Neurological Monitoring for Breakthrough Seizures in Admitted Patients
Yes, patients admitted for breakthrough seizures should receive regular neurological examinations during routine vital sign monitoring, particularly within the first 6 hours when recurrence risk is highest. 1, 2
Rationale for Neurological Monitoring
Patients with breakthrough seizures require neurological checks because the mean time to seizure recurrence is 121 minutes (median 90 minutes), with more than 85% of early recurrences occurring within 6 hours of presentation. 2 This high early recurrence rate justifies close monitoring during the acute admission period.
The Canadian Stroke Best Practice guidelines specifically recommend that patients who have had a seizure should be monitored for recurrent seizure activity during routine monitoring of vital signs and neurological status. 1 This applies to breakthrough seizures in patients with established epilepsy, not just new-onset seizures.
What to Monitor During Neurological Checks
Your neurological examinations should specifically assess for:
- Return to baseline mental status – persistent altered consciousness may indicate nonconvulsive status epilepticus 2
- Focal neurological deficits – new deficits suggest structural pathology or Todd's paralysis 1, 2
- Level of consciousness and orientation 1
- Any signs of recurrent seizure activity 1
Frequency of Monitoring
Neurological checks should be incorporated into routine vital sign monitoring, which typically occurs every 4 hours on general medical floors or more frequently in higher-acuity settings. 1 Given that 85% of recurrences happen within 6 hours, more frequent monitoring (every 1-2 hours) is warranted during the first 6 hours after admission. 2
Key Distinction: Breakthrough vs. New-Onset Seizures
It's important to note that routine neuroimaging is not necessary after a breakthrough seizure in a patient with established epilepsy 1, unlike new-onset seizures where emergent imaging is often indicated. However, this does not eliminate the need for clinical neurological monitoring.
Common Pitfalls to Avoid
- Do not assume the patient is stable simply because they have "known epilepsy" – breakthrough seizures can signal medication non-adherence, drug interactions, metabolic derangements, or new structural pathology 3, 4
- Do not miss nonconvulsive status epilepticus – patients with persistent altered consciousness after a seizure require emergent EEG, not just clinical monitoring 2
- Do not discharge patients who have not returned to baseline – persistent abnormal neurological examination warrants admission and continued monitoring 1, 2
Management During Admission
If recurrent seizures occur during monitoring, treat with appropriate short-acting medications (e.g., lorazepam IV) if they are not self-limiting. 1 Recurrent seizures should be managed according to standard treatment protocols for seizures in neurological conditions. 1
Communication with the patient's outpatient neurologist or primary care physician is critical to identify potential causes of the breakthrough seizure, such as medication non-adherence, drug interactions, sleep deprivation, or other precipitants. 4