and a CT scan as soon as possible after the seizure. These should be done before the first FSC appointment, which would happen, again ideally, within two weeks of the event.
An EEG can pick up epilepsy brainwave activity between seizures, especially up to two days later, but also in the weeks following when the patient is feeling fine and unaware of it, Dr Vaughan said.
While MRIs offer more detail about brain structures, CTs are quicker to obtain in the first instance. Dr Foster said there should be a non-contrast CT first to show up any fresh blood, to indicate a ruptured aneurysm or other irritation in the brain, followed by contrast CT to look for brain tumours.
Blood tests are usually done at the emergency stage to look for biochemical changes, since hypoglycaemia, hyponatraemia and sudden alcohol withdrawal can cause seizures.
A lumbar puncture might also be ordered to look for evidence of infection.
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Then a detailed history is taken, from the patient and any eyewitnesses, to differentiate an epileptic seizure from the many mimics, such as syncope.
“People might feel a rising sensation in their stomach or a strange taste or smell, or they might have intense déjà vu,” Dr Foster said.
“People on the outside can’t really tell that that’s what someone’s experiencing. But they can say: my friend just blanked out for 10 seconds and their eyes glazed over, they weren’t really responding, there was a bit of lip smacking. The person who experienced the sensations may not realise that.
“It’s challenging – sometimes within our clinic, where we’ve all been doing this for many years, we still get different stories from the same person.”
Dr Vaughan said smartphone videos from loved ones could be extremely helpful, though this usually only happened when seizures were a regular occurrence.
“It’s becoming more and more common for people to bring along a video of the event … It’s a good thing to have the person’s permission, of course.”
Dr Foster said sometimes a patient would present after their first convulsive seizure, but a careful history would reveal they had been experiencing subtler events for months.
She said there were “three Ss” that marked out these low-key seizures:
1) short (typically <1 min)
2) stereotyped (it looks and feels exactly the same, every single time)
3) surprise (these events occur at random, with no obvious triggers, time of day, activity, etc.)
Dr Vaughan said awareness among GPs of the subtler kind of seizures could make a big difference for patients.
“I get some really excellent referrals from GPs who’ve spoken to patients who are having subtle events, perhaps with loss of awareness, but not with collapse or shaking – focal seizures with impaired awareness.
“When GPs have had the radar up for those events and thought ‘could these be seizures?’ and then referred on for more evaluation, that’s made a really enormous difference for those patients.”
Epilepsy can start at any age, but onset is most common before the age of five and after 65 – often to the surprise of the older patient. Nearly all adult-onset epilepsy is focal, originating from a tumour, stroke site or lesion. Generalised epilepsy, in which synchronised abnormal electrical activity occurs in both hemispheres at once, more often has a genetic origin.
Two spontaneous seizures more than 24 hours apart is sufficient for a diagnosis. So is a single seizure with an identifiable but not easily treatable cause, like a tumour.
As well as seeking specialised advice, Dr Vaughan recommended people who’ve had a first seizure get in touch with the Epilepsy Foundation: “I think they’re a really great advocacy group and they’ve got some very sensible advice around engaging with schools and employers and friends and colleagues.”
Dr Foster said that if a clinic appointment wasn’t available, seeing a general neurologist was still helpful.
“Even at a specialist level, it can be tricky to know what’s happening,” she said. “Our GP colleagues are excellent – that’s honestly the hardest specialty in medicine – but we have the luxury of diving deeper.
“There will need to be more studies drilling down into what happens in first seizure clinics that makes good outcomes. Then what we’d like to do is translate that into a non-first seizure clinic environment. We could then say to GPs: these are the things that we do in our clinic, which perhaps you could do in your rooms, that will help people’s outcomes.”
