Who can help get a patient with 4 recent seizures and a left cortical abnormality into a hospital or epilepsy center ASAP?

Urgent Referral for Recurrent Seizures with Cortical Abnormality

Your patient requires immediate neurologist consultation and urgent referral to a Level 4 Epilepsy Center, as recurrent seizures with structural brain abnormalities indicate potential surgical candidacy and necessitate specialized evaluation to prevent long-term morbidity.

Immediate Actions and Referral Pathway

Emergency Department Evaluation

• Activate EMS or present to the ED immediately if the patient experiences another seizure lasting >5 minutes, multiple seizures without return to baseline, or any seizure with traumatic injury or respiratory distress 1.
• The ED physician should perform neuroimaging in the emergency setting given the known cortical abnormality and recurrent seizures 1.
• A head CT scan should be performed emergently when an acute intracranial process is suspected, particularly with a focal neurologic examination or known structural abnormality 1.

Neurology Referral

• Contact a general neurologist immediately for urgent outpatient evaluation if the patient is currently stable 2.
• Request expedited appointment scheduling, emphasizing the recurrent nature (4 seizures in recent months) and presence of a structural lesion 2.
• Within integrated healthcare systems, the mean time from diagnosis to epilepsy center evaluation is approximately 3.2 years, but patients with structural abnormalities require much faster referral 2.

Epilepsy Center Referral

• Request direct referral to a Level 4 Epilepsy Center for comprehensive evaluation, as patients with focal cortical abnormalities are potential surgical candidates 3, 2.
• Early identification of surgical candidates prevents years of uncontrolled disease and associated morbidity 3.
• MRI is the preferred imaging modality for epilepsy evaluation and should be obtained if not already performed, as it identifies structural abnormalities in 85% of patients with refractory partial seizures 4, 5.

Critical Clinical Context

Why Urgent Referral Matters

• Structural abnormalities with recurrent seizures represent potentially treatable epilepsy that may respond to surgical intervention 3, 4.
• Delays in surgical evaluation historically average 15-18 years in some settings, leading to preventable morbidity 2.
• Patients with focal cortical lesions identified early have significantly better outcomes when appropriate interventions are implemented promptly 3.

Imaging Considerations

• The "subtle abnormality in the left cortex" requires systematic MRI evaluation by epilepsy specialists 5.
• Cortical thickening, focal atrophy, or gray matter heterotopia may indicate developmental anomalies that are surgically treatable 5.
• Hippocampal involvement should be evaluated regardless of other findings to avoid missing dual pathology 5.

Hospital Admission Criteria

Indications for Immediate Hospitalization

• Admit if the patient has seizure recurrence within 24-72 hours of ED presentation, as 19% of first-time seizure patients experience recurrence within 24 hours 1.
• Hospital admission is warranted if there is concern for status epilepticus, underlying life-threatening etiology, or inability to ensure reliable outpatient follow-up 1.
• Patients with focal neurologic deficits that do not quickly resolve require emergent neuroimaging and likely admission 6.

Common Pitfalls to Avoid

• Do not delay referral assuming the patient needs to "fail" multiple antiepileptic drugs first—structural lesions warrant early epilepsy center evaluation 3, 2.
• Do not rely solely on CT imaging—MRI is superior for identifying subtle cortical abnormalities and should be obtained if not already done 4, 5.
• Do not dismiss the urgency based on seizure-free intervals between events—four seizures in recent months with a structural lesion indicates active, potentially progressive disease 3.
• Ensure reliable follow-up is arranged before discharge from any ED visit, as social factors and timely follow-up are critical considerations 1.

Practical Contact Strategy

• Call the neurology department directly and speak with the on-call neurologist or clinic scheduler, emphasizing: (1) recurrent seizures, (2) known cortical abnormality, (3) need for urgent evaluation 2.
• If within an integrated healthcare system, request expedited referral through the electronic health record with "urgent" priority 2.
• For immediate concerns or if another seizure occurs, call 911 or present to the nearest ED with neurology consultation capabilities 1.