Electronic Letters to:
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eLetters: Electronic letters published:
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When 'first seizure' is not a seizure
- Cathryn Wield (7 June 2005)
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Neuroimaging in adults with an uncomplicated first generalised seizure – CT or MRI
- Eric K Woo (26 April 2005)
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Cathryn Wield, SpR A&E
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cathy{at}wields.co.uk Cathryn Wield
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Dear Editor The authors of 'Early management of adults with an uncomplicated first generalised seizure' touch briefly on the important differential diagnoses. However, they suggest that when the diagnosis is in doubt that a psychiatric history should be taken. This is unlikely to yield much in the way of useful information, unless of course the patient is suffering from panic disorder or generalised anxiety disorder. In which case it would be better if the authors had mentioned these specific conditions. A psychosocial history may be more revealing. Likewise they recommend the possibility of referral to a psychiatrist, I cannot think of any occasion where either a patient presenting with a pseudo-fit or a panic attack would be appropriately referred to psychiatry. On the other hand, referral back to the GP would be entirely reasonable. One must remember that psychiatry is a speciality and appropriate referral needs to be made for patients with a particular diagnosis which requires specialist intervention. These symptoms are neither life threatening nor specific to any of the major psychiatric illnesses with the exceptions that I have already mentioned. Both generalised anxiety and panic disorder would definitely require continued assessment in primary care before they came to the attention of the overloaded psychiatric services. |
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Eric K Woo, SpR Radiology Deparment of Radiology, St. Thomas' Hospital, London, UK
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e.woo{at}doctors.org.uk Eric K Woo
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Dear Editor, Neuroimaging is important in the assessment of an uncomplicated first generalised seizure. MRI is the investigation of choice [1]. CT scanning is more readily available to the emergency department and is therefore more likely to be performed [2]. There are however potential problems. With early seizure clinic follow up, it is likely the specialist would request a MRI and therefore the patient would have received unnecessary irradiation by the CT scan. There is also the issue with resources especially with the increased number of requests of CTs due to the NICE head injury guidelines. However, if MRI is not requested, there may be missed pathology. Providing that there is no focal neurology and that the patient has fully recovered post seizure, a sensible approach would be to perform an early MRI as an outpatient and then the patient can be reviewed in the clinic with the results. This has certainly worked well within our institution. References 1. Scottish Intercollegiate Guidelines Network. Diagnosis and management of epilepsy in adults. April 2003. 2. M J G Dunn, D P Breen, R J Davenport, and A J Gray. Early management of adults with an uncomplicated first generalised seizure. Emerg Med J 2005;22:237-242. |
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