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Alok K, Lin A, Rahman Dematteo C, Abrar H, Levy Z. Brivaracetam-Associated Rhabdomyolysis Requiring Renal Replacement Therapy: A Case Report and Review of the Literature. Cureus 2024; 16:e58183. [PMID: 38741805 PMCID: PMC11089833 DOI: 10.7759/cureus.58183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 05/16/2024] Open
Abstract
Rhabdomyolysis is a rare adverse reaction that has a previously established association with levetiracetam use, which selectively binds the synaptic vesicle glycoprotein 2A (SV2A). Its structural analogue, brivaracetam, is a new third-generation antiseizure medication that has a higher affinity for SV2A, and current data suggests it provides a more favorable adverse event profile. Here, however, we report a case of rhabdomyolysis requiring dialysis in which serum creatine kinase level increased rapidly for several days until brivaracetam was discontinued. The delayed creatine kinase peak, rapid decline upon discontinuation of brivaracetam, and prior association of rhabdomyolysis with levetiracetam strongly suggest a causal relationship. To date, there are three reported cases of brivaracetam-associated rhabdomyolysis in the food and drugs administration adverse event reporting system (FAERS). Despite its favorable side effects profile, the use of brivaracetam may be associated with life-threatening rhabdomyolysis.
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Affiliation(s)
- Khaled Alok
- Neurocritical Care, Northwell Health, Manhasset, USA
| | - Amanda Lin
- Pharmacy, Neurocritical Care, Northwell Health, Manhassett, USA
| | | | - Husain Abrar
- Internal Medicine, Northwell Health, Manhasset, USA
| | - Zachary Levy
- Neurocritical Care, Northwell Health, Manhasset, USA
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Abdelnaby R, Elgenidy A, Heckelmann J, Bedewy MM, Shabib AS, Ebrahim MA, Elmenawi KA, Maallem I, Youssef MW, Attia AM, Moawad MH, Mohamed KA, Gaballa A. The role of creatine kinase in distinguishing generalized tonic-clonic seizures from psychogenic non-epileptic seizures (PNES) and syncope: a retrospective study and meta-analysis of 1300 patients. Neurol Res Pract 2023; 5:56. [PMID: 37821955 PMCID: PMC10568853 DOI: 10.1186/s42466-023-00286-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND/AIM As the clinical differentiation between epileptic seizures, psychogenic non-epileptic seizures (PNES), and syncope depends mainly on a detailed report of the event, which may not be available, an objective assessment of a potential biochemical analysis is needed. We aimed to investigate whether serum creatine kinase (CK) could be used to differentiate epileptic seizure from PNES and syncope and to assess the strength of evidence present. METHODS We directed a retrospective cohort study coupled with a systematic review and meta-analysis of studies that measured CK in patients with epilepsy, PNES, syncope, and healthy controls. RESULTS The cohort study, which traced 202 patients, showed that the CK level was significantly higher 48 h after the event in the epilepsy group versus patients with syncope (p < 0.01) Along with 1086 patients obtained through a database search for meta-analysis, CK level compared to different types of seizures from PNES was higher in epileptic seizure patients with a mean difference of 568.966 mIU/ml (95% CI 166.864, 971.067). The subgroup analysis of CK showed that it was higher in GTCS compared to syncope with a mean difference of 125.39 mIU/ml (95% CI 45.25, 205.52). DISCUSSION Increased serum levels of CK have been associated mainly with epileptic seizures in relation to non-epileptic events. However, further studies would try to explore the variation in measurements and any other potential diagnostic marker. CONCLUSION The cohort study shows that the CK level in epilepsy seizures is higher after 48 h from the event compared to syncope. Moreover, the meta-analysis results show the present diagnostic utility of CK and its importance to be used in accordance with a detailed report of the event.
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Affiliation(s)
- Ramy Abdelnaby
- Department of Neurology, RWTH Aachen University, Aachen, Germany.
| | | | - Jan Heckelmann
- Department of Neurology, RWTH Aachen University, Aachen, Germany
| | | | | | | | | | - Imene Maallem
- Faculté de Pharmacie, 23 Avenue Maquis du Grésivaudan, 38700, La Tronche, Grenoble, France
| | | | | | - Mostafa Hossam Moawad
- Faculty of Pharmacy, Clinical Department, Alexandria University, Alexandria, Egypt
- Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | | | - Ahmed Gaballa
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Campus Bielefeld- Bethel, Bielefeld, Germany
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Wang K, Yang J, Xu W, Wang L, Wang Y. Characteristics and treatments of patients with significantly elevated creatine kinase levels induced by seizures: Case report and literature review. Clin Case Rep 2023; 11:e7788. [PMID: 37601426 PMCID: PMC10432580 DOI: 10.1002/ccr3.7788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/14/2023] [Accepted: 07/11/2023] [Indexed: 08/22/2023] Open
Abstract
Motor signs accompanying seizures have been considered to result in overexertion of muscles and have the ability to cause elevated levels of serum creatine kinase (CK). There were no previous studies on the treatment of seizure-induced elevated CK. We summarized the characteristics and treatments of six patients with significant elevation of CK after seizure onset. There were four males and two females, the age range was 16-68 years. The CK levels were greater than 5000 U/L in five of the six patients and the highest CK level was 39,300 U/L. All patients exhibited an estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73m2. No patient developed renal failure or required continuous renal replacement therapy. We determined that serial assessment of CK, myoglobin, eGFR, and electrolytes should be performed in patients following seizures. Furthermore, fluid resuscitation, urine alkalization, and diuretic agents should be administrated when CK are significantly elevated after seizure onset. Serial assessment of CK levels after seizures should be performed, especially when the patient experiences electrolyte disorders. Fluid resuscitation, urine alkalization, and diuretic agents also should be administrated to patients when they exhibit a significantly elevated CK or myoglobin after seizures.
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Affiliation(s)
- Kai Wang
- The First Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Jinwei Yang
- The First Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Wenhao Xu
- The First Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Lei Wang
- The First Affiliated Hospital of Anhui Medical UniversityHefeiChina
| | - Yu Wang
- The First Affiliated Hospital of Anhui Medical UniversityHefeiChina
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Wang L, Lu Y, Yang Y, Li H, Wang Y. Elevated body temperature and leukocyte count are associated with elevated creatine kinase after seizures. Heliyon 2022; 8:e12509. [PMID: 36643300 PMCID: PMC9834749 DOI: 10.1016/j.heliyon.2022.e12509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 10/15/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
Objective To evaluate the independent risk factors for elevated creatine kinase (hyperCKemia) after seizures. Methods Data included in this retrospective study were obtained from two hospitals from July 1, 2017, to March 31, 2022. Clinical and laboratory data were acquired from the emergency department or within 24 h after patient admission. Variables that exhibited statistical differences (P < 0.05) were selected for further analysis. Associations between body temperature (BT), leukocyte count (LEU), percentage of neutrophils (NEU), and C-reactive protein (CRP) and creatine kinase (CK) levels were assessed using binary logistic regression analysis. Results One hundred twenty-three patients who exhibited seizures were included in the study, and 39 (31.7%) patients exhibited hyperCKemia based on a CK level that was >1.5 times the upper limit of the normal range for CK. No statistical differences were observed among the patient characteristics, seizure-related parameters, or electrolyte levels. However, BT, LEU, NEU, and CRP were elevated in patients with hyperCKemia compared to patients with normal CK levels. Specifically, a BT ≥ 37.5 °C (fever) and LEU >9.5×109/L (elevated LEU) exhibited positive correlations with hyperCKemia, and presented an adjusted OR of 8.87 (95% CI: 2.11-37.24, P = 0.003) and 3.01 (95% CI: 1.12-8.05, P = 0.029), respectively. Conclusion In this study, hyperCKemia occurred in 31.7% of patients after seizures. Fever and elevated LEU were independent risk factors for seizure-related hyperCKemia. Earlier recognition of risks for seizure-related hyperCKemia would be beneficial in taking prophylactic measures.
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Affiliation(s)
- Lei Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yanan Lu
- Department of Neurology, Anhui Provincial Hospital, Hefei, China
| | - Yujing Yang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hanli Li
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yu Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, China,Department of Neurology, Anqing First People's Hospital Affiliated to Anhui Medical University, Anqing, China,Corresponding author.
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Höller Y, Nardone R. Quantitative EEG biomarkers for epilepsy and their relation to chemical biomarkers. Adv Clin Chem 2020; 102:271-336. [PMID: 34044912 DOI: 10.1016/bs.acc.2020.08.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The electroencephalogram (EEG) is the most important method to diagnose epilepsy. In clinical settings, it is evaluated by experts who identify patterns visually. Quantitative EEG is the application of digital signal processing to clinical recordings in order to automatize diagnostic procedures, and to make patterns visible that are hidden to the human eye. The EEG is related to chemical biomarkers, as electrical activity is based on chemical signals. The most well-known chemical biomarkers are blood laboratory tests to identify seizures after they have happened. However, research on chemical biomarkers is much less extensive than research on quantitative EEG, and combined studies are rarely published, but highly warranted. Quantitative EEG is as old as the EEG itself, but still, the methods are not yet standard in clinical practice. The most evident application is an automation of manual work, but also a quantitative description and localization of interictal epileptiform events as well as seizures can reveal important hints for diagnosis and contribute to presurgical evaluation. In addition, the assessment of network characteristics and entropy measures were found to reveal important insights into epileptic brain activity. Application scenarios of quantitative EEG in epilepsy include seizure prediction, pharmaco-EEG, treatment monitoring, evaluation of cognition, and neurofeedback. The main challenges to quantitative EEG are poor reliability and poor generalizability of measures, as well as the need for individualization of procedures. A main hindrance for quantitative EEG to enter clinical routine is also that training is not yet part of standard curricula for clinical neurophysiologists.
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Affiliation(s)
- Yvonne Höller
- Faculty of Psychology, University of Akureyri, Akureyri, Iceland.
| | - Raffaele Nardone
- Department of Neurology, Franz Tappeiner Hospital, Merano, Italy; Spinal Cord Injury and Tissue Regeneration Center, Salzburg, Austria; Department of Neurology, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
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6
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Barbella G, Barras P, Rossetti AO, Novy J. Hypophosphatemia compared to classical biomarkers of tonic clonic seizures. Epilepsy Res 2020; 163:106326. [PMID: 32305859 DOI: 10.1016/j.eplepsyres.2020.106326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 03/09/2020] [Accepted: 03/30/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hypophosphatemia was recently reported as a potential marker of tonic-clonic (TC) seizures among patients with transitory loss of consciousness (TLOC). Its value compared to classical markers (creatine kinase [CK] and lactate) is however unknown. AIM Compare the diagnostic performance of hypophosphatemia, plasma CK, and lactate levels for distinguishing TC seizures from other TLOCs, alone or in combination. METHODS 128 patients aged 18-90, consecutively admitted to our hospital emergency department for TLOC were included. Diagnostic accuracy of plasma phosphate, CK, and lactate levels were compared with ROC curves. RESULTS We found significantly higher CK (median 154 U/l, range 38-5608; vs 115.5, 37-2340 U/l; p = 0.037) and lower phosphatemia (median 0.79 mmol/l, 0.34-1.37; vs 0.93, 0.52-1.89 mmol/l, p = 0.007) in TC seizures compared to other TLOCs; lactatemia was not different, although using a smaller sample (n = 72). Hypophosphatemia was the only independent predictor of TC seizures, even in later samples (>2 h). Comparing ROC curves, Combining hypophosphatemia and hyperCKemia had higher diagnostic accuracy for TC seizures than hyper-CKemia alone (AUC 0.68, 95 % CI 0.571-0.783 vs. 0.59, 95 % CI 0.475-0.706; p = 0.018), but the combination was only marginally better than hypophosphatemia alone (AUC 0.67, 95 % CI 0.559-0.778). CONCLUSION Hypophosphatemia seems to be more useful than CK levels for diagnosing TC seizures in patients assessed in an emergency setting for TLOC. Combining both parameters together does not significantly increase the diagnostic yield. No conclusion could be drawn regarding the comparison with lactate. A prospective study is needed.
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Affiliation(s)
- Giuseppina Barbella
- Neurology Service, Department of Clinical Neurosciences, CHUV, Lausanne University Hospital, Switzerland; Neurology Unit, San Gerardo Hospital, Monza, Italy; School of Medicine and Surgery and Milan-Center for Neuroscience (NeuroMI), University of Milano-Bicocca, Milan, Italy
| | - Pierre Barras
- Master of Medicine, University of Lausanne, Switzerland
| | - Andrea O Rossetti
- Neurology Service, Department of Clinical Neurosciences, CHUV, Lausanne University Hospital, Switzerland
| | - Jan Novy
- Neurology Service, Department of Clinical Neurosciences, CHUV, Lausanne University Hospital, Switzerland.
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Javali M, Acharya P, Shah S, Mahale R, Shetty P, Rangasetty S. Role of Biomarkers in Differentiating New-onset Seizures from Psychogenic Nonepileptic Seizures. J Neurosci Rural Pract 2019; 8:581-584. [PMID: 29204018 PMCID: PMC5709881 DOI: 10.4103/jnrp.jnrp_139_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction: Review of literature revealed very limited studies considering a combination of serum prolactin (PRL) and serum creatine kinase (CK) as markers for differentiating epileptic and psychogenic nonepileptic seizures (PNES). Therefore, in the present study, we analyzed the role of serum PRL and serum CK, individually and in combination. Methodology: This prospective study was conducted in a tertiary care medical teaching hospital over a period of 18 months. Patients aged over 15 years suspected to have new-onset seizures presenting within 5 h of ictus were included in this study. CK, serum PRL was measured at 0–1, 1–3, and 3–5 h after seizures. Results: Hundred subjects were studied for the role of serum PRL and serum CK in differentiating epileptic and PNES. The mean age was 42.24 years with a male:female ratio of 1.27:1. All patients of generalized tonic–clonic seizures (GTCS), who presented within 1 h, had elevated PRL, whereas 75% of patients with partial seizures had elevated PRL within 1 h of presentation. Nearly 91.66% of patients with GTCS who presented within 1 h had elevated CPK, whereas 70% of patients with partial seizures had elevated CPK. None of the patients diagnosed with PNES showed rise in either of the markers. Conclusion: In the present study, none of the patients with PNES showed raise in either serum PRL or CK. However, there was no correlation between the types of seizure and PRL or serum CK levels.
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Affiliation(s)
- Mahendra Javali
- Department of Neurology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Purushottam Acharya
- Department of Neurology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Shripal Shah
- Department of Neurology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Rohan Mahale
- Department of Neurology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Pushparaja Shetty
- Department of Neurology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Srinivasa Rangasetty
- Department of Neurology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India
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8
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Dafotakis M, Heckelmann J, Zechbauer S, Litmathe J, Brokmann J, Willmes K, Surges R, Matz O. [Laboratory diagnostics in transient loss of consciousness : Serum lactate compared to serum creatine kinase as diagnostic indicator for generalized tonic-clonic seizures]. DER NERVENARZT 2019; 89:922-927. [PMID: 29564468 DOI: 10.1007/s00115-018-0505-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Laboratory parameters can help in the differential diagnostics of acute episodes of transient loss of consciousness. Especially serum lactate and serum creatine kinase (CK) levels may provide valuable hints to distinguish generalized tonic-clonic seizures (GTCS) from syncope. MATERIAL AND METHODS Serum lactate levels at admission and CK levels 10-48 h after the episodes that led to admission were compared between patients with GTCS (n = 30) and those with syncope (n = 15). In addition, sensitivity and specificity of lactate and CK as diagnostic markers for syncope and GTCS were determined. RESULTS The serum lactate and serum CK levels were significantly increased in patients with GTCS as compared to syncope patients (serum lactate: p < 0.001; CK: p < 0.005). The area under the curve (AUC) for serum lactate as an indicator for GTCS was 0.94 (95% confidence interval [CI] 0.88-1.0). For CK the receiver operating characteristics (ROC) analysis produced an AUC of only 0.77 (95% CI: 0.63-0.9). CONCLUSION The determination of the lactate value as point-of-care diagnostics appears to be highly relevant in the rapid clarification of unclear episodes with transient loss of consciousness. The CK level at follow-up is also suitable for distinguishing GTCS from syncope but is inferior to the serum lactate value.
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Affiliation(s)
- M Dafotakis
- Klinik für Neurologie, Universitätsklinikum RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - J Heckelmann
- Klinik für Neurologie, Universitätsklinikum RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - S Zechbauer
- Klinik für Neurologie, Universitätsklinikum RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - J Litmathe
- Klinik für Neurologie, Universitätsklinikum RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - J Brokmann
- Zentrale Notaufnahme, Universitätsklinikum RWTH Aachen, Aachen, Deutschland
| | - K Willmes
- Klinik für Neurologie, Universitätsklinikum RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - R Surges
- Klinik für Neurologie, Universitätsklinikum RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland
| | - O Matz
- Klinik für Neurologie, Universitätsklinikum RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland.
- Zentrale Notaufnahme, Universitätsklinikum RWTH Aachen, Aachen, Deutschland.
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Barras P, Siclari F, Hügli O, Rossetti AO, Lamy O, Novy J. A potential role of hypophosphatemia for diagnosing convulsive seizures: A case‐control study. Epilepsia 2019; 60:1580-1585. [DOI: 10.1111/epi.16090] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/27/2019] [Accepted: 05/27/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Pierre Barras
- Bachelor of Medicine University of Lausanne Lausanne Switzerland
| | - Francesca Siclari
- Center for Investigation and Research on Sleep Lausanne University Hospital Lausanne Switzerland
| | - Olivier Hügli
- Emergency Department Lausanne University Hospital Lausanne Switzerland
| | - Andrea O. Rossetti
- Neurology Service Department of Clinical Neurosciences Lausanne University Hospital Lausanne Switzerland
| | - Olivier Lamy
- Center of Bone Diseases and Service of Internal Medicine Lausanne University Hospital Lausanne Switzerland
| | - Jan Novy
- Neurology Service Department of Clinical Neurosciences Lausanne University Hospital Lausanne Switzerland
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Matz O, Heckelmann J, Zechbauer S, Litmathe J, Brokmann JC, Willmes K, Schulz JB, Dafotakis M. Early postictal serum lactate concentrations are superior to serum creatine kinase concentrations in distinguishing generalized tonic-clonic seizures from syncopes. Intern Emerg Med 2018; 13:749-755. [PMID: 28900842 DOI: 10.1007/s11739-017-1745-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 09/04/2017] [Indexed: 10/18/2022]
Abstract
Concentrations of serum creatine kinase (CK) and serum lactate are frequently measured to help differentiate between generalized tonic-clonic seizures (GTCS) and syncope. The aim of this prospective cohort study was to systematically compare these two markers. The primary outcome is the measurement of serum lactate and CK in blood samples drawn within 2 h of the event in patients admitted with either a GTCS (n = 49) or a syncope (n = 36). Furthermore, the specificity and sensitivity of serum lactate and CK are determined as diagnostic markers in distinguishing between GTCS and syncope. GTCS patients have significantly higher serum lactate levels compared to syncope patients (p < 0.001). In contrast, CK does not differ between groups at admission. Regarding the first hour after the seizure, we identify a cut-off for serum lactate of 2.45 mmol/l for diagnosing GTCS as the cause of an impairment of consciousness with a sensitivity of 0.94 and a specificity of 0.93 (AUC: 0.97; 95% CI 0.94-1.0). In the second hour after the event, the ROC analysis yields similar results (AUC: 0.94; 95% CI 0.85-1.0). Serum lactate is a sensitive and specific diagnostic marker to discriminate GTCS from syncope and is superior to CK early after admission to the emergency department.
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Affiliation(s)
- Oliver Matz
- Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany.
- Emergency Department, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany.
| | - Jan Heckelmann
- Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
| | - Sebastian Zechbauer
- Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
| | - Jens Litmathe
- Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
| | - Jörg C Brokmann
- Emergency Department, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
| | - Klaus Willmes
- Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
| | - Jörg B Schulz
- Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH, RWTH Aachen University, Aachen, Germany
| | - Manuel Dafotakis
- Department of Neurology, University Hospital, Rheinisch-Westfälische Technische Hochschule [RWTH] Aachen, Aachen, Germany
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11
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Nass RD, Meiling S, Andrié RP, Elger CE, Surges R. Laboratory markers of cardiac and metabolic complications after generalized tonic-clonic seizures. BMC Neurol 2017; 17:187. [PMID: 28927394 PMCID: PMC5605980 DOI: 10.1186/s12883-017-0965-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/11/2017] [Indexed: 11/15/2022] Open
Abstract
Background Generalized tonic-clonic seizures (GTCS) frequently lead to emergency inpatient referrals. Laboratory blood values are routinely performed on admission to detect underlying causes and metabolic or cardiac complications. Our goal was to assess the nature and frequency of complications occurring in association with GTCS. Methods We retrospectively extracted data from emergency protocols and discharge letters of adult patients admitted to the Department of Epileptology between 01/2010 and 06/2015. Inclusion criteria were diagnosis of GTCS and admission via emergency services. Exclusion criteria were status epilepticus prior to admission to hospital and non-generalized seizures. Results A total of 223 patients (of 986 screened cases) were included. Overall, 1.8% required intubation while 1.3% had less severe respiratory problems. In 5.6% of patients, a transient hypoxemia was measured. Hypertensive urgencies affected 7.8% of the patients, sinus tachycardia occurred in 41.2%. Troponin I (cTNI) was determined in 75 patients and was increased in 12% of these cases. Occurrence of elevated cTNI levels was significantly correlated with patient’s age. Four patients were diagnosed with NSTEMI and one patient with STEMI. Creatine kinase (CK) was increased in 59.4% of the patients, with <5-fold increases in 47%, <10-fold in 5.8% and >10-fold increases in 4.3%. Rhabdomyolysis with an >50 fold increase in CK was detected in 1.9% of patients. Prolonged disturbances of consciousness affected 5% of cases while agitation, delirium, and psychotic episodes occurred in 6.3%. Minor traumatic injuries affected 45.7% of patients. Conclusions Troponin elevations in association with GTCS are one of the more common complications after emergency admissions especially in older patients. In our selected patient population, serious complications such as intracranial hemorrhage, myocardial infarction and acute renal failure occurred in <1% of GTCS only.
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Affiliation(s)
- Robert D Nass
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Sina Meiling
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - René P Andrié
- Department of Medicine - Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Rainer Surges
- Department of Epileptology, University Hospital Bonn, Bonn, Germany. .,Department of Neurology, Section of Epileptology, RWTH University Hospital Aachen, Aachen, Germany.
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12
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The role of postictal laboratory blood analyses in the diagnosis and prognosis of seizures. Seizure 2017; 47:51-65. [DOI: 10.1016/j.seizure.2017.02.013] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 12/18/2022] Open
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13
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Brigo F, Igwe SC, Erro R, Bongiovanni LG, Marangi A, Nardone R, Tinazzi M, Trinka E. Postictal serum creatine kinase for the differential diagnosis of epileptic seizures and psychogenic non-epileptic seizures: a systematic review. J Neurol 2014; 262:251-7. [PMID: 24824225 DOI: 10.1007/s00415-014-7369-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 05/06/2014] [Indexed: 10/25/2022]
Abstract
The aim of this review was to evaluate the sensitivity and specificity of postictal creatine kinase (CK) levels in the differential diagnosis of epileptic seizures (ES) and psychogenic non-epileptic seizures (PNES). A systematic search was conducted for studies that evaluated postictal CK levels in patients with ES (all types) and PNES. Sensitivity and specificity with 95 % confidence intervals were determined for each study, taking into account: (a) the upper limits adopted; and (b) the 95.7th percentile values, which are recently proposed practical upper reference limits for CK activity. Four studies, comprising a total of 343 events (248 ES and 95 PNES), were available for analysis. Most patients (47/78, 60 %) with ES considered had primarily or secondarily generalized tonic-clonic seizures. The sensitivity of increased postictal CK levels for ES ranged from 14.6 to 87.5, whereas specificity ranged from 85.0 to 100.0. At the 95.7th percentile threshold, sensitivity ranged from 14.6 to 62.5 and specificity was 100.0. The limited number of studies available, their small sample size, and lack of individual event data prevented further stratification analysis by seizure type. Despite the clinical heterogeneity and the limitations of the included studies, increased postictal CK levels are highly specific for the diagnosis of ES, although no definite conclusion on its role in differentiating between convulsive and non-convulsive ES can be drawn. Postictal serum CK levels can provide valuable retrospective information at the later stages of the differential diagnosis of ES and PNES. Due to low sensitivity, normal postictal CK levels do not exclude ES.
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Affiliation(s)
- Francesco Brigo
- Section of Clinical Neurology, Department of Neurological and Movement Sciences, University of Verona, Piazzale L.A. Scuro, 10, 37134, Verona, Italy,
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Hung TY, Chen CC, Wang TL, Su CF, Wang RF. Transient hyperammonemia in seizures: a prospective study. Epilepsia 2011; 52:2043-9. [PMID: 21972984 DOI: 10.1111/j.1528-1167.2011.03279.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE To investigate the incidence and duration of transient hyperammonemia in seizures and to verify the significant confounders related to transient hyperammonemia in seizures. METHODS One hundred twenty-one noncirrhotic adult patients with seizures admitted to the emergency department were enrolled in the study. Laboratory examination was performed, including plasma ammonia level assessment. In addition, the basic parameters, underlying systemic diseases, and seizure-related conditions were assessed. The patients were classified into a group with hyperammonemia on arrival and a group without, in order to compare seizure-related adverse events that occurred during a 9-month period. KEY FINDINGS The incidence of hyperammonemia in patients with seizures was 67.77%. Plasma ammonia levels in patients with generalized tonic-clonic (GTC) seizures were significantly higher than those in patients in the non-GTC seizure group (median 174.5 vs. 47 μg/dl; proportion 76.5% vs. 21.1%; p < 0.001). Median plasma ammonia levels decreased spontaneously from 250 to 54 μg/dl (p < 0.00001) in an average interval of 466.79 min. GTC seizures (p < 0.0001), male gender (p < 0.0001), bicarbonate (p < 0.0001), diabetes (p = 0.0139), and alcohol-related seizures (p = 0.0002) were significant factors associated with hyperammonemia on arrival. No significant differences related to admission rates or mortalities were found between the two groups. SIGNIFICANCE The presence of transient hyperammonemia in patients with seizures is significantly related to GTC seizures, male gender, bicarbonate, diabetes, and alcohol-related seizures. The appropriate period to study ammonia levels following a seizure event is within 8 h. Because these phenomena are self-limited, ammonia-lowering management are not necessary. Hyperammonemia on arrival is not necessarily related to adverse outcomes.
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Affiliation(s)
- Tzu-Yao Hung
- Emergency Department, Keelung Hospital, Department of Health, Executive Yuan, Keelung, Taiwan
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Abstract
BACKGROUND Exercise-induced hypoglycaemia is common in people with insulin-treated diabetes and if severe can provoke neurological morbidity including coma and seizures. Depending on the duration and demands of the physical activity, various strategies can be used to limit the risk of hypoglycaemia with strenuous exercise. However, metabolic events occurring in the 48 h before the exercise can influence the risk and responses to exercise-induced hypoglycaemia. CASE REPORT A 27-year-old man with Type 1 diabetes suffered an episode of nocturnal hypoglycaemia which provoked a tonic-clonic seizure. Despite this he ran in a marathon the following day during which he collapsed with severe hypoglycaemia and a further associated seizure. He subsequently developed severe myalgia accompanied by a pronounced and persistent elevation of plasma creatine kinase, indicating rhabdomyolysis, and deranged liver function, suggestive of hypoxic hepatitis. The biochemical abnormalities and symptoms lasted for several weeks. CONCLUSIONS The case highlights the dangers of intense and prolonged physical exercise following severe hypoglycaemia, demonstrating the risks of acute damage to skeletal muscle and to organs such as the liver, in addition to the risk of severe neuroglycopenia and the induction of seizures. The mechanisms underlying these problems are discussed. People with insulin-treated diabetes should be advised not to undertake prolonged intensive exercise after severe hypoglycaemia.
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Affiliation(s)
- A J Graveling
- Department of Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
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Petramfar P, Yaghoobi E, Nemati R, Asadi-Pooya AA. Serum creatine phosphokinase is helpful in distinguishing generalized tonic-clonic seizures from psychogenic nonepileptic seizures and vasovagal syncope. Epilepsy Behav 2009; 15:330-2. [PMID: 19383552 DOI: 10.1016/j.yebeh.2009.04.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Revised: 04/11/2009] [Accepted: 04/14/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Distinguishing epileptic generalized tonic-clonic seizures (GTCS) from either psychogenic nonepileptic seizures (PNES) or vasovagal syncope (VVS) is important. In this study, we investigated the use of postictal serum creatine phosphokinase (CPK) concentrations in distinguishing between these events. METHODS Patients admitted to the Neurology Ward at Namazi Hospital in Shiraz, Iran, with an attack of transient loss of consciousness and abnormal movements witnessed by a neurologist were studied. We categorized the patients into three groups: 20 patients with GTCS, 22 with VVS, and 20 with PNES. A group of 20 normal healthy individuals were included in the study as the control group. Serum CPK concentration was measured 12-15 h after the attack in all patients and at one time in the control group. A P value less than 5% was considered significant. RESULTS There were no significant differences between the four groups with respect to age and sex. Mean CPK concentrations statistically significantly differed between the four groups, with higher levels in patients with GTCS (P=0.0001). Serum CPK concentration had a sensitivity of 75% and specificity of 86% for the diagnosis of GTCS. CPK concentration was above 160 mg/dl in 75% of patients with GTCS, 15% of patients with PNES, 13.6% of patients with VVS, and 15% of the control group (P=0.0001). The PNES, VVS, and control groups did not statistically significantly differ with respect to CPK concentrations. CONCLUSION In patients with a recent loss of consciousness and abnormal movements, serum CPK concentration is a useful, practical, and relatively accurate parameter to assist in the differentiation of epileptic seizures from either VVS or PNES.
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Affiliation(s)
- Peyman Petramfar
- Department of Neurology, Shiraz University of Medical Sciences, Shiraz, Iran.
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Seizure or syncope: the diagnostic value of serum creatine kinase and myoglobin levels. Eur J Emerg Med 2009; 16:84-6. [DOI: 10.1097/mej.0b013e32830abe06] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chowdhury FA, Nashef L, Elwes RDC. Misdiagnosis in epilepsy: a review and recognition of diagnostic uncertainty. Eur J Neurol 2008; 15:1034-42. [DOI: 10.1111/j.1468-1331.2008.02260.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gandelman-Marton R, Theitler J, Chaim SB, Rabey JM. Delayed post-ictal event-related potentials do not differentiate between generalized tonic-clonic seizures and syncope. Seizure 2007; 16:454-8. [PMID: 17412616 DOI: 10.1016/j.seizure.2007.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2006] [Revised: 01/21/2007] [Accepted: 03/12/2007] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The differentiation between generalized tonic-clonic seizure (GTCS) and syncope is an important clinical problem. Corroborative investigations, which are requested when history is unclear or insufficient, have limited diagnostic value. The aim of our study was to determine whether auditory event-related potentials (ERPs) can be utilized in post-event differentiation between GTCS and syncope. MATERIALS AND METHODS ERPs were recorded in 18 patients with a single seizure and in 21 patients following syncope, either on one or two occasions. ERP latencies and amplitudes were compared between groups and sessions. RESULTS No significant differences of P3, N2, P2 and N1 latencies and P3, N2 and P2 amplitudes were found between patients following a single GTCS as compared to patients following syncope on either session. CONCLUSION Post-event ERPs are insufficient to differentiate between GTCS and syncope. Further investigations are needed to evaluate the influence of different post-event intervals and ERP paradigms on ERP parameters in patients with GTCS.
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Willert C, Spitzer C, Kusserow S, Runge U. Serum neuron-specific enolase, prolactin, and creatine kinase after epileptic and psychogenic non-epileptic seizures. Acta Neurol Scand 2004; 109:318-23. [PMID: 15080857 DOI: 10.1046/j.1600-0404.2003.00232.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the discriminative power of serial, simultaneous determinations of serum neuron-specific enolase (NSE), prolactin (PRL) and creatine kinase (CK) in differentiating psychogenic non-epileptic seizures (PNES) from epileptic seizures (ES). METHODS Prospective measurement of the three markers after 44 single seizures (32 ES and 12 PNES) during continuous video-EEG monitoring at seven different sampling points. RESULTS Patients with ES had a significantly greater increase in PRL at 10, 20, 30 min, 1 and 6 h. The sensitivity for elevated NSE and CK was low. PRL showed a higher sensitivity. However, the corresponding positive predictive value was lower than in CK and NSE. Additionally, PRL had the lowest specificity of all parameters. CONCLUSIONS The limited discriminative power of PRL, CK, and NSE calls into question if these markers are helpful in differentiating PNES and ES.
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Affiliation(s)
- C Willert
- Neurological Rehabilitation Center, Greifswald, Germany
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Abstract
Making a correct diagnosis in patients presenting with attack disorders is important. The clinical features of autosomal dominant nocturnal frontal lobe epilepsy and concussive seizures are reviewed. Recent work on the diagnosis and investigation of psychogenic non-epileptic attacks, drop attacks, falls, syncope and sleep disorders is discussed.
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Affiliation(s)
- R Roberts
- University of Dundee, Department of Medicine, Ninewells Hospital and Medical School, UK
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