Management and Outcomes in Confirmed or Suspected Acute Symptomatic Seizure: Role of Structured Outpatient Care

Abstract

Objective: Post-discharge management and outcomes of acute symptomatic seizures (ASyS) remain underexplored. We analyzed post-discharge ASM management and outcomes in ASyS patients undergoing continuous EEG (cEEG), including the role of outpatient care through a post-acute symptomatic seizure (PASS) clinic. Methods: We performed a single-center, retrospective study of adults without epilepsy discharged on ASMs due to witnessed or suspected ASyS in 2019. A cause-specific cumulative distribution function was used to estimate outcome probabilities, and cause-specific Cox proportional hazards models examined factors influencing the first ASM discontinuation, subsequent unprovoked seizure, and death. Results: The study evaluated 307 patients [mean 61.6 years; 51.8% females], 60.2% with confirmed ASyS [144 (46.9%) clinical ASyS; 41 (13.4%) with electrographic ASyS only]. During median 14-month follow-up, 31.9% discontinued ASM, 18.6% experienced unprovoked seizure, and 38.4% died. Based on cumulative incidence function, ASM discontinuation, unprovoked seizure, and death at 12 months occurred in 26.2%, 14.1%, and 29.3% of patients, respectively. 59.6% of alive patients without unprovoked seizures were taking ASMs. Clinical ASyS (HR 0.48; 95% CI 0.31, 0.76), electrographic ASyS only (HR 0.37; 0.17, 0.82), and acute epileptiform abnormalities (HR 0.48; 0.27, 0.84) were associated with lower ASM discontinuation. Unprovoked seizures were associated with epileptiform outpatient EEG (HR 5.40; 2.62, 11.12). PASS clinic patients discontinued ASMs 74% faster (HR 1.74; 1.12, 2.71), with 88% lower risk of unprovoked seizures (HR 0.12; 0.04, 0.34). Interpretation: Outpatient ASM overuse in ASyS patients is common. Outpatient epileptiform abnormalities may predict unprovoked seizures. Structured outpatient care, such as PASS clinics, facilitates faster yet safer ASM discontinuation.