Management of hospital-onset seizures lacks standards

By Peter Sergo, medwireNews Reporter

Seizures in patients admitted to hospital for nonseizure reasons - hospital-onset seizures (HOS) - largely affect those without any history of seizures, often recur, and are linked to a high mortality, according to a study in JAMA Neurology.

While the cause of HOS could not be pinned to a particular etiology, they likely stem from acute symptomatic circumstances that occur when seizures coincide with a systemic insult or documented brain injury, the study shows.

Of the 218 patients identified with HOS, nearly two-thirds had never experienced a seizure before while 61% experienced a recurrence during their inpatient stay. A large proportion (43%) of recurrences occurred in patients with new-onset seizures, compared with those who had a history of seizures (32%). The multiple HOS usually spanned several days without ever exhibiting a persistent seizure state that reached status epilepticus criteria.

Madeline Fields, from Mount Sinai School of Medicine in New York, USA, and colleagues identified metabolic derangement as the most common identifiable trigger of recurrent hospital seizures.

"To our knowledge, this observation has never been reported and may be important for HOS management," write the researchers. Fields and colleagues suggest that use of electroencephalography monitoring could have detected more seizures than they discovered just from clinical observations.

Patients with new-onset forms of HOS were also more prone to dying during hospitalization or being discharged to a hospice compared with those with a history of seizure (19 and 5%, respectively).

"However, it is likely that death occurred as a direct consequence of the acuity of the underlying illness, not as a result of seizure occurrence or medication choice," write the researchers. In light of that, they note that the use of the anti-epileptic drug phenytoin "was not ideal," as it was likely given to an ill population that concomitantly took other medications and was generally "not always used in a manner commensurate with current standards."

As much as 24% of patients with seizure history re-experienced them again during hospitalization despite being well controlled beforehand; however, patients with a history of epilepsy were generally less ill than new-onset patients.

"In general, patients in the hospital have unique characteristics, and the epidemiology of HOS likely differs from that of seizures in non-hospitalized patients," the study authors write. "Currently, no guidelines are available for the management of HOS, which could lead to substantial variance in management strategies."

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