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In this episode, we review the American College of Emergency Physicians (ACEP) clinical policy on headache, which is primarily regarding the evaluation of patients with potential subarachnoid hemorrhage (SAH).

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Psychogenic non-epileptic attacks (PNEA) have been formally referred to as pseudoseizures or psychogenic non-epileptic seizures. Recently, this entity has been rebranded to PNEA to reflect that there is no actual seizure activity and potentially prevent confusion and mislabeling among patients.

A 10-year-old girl presents with episodes of brief staring spells that she is unaware of. The patient’s mother states that the onset and termination of the spells are abrupt. The patient is otherwise healthy. She has lots of friends at school and has excellent academic performance. Physical examination and laboratory studies are normal at this time. Which of the following is the most likely diagnosis?

1. Absence seizure
2. Attention deficit hyperactivity disorder
3. Autism spectrum disorder
4. Complex partial seizure

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1. Absence seizure is a type of generalized seizure characterized by loss of consciousness sometimes accompanied by myotonic, atonic, clonic, or tonic components, autonomic components (e.g., enuresis), or automatisms. The onset of absence seizure commonly occurs in early childhood with a predilection to the female sex. It usually terminates by the age of 20 years or may transform into another form of generalized seizure. Absence seizure may be typical or atypical. The onset and termination of a typical absence seizure are abrupt while they may be gradual in an atypical absence seizure. Additionally, atypical seizure commonly occurs in patients with multiple seizure types and demonstrates more marked changes in tone. Patients with an atypical absence seizure may also have a developmental delay or mental retardation. Patients with absence seizure may miss a few words or break off mid-sentence during an attack. The attack period is so brief that the patient is unaware of it. Physical examination may be normal. Having the child hyperventilate for three to five minutes may precipitate a staring attack. Diagnosis of typical absence seizure is with electroencephalography that shows bursts of bilateral synchronous and symmetric 3-Hertz spike-wave activity. A slower spike-wave discharge is noted in an atypical absence seizure. Treatment is with antiepileptic medications including ethosuximide and valproic acid. All patients with absence seizure should be referred to a neurologist for management. Drug levels of valproic acid should be monitored.While attention deficit hyperactivity disorder (B) has a childhood onset, it is marked by symptoms of inattentiveness, hyperactivity, and impulsivity that are not present in the vignette above. Autism spectrum disorder (C) may also have an early onset. However, patients suffer from pervasive difficulties with social communication and repetitive interests and behavior that are absent in the vignette above. In complex partial seizure (D), the duration of seizure usually lasts > 30 seconds, automatisms are present, and the termination of the seizure is gradual.

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References:

1. Lafrance WC, Baker GA, Duncan R, Goldstein LH, Reuber M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach: a report from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia. 2013;54(11):2005-18.
2. Wardrope A, Newberry E, Reuber M. Diagnostic criteria to aid the differential diagnosis of patients presenting with transient loss of consciousness: A systematic review. Seizure. 2018;61:139-148.
3. Chen et al. Value of witness observations in the differential diagnosis of transient loss of consciousness.  Neurology. 2019 Feb 26;92(9):e895-e904. doi: 10.1212/WNL.0000000000007017. Epub 2019 Jan 25.
4. Shmuely S, Bauer PR, Van zwet EW, Van dijk JG, Thijs RD. Differentiating motor phenomena in tilt-induced syncope and convulsive seizures. Neurology. 2018;90(15):e1339-e1346.
5. Doğan EA, Ünal A, Ünal A, Erdoğan Ç. Clinical utility of serum lactate levels for differential diagnosis of generalized tonic-clonic seizures from psychogenic nonepileptic seizures and syncope. Epilepsy Behav. 2017;75:13-17.

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We cover a post by Dr. Rory Spiegel, EMNerd: The Case of Differing Perspectives, on the results of the ATACH-2 trial on blood pressure control in intracranial hemorrhage (ICH). This study sought to determine the safety and efficacy of the intensive blood pressure lowering.

Population: adults (>18 y/o) with ICH on CT scan, GCS ≥ 5 and <4.5 hours since symptom onset (changed mid-study)

Intervention: Reduce and maintain the hourly minimum systolic blood pressure in the range of 110 to 139 mm Hg throughout the period of 24 hours after randomization (“intensive treatment”). Preferred agents for blood pressure control in order of preference were 1. nicardipine 2. labetalol (diltiazem or urapidil if not available)

• Mean minimum in hours 0-2: 128.9±16 mm Hg

Control: Reduce and maintain the hourly minimum systolic blood pressure in the range of 140 to 179 mm Hg throughout the period of 24 hours after randomization.

• Mean minimum in hours 0-2: 141.1±14.8 mm Hg

Outcome: The primary outcome was the proportion of patients who had moderately severe or severe disability (modified Rankin scale score (mRS) 4-5) or those who had died (mRS 6; hereafter referred to as “death or disability”) at 3 months.

• death or disability: Intensive treatment = 186 participants (38.7%) vs Standard treatment = 181 (37.7%)

Bottom Line:  INTENSIVE blood pressure lowering <140mmHg is not supported by the literature. AHA and Rosens/Tintinalli recommend goal of 160-180 mmHg or diastolic <130 mmHg.

We also discuss the history of blood pressure control in ICH and the pendulum swing on this in recent years, using an episode of the Skeptic’s Guide to Emergency Medicine, Episode 73. This episode covers the Interact-2 trial.

Core Content

We delve into core content on ICH using Rosen’s (8th ed) and Tintinalli (8th ed)

The use of platelets in patients with ICH on antiplatelet agents (aspirin, clopidogrel, etc) has been controversial and both Rosen’s and Tintinalli acknowledge that there is no good quality evidence that platelets are beneficial in this population.   The PATCH trial, recently published in the Lancet, found no benefit to platelet transfusion in patients with ICH who had taken antiplatelet agents in the 7 days prior to their ICH. See this review from Dr. Salim Rezaie of Rebel EM.

Population: patients ≥18years of age with non-traumatic ICH confirmed by CT and GCS ≥ 8 who took antiplatelet agent for at least 7 days prior (excluded thrombocytopenia/known coagulopathy)

Intervention: platelet transfusion

Control: standard care without platelet confusion

Outcome: primary outcome was the difference in functional outcome at 3 months after randomisation scored with the mRS

• Odds of a shift towards death or dependence at 3 months: adjusted OR 2.05 (95% CI 1·18–3·56; p = 0.0114). This favors the control group.
• Secondary outcome of survival: 68% in platelet transfusion group vs 77% in standard group (p = 0.15)

Note:  Like many stroke trials, the planned statistical analysis plan changed after the data came in. Initially authors planned a fixed dichotomous analysis (yes or no, did they have an mRS of 4-6 at 3 months). They changed this to an ordinal logistic regression analysis of the shift of all categories of the mRS at 3 months as this has greater “statistical efficiency”.

Generously Donated Rosh Review Questions

Question 1.  A patient presents with nausea, vomiting, right-sided hemiplegia and non-occipital headache. His gaze is deviated to the left, but he denies loss of sensation. Thirty minutes later, he becomes stuporous and progresses into coma. The pupils are now fixed and dilated. Abnormal posturing is absent. A brain CT scan is ordered. You would expect to find intracerebral hemorrhage in which of the following sites

A. Left pons

B. Left putamen

C. Right cerebellum

D. Right thalamus

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A large putamen hemorrhage results in a rapid progression of hemiplegia, nausea, vomiting and headache over 30 minutes, which is quickly followed by ipsilateral deviation of the eyes,stupor, coma and mydriatic pupils (“blown-pupil”, associated with brainstem compression and occulomotor nerve palsy). Acute management includes controlling intracranial pressure and hypertension. Surgical removal of clots is seldom successful, however, some neurologic function may be salvaged in those without coma or those with lobar clots.

Pontine hemorrhages (A) are characterized by total paralysis, rapid coma, decerebrate rigidity (abnormal posturing marked by shoulder adduction, elbow extension, wrist pronation and flexion, digit flexion, leg extension and plantarflexion) and small (miotic), not mydriatic, reactive pupils. Cerebellar insults (C) are evidenced by vomiting, occipital headache, inability to stand, vertigo, and eye deviation to the opposite side of the lesion. In this scenario, the eye deviation makes sense, but not the presenting symptoms.Thalamic lesions (D) are marked by complete hemisensory loss. Also common is hemiparesis (bleeding extension into the internal capsule) and aphasia.

Putamen Hemorrhage: Contralateral hemiparesis/hemiplegia, Contralateral sensory loss, Homonymous hemianopia

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References:

1. Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med [Internet] 2016;NEJMoa1603460. Available from: http://www.nejm.org/doi/10.1056/NEJMoa1603460
2. Anderson C, Heeley E, Huang Y, et al. Rapid Blood-Pressure Lowering in Patients with Acute Intracerebral Hemorrhage. N Engl J Med [Internet] 2013;368(25):2355–65. Available from: http://www.nejm.org/doi/abs/10.1056/NEJMoa1214609
3. “Spontaneous Subarachnoid and Intercerebral Hemorrhage.”  Chapter 166.  Tintialli’s Emergency Medicine: A Comprehensive Review. 8th ed.
4. “Stroke.” Chapter 101. Rosen’s Emergency Medicine. 8th ed.
5. Baharoglu MI, Cordonnier C, Salman RA-S, et al. Platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH): a randomised, open-label, phase 3 trial. Lancet [Internet] 2016;6736(16):1–9. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0140673616303920

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The Free Open Access Medical Education (FOAM)

We cover Special Seizures from EMin5.com by Dr. Anna Pickens. This is a short video summarizing important diagnoses to consider when a seizure doesn’t stop after the first or second round of benzodiazepines.

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Consider eclampsia, which typically occurs >20 weeks gestation to 6 weeks post-partum. Magnesium 4-6 grams IV, followed by infusion. Watch for apnea, check reflexes. [/expand]

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Consider alcohol withdrawal seizure. These patients respond to benzodiazepines and will typically NOT respond to antiepileptics such as phenytoin. They just need larger doses of benzodiazepines, so ramp up the dosages of those (10-100 mg of diazepam) and may require phenobarbital or propofol. [/expand]

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Isoniazid toxicity can cause seizures, coma, metabolic acidosis, often within only 30 minutes of ingestion. The treatment here is pyridoxine (vitamin B6). These patients will need large doses and many recommend empirically giving 5 GRAMS intravenously (note: this is takes many vials as the typical dose of this medication is 50-100 MILLIGRAMS). This is a great review by First10inEM [/expand]

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Treat with 100 mL of 3% hypertonic saline over 10-15 minutes. Can repeat x 1. Beware of rapidly correcting sodium in these patients due to central pontine myelinolysis/osmotic demyelination syndrome. [/expand]

Core Content

We delve into core content on seizures using Rosen’s (8th edition) Chapter 18 and Chapter 171 in Tintinalli (8th edition)

Febrile Seizures AAP Guidelines

Febrile Seizures

Generously Donated Rosh Review Questions

A fifteen-year-old girl presents for evaluation and clearance for sports play. She has played team sports in the past, and would like to join the swim team this year. She was recently diagnosed with a seizure disorder. Her seizures are usually in the mornings, are generalized tonic-clonic seizures, and last for 1-2 minutes. They occur once per week. She is currently taking topiramate for seizure control. Her physical exam and vital signs are reassuring. Which of the following is the best recommendation for this patient?A. Allow participation in swimming as this is not a contact sport
B. Deny participation in all sports until seizures are better controlled
C. Permit patient to join the swim team as long as she has rectal diazepam with her at all times
D. Refuse participation in swimming as seizures are poorly controlled

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D. Refuse participation in swimming as seizures are poorly controlled. Swimming (A) is a danger to children with poorly controlled seizures, as there is a risk that the child will have a seizure during the exercise and could suffer near-drowning or death. Some sporting events are safe for children with epilepsy (B), such as running. While the child participating in non-contact and non-aquatic sports may still have a seizure, the risk of morbidity and mortality to the child and other participants is low. Rectal diazepam (C) is a pharmacologic therapy that can stop seizures once they begin; however, the risk for morbidity and mortality remains high for children with poorly controlled seizures.

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A full-term 3-week-old girl is brought in by her parents who report that she has been “acting funny” for 2 hours. They noticed that she has been moving her lips nonstop. She was a full-term, normal, spontaneous vaginal delivery and has been feeding well with adequate wet diapers since hospital discharge. She is afebrile and vital signs are normal. The anterior fontanelle is flat, and red reflexes are present. Heart, lung, and abdominal exams are normal. Her neurologic exam is positive for root, suck, and Moro reflexes, upgoing Babinski reflexes, and rhythmic lip-smacking movements. What is the most appropriate next step to take with this baby?
A. Administer a benzodiazepine
B. Initiate EEG monitoring
C. Perform a CT scan of the brain
D. Provide reassurance that this is normal behavior

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This baby is having neonatal seizures, which are often subtle and more likely to be focal than tonic clonic. The most common manifestations are lip smacking, eye deviation, staring, rhythmic blinking, and bicycling movements. The patient should receive a benzodiazepine, such as lorazepam, midazolam, or diazepam, to stop the seizure. This should be followed by a workup that is directed at finding the underlying cause because neonatal seizures are less likely to be idiopathic than seizures in older children. A full septic workup is mandated for neonates with seizures, whether or not they are febrile. This includes CBC, blood culture, chemistry, UA, urine culture, chest x-ray, and CSF analysis. The infant should receive antibiotics and acyclovir and should be admitted to the hospital for further evaluation. Trauma can also cause neonatal seizures. It is important to look for signs of trauma such as bruising, bulging fontanelles, and retinal hemorrhages; the history may also include poor feeding, lethargy, or vomiting. Any infant with suspected head trauma should have a CT scan (C) and undergo a full child-abuse workup. An EEG (B) can be considered after more life-threatening causes of seizures, such as infection or trauma, are ruled out. A newborn (< 1 month old) with abnormal behavior should never be sent home with parental reassurance (D) only. Many new parents mistake normal behaviors for abnormal ones, but any truly abnormal behavior needs further investigation.[/expand]

References:

Kornegay JG. Chapter 171: Seizures Tintinalli’s Emergency Medicine: A Comprehensive Review (8e).

McMullan JT, Davitt AM, Pollack CV. “Seizures.” Rosen’s Emergency Medicine, Chapter 18, 156-161.e1