Bilinç kaybı yaşayan hastalarda epileptik nöbet ve senkop ayırıcı tanısında kullanılabilecek belirteçler

Öz

Amaç: Bilinç kaybı, senkop ve epileptik nöbetlerin ortak belirtisidir. Çalışmamızda acil servise bilinç kaybı ile başvuran hastalarda senkop ve epileptik nöbet ayırıcı tanısı için kullanılabilecek klinik ve biyokimyasal biyobelirteçleri belirlemek amaçlanmıştır. Gereç ve Yöntemler: Hastanemiz acil servisine üç ay boyunca bilinç kaybı şikâyeti ile başvuran hastaların dosyaları ve laboratuvar incelemeleri (laktat, hemoglobin, nötrofil, lenfosit) sonuçları tarandı, demografik özellikleri ve eşlik eden hastalıkları kaydedildi. Elde edilen veriler istatistiksel analizinde SofaStat (Auckland, New Zealand) programı kullanıldı. Bulgular: Epileptik nöbet nedeniyle başvuran hastalar, senkop nedeniyle başvuranlara kıyasla daha genç hastalardı ancak cinsiyet dağılımı birbirine benzerdi. Senkop ile başvuranlarda diyabet ve hipertansiyon öyküsü daha fazlaydı. İlk kez başvuranlara kıyasla daha önce benzer nöbet yaşayanların epilepsi olma olasılığı daha fazlaydı. Epileptik nöbet ile başvuranlarda, epizot sonrasında konfüzyon öyküsü senkop ile başvuranlardan daha fazlaydı. Epileptik nöbet nedeniyle başvuranların serum laktat düzeyi ortancası (3,3 U/L), senkop nedeniyle başvuranlara (2,3 U/L) kıyasla anlamlı düzeyde daha yüksekti (p=0,002). Serum laktat değerleri analiz edildiğinde, epilepsi ve senkop hastalarını ayırt etmek için en iyi eşik değer 2,5 U/L idi. Bu eşik değerin tanısal doğruluk oranı % 60,5 iken, sensitivitesi %60,2 ve spesifisitesi %62,3 idi. Kadınların hemoglobin ve hematokrit değerlerinin ortancası erkeklere kıyasla anlamlı düzeyde daha düşüktü. Sonuç: Çalışmamızın sonuçları, serum laktat düzeylerinin epileptik nöbet nedeniyle başvuran hastaları senkop nedeniyle başvuranlardan ayırt etmede önemli bir biyobelirteç olduğunu göstermektedir. Serum laktat değeri özellikle hasta ve hasta yakınlarının epizodu tarifleyemediği durumlarda değerli bilgiler sunabilir.

Anahtar Kelimeler

• Epileptik Nöbet
• Senkop
• Laktat
• Klinik ve Biyokimyasal Biyobelirteç

Markers that can be used in the differential diagnosis of epileptic seizure and syncope in patients with loss of consciousness

Öz

Aim: Loss of consciousness is a common finding of syncope and epileptic seizures. In our study, we aimed to determine the clinical and biochemical biomarkers that can be used to differentiate syncope and epileptic seizures in patients admitted to emergency departments with loss of consciousness. Material and Methods: The files and laboratory examination results of the patients who applied to the emergency department for three months with loss of consciousness were scanned, and their demographic characteristics and accompanying disorders were derived. SofaStat (Auckland, New Zealand) program was used for statistical analysis of the obtained data. Results: Patients presenting with epileptic seizures are younger than those presenting with syncope but the gender distribution of patients was similar. Those presenting with syncope were more likely to have a history of diabetes and hypertension. The median serum lactate level (3.3 U/L) of those presenting with epileptic seizures was significantly higher than those presenting with syncope (2.3 U/L). (p=0.002) The best cut-off level of lactate level in differentiating the epileptic seizure and syncope was 2.5 U/L. The diagnostic accuracy of this level was 60.5%, whereas the sensitivity was 60.2% and specificity was 62.3%. The median hemoglobin and hematocrit values of women were significantly lower than men. Conclusion: The data in our study show that serum lactate levels are an important biomarker in differentiating patients presenting with epileptic seizures from those presenting with syncope. The serum lactate value can provide valuable information, in particular for the cases in whom the patient or their relatives could not describe the episode.

Anahtar Kelimeler

• Epileptic seizure
• Syncope
• Lactate
• Clinical and Biochemical Biomarker

Kaynakça

1. Patel J, Tran QK, Martinez S, Wright H, Pourmand A. Utility of serum lactate on differential diagnosis of seizure-like activity: A systematic review and meta-analysis. Seizure. 2022; 102:134-142
2. Ma J‑F, Zeng R. Syncope. In: Handbook of Clinical Diagnostics. Singapore: Springer; 2020; 89‑90.
3. Plásek J, Doupal V, Václavík J, Petejová N, Martínek A, Táborský M. Diagnostic algorithm of syncope: integrative approach. Vnitr Lek. 2011; 57(10):826-33
4. Stafstrom CE, Carmant L. Seizures and epilepsy: an overview for neuroscientists. Cold Spring Harb Perspect Med. 2015; 5(6):a022426
5. Engelborghs S, D'Hooge R, De Deyn PP. Pathophysiology of epilepsy. Acta Neurol Belg. 2000;100(4):201-13
6. Hamilton K, Parko K. Epileptic and nonepileptic seizures after traumatic brain injury. In: Traumatic Brain Injury. Cham: Springer; 2020; 181‑96
7. Fowle A.J, Binnie D. Uses and abuses of the EEG in epilepsy. Epilepsia, 3 rd ed. 2000;41: 10-18, doi:10.1111/j.1528-1157.2000.tb01529.x Masoumi B, Mozafari S, Golshani K, Heydari F, Nasr-Esfahani M. Differential Diagnosis of Seizure and Syncope by the Means of Biochemical Markers in Emergency Department Patients. Int J Prev Med. 2022;13:58. doi: 10.4103/ijpvm.IJPVM_129_20.
8. Sueri C, Gasparini S, Balestrini S, Labate A, Gambardella A, Russo E, et al. Diagnostic Biomarkers of Epilepsy. Curr Pharm Biotechnol. 2018;19(6):440-450. doi: 10.2174/1389201019666180713095251.

9. Bergfeldt L. Differential diagnosis of cardiogenic syncope and seizure disorders. Heart 2003;89:353‑8.
10. McKeon A, Vaughan C, Delanty N. Seizure versus syncope. Lancet Neurol. 2006;5(2):171-80. doi: 10.1016/S1474-4422(06)70350-7. Erratum in: Lancet Neurol. 2006;5(4):293.
11. Carreño M. Recognition of nonepileptic events. Semin Neurol. 2008;28(3):297-304
12. Leibetseder A, Eisermann M, LaFrance WC Jr, Nobili L, von Oertzen TJ. How to distinguish seizures from non-epileptic manifestations. Epileptic Disord. 2020;22(6):716-738
13. Gosselin M, Mabire C, Pasquier M, Carron PN, Hugli O, Ageron FX, et al. Prevalence and clinical significance of point of care elevated lactate at emergency admission in older patients: a prospective study. Intern Emerg Med. 2022;17(6):1803-1812.
14. Shimmura M, Takase KI. Clinical utility of serum prolactin and lactate concentrations to differentiate epileptic seizures from non-epileptic attacks in the emergency room. Seizure. 2022;95:75-80.
15. Kramer A, Al Agha S, Böhm L, Michael M, Schulze-Bosse K, Bernhard M. Lactat in der Notfallmedizin [Lactate in emergency medicine]. Anaesthesist. 2020;69(11):826-834.
16. G. Broder, M.H Weil. Excess lactate: an index of reversibility of shock in human patients Science, 143 (3613) 1964; 1457-1459, doi:10.1126/science.143.3613.1457
17. Orringer CE, Eustace JC, Wunsch CD, Gardner LB. Natural history of lactic acidosis after grand-mal seizures. A model for the study of an anion-gap acidosis not associated with hyperkalemia. N Engl J Med. 1977;297(15):796-9. doi: 10.1056/NEJM197710132971502.
18. Matz O, Zdebik C, Zechbauer S, Bündgens L, Litmathe J, Willmes K,et al. Lactate as a diagnostic marker in transient loss of consciousness. Seizure. 2016;40:71-5. doi: 10.1016/j.seizure.2016.06.014.
19. Matz O, Heckelmann J, Zechbauer S, Litmathe J, Brokmann JC, Willmes K, et al. Early postictal serum lactate concentrations are superior to serum creatine kinase concentrations in distinguishing generalized tonic-clonic seizures from syncopes. Intern Emerg Med, 2018; 13 (5): 749-755, doi:10.1007/s11739-017-1745-2
20. Levy B: Lactate and shock state: The metabolic view. Curr Opin Crit Care 2006; 12:315–21
21. Doğan EA, Ünal A, Ünal A, Erdoğan Ç. Clinical utility of serum lactate levels for differential diagnosis of generalized tonic-clonic seizures from psychogenic nonepileptic seizures and syncope. Epilepsy Behav.2017;75:13-17
22. Auvin S, Lodé N, Brunet SR. Prehospital capillary lactate in children differentiates epileptic seizure from febrile seizure, syncope, and psychogenic nonepileptic seizure. Epilepsy Behav. 2022;127:108551
23. Hosseini S, Mofrad AME, Mokarian P, Nourigheimasi S, Azarhomayoun A, Khanzadeh S, et al. Neutrophil to Lymphocyte Ratio in Epilepsy: A Systematic Review. Mediators Inflamm. 2022;4973996