A Clinical Risk Case Study- Necessity of Neuroimaging upon Diagnosing Epilepsy

A Clinical Risk Case Study- Necessity of Neuroimaging upon Diagnosing Epilepsy

Setting the Scene

The patient, in this case, had a long history of seizures. Although they would have some periods of time without seizures, the issue was never fully controlled.

The patient also suffered what was thought to be anxiety triggered epileptic and migraine attacks, which prompted psychological review. These attacks commenced again, and the patient underwent an MRI scan.

The results of the MRI scan showed an abnormality in the left temporal lobe, indicative of either cortical dysplasia or a low-grade tumour.

The main learning points from this review stem from the following events:

  • Not undertaking neuroimaging of the patient upon being diagnosed with epilepsy on two separate occasions over 10 years apart

  • Further neglecting to undertake neuroimaging at any point over the patient’s prolonged history despite persisting seizures

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:

  • Undertake neuroimaging in the form of MRI, or CT scan if MRI is not available, at the earliest possible opportunity after diagnosis of epilepsy in accordance with guidance from NICE and the International League Against Epilepsy. Neuroimaging is important in identifying any potential underlying causes of epilepsy, which in turn may have implications for treatment.

  • Consider repeat neuroimaging throughout the patient’s life in order to monitor the development of existing abnormalities, or to identify new abnormalities in patients with persisting seizures. These may not have been identified on earlier, less sensitive neuroimaging, and will enable other potential treatment options such as epilepsy surgery.

  • Seek the opinion of an expert neuroradiologist when reviewing imaging in order to increase the likelihood of subtle abnormalities being picked up. This further increases the likelihood of patients receiving the correct treatment in a timely fashion.

To Summarise

Neuroimaging must be undertaken upon diagnosis of epilepsy. This would ideally be performed as an MRI scan; however, CT scan is also an acceptable modality if MRI is not available. Imaging should be performed so as to identify any abnormalities that may be present in the brain that could be the cause of epilepsy, and potentially affect the treatment plan for the patient’s condition.

References

  • ILAE Neuroimaging Commission: Recommendations for Neuroimaging of Patients with Epilepsy; Barkovich, A. J., Berkovic, S. F., Cascino, G. D., Chiron, C., Duncan, J. S., Gadian, D. G.,Theodore, W. H. (1997) Epilepsia, 38(11), 1255-1256
  • The value of repeat neuroimaging for epilepsy at a tertiary referral centre: 16 years of experience; Winston GP, Micallef C, Kendell BE, Bartlett PA, Williams EJ, Burdett JL, Duncan JS. (2013) Epilepsy Research 105(3), 349-355
  • Epilepsy: Repeat MRI in patients with chronic epilepsy; Seeck, M. (2013). Nature Reviews Neurology; 9; 545-546.
  • [Co-written by The TMLEP Clinical Risk and Patient Safety Publishing Group and Dr Mahinda Yogarajah, Consultant Neurologist. (2019). A Clinical Risk Case Study- Necessity of Neuroimaging upon Diagnosing Epilepsy. TMLEP Clinical Risk Case Studies. 3 (3), 1.]

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable. To request an independent clinical review, please contact admin@tmlep.com or call +44 (0) 203 355 9796.