Authors :
Presenting Author: MarieElena Byrnes, DO, MS – Cleveland Clinic
Nicholas Thompson, MS – Cleveland Clinic; Stephen Hantus, MD – Cleveland Clinic; Neishay Ayub, MD – Rhode Island Hospital, Brown University; Clio Rubinos, MD, MS – University of North Carolina; Adithya Sivaraju, MD, MHA – New Haven Hospital, Yale University; Sahar Zafar, MBBS – Massachusetts General Hospital, Harvard University; Vineet Punia, MD, MS – Cleveland Clinic
Rationale: Most patients with acute symptomatic seizures (ASyS) are discharged on anti-seizure medications (ASM) and stay on them long-term despite an overall low risk of seizure recurrence. The post-acute symptomatic seizure (PASS) clinic at the Cleveland Clinic is a model of care that individualizes ASM management in these patients leading to their timely discontinuation. The aim of the study was to analyze the predictors of PASS clinic adherence, ASM discontinuation, and seizure recurrence risk.
Methods: We performed a single-center, retrospective cohort study of adults hospitalized from 01/01/2019 to 09/30/2019 who were eligible for PASS clinic care (study population); adults without epilepsy history discharged on ASMs due to a witnessed or suspected ASyS. Due to high post-discharge mortality in the study population, we performed cause-specific Cox proportional hazards models for the three analyses. We checked for multicollinearity, computed hazard ratios (HR), and 95% confidence intervals (CI).
Results:
A total of 307 PASS clinic eligible patients were included (mean age = 61.6 ±16.5 years; 51.8% females). A total of 136 (44.3%) patients died after discharge, including 24 who visited PASS clinic before their death. The median follow-up time of the study population was 14 (Interquartile range [IQR] = 2-34) months. Among them, 95 (30.9%) were seen in the PASS clinic with a median time from discharge to first PASS visit of 70 days (IQR = 27-106). On multivariable analysis, PASS clinic adherence was significantly associated with epileptiform abnormality (HR = 1.69, 95% CI = 1.10–2.59, P = 0.016) on the inpatient EEG and the PASS clinic appointment provided at hospital discharge (HR = 3.39, 95% CI = 2.15–5.33, P < 0.001). Patients with progressive brain injury (i.e., neoplasm) were less likely to attend PASS clinic (HR = 0.55, 95% CI = 0.32–0.95, P = 0.032) compared to acute brain injury. A total of 92 patients (30%) had their ASM discontinued post-discharge with a median time to discontinuation of four months (IQR = 1.7–10.5). For analysis of ASM discontinuation and seizure recurrence predictors, a PASS clinic visit was considered an independent variable. In the multivariable model, attending the PASS clinic increased the ASM discontinuation rate by 3-fold (HR = 3.25, 95% CI = 1.89–5.58, P < 0.001). The two factors associated with seizure recurrence included epileptiform EEG performed after hospital discharge (HR = 6.13, 95% CI = 2.96–12.65, P < 0.001) and PASS clinic visit clinic (HR = 0.13, 95% CI = 0.05–0.34, P < 0.001). Figure 1 shows cumulative incidence of ASM discontinuation, post-discharge seizure, and death in the study population.