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Epilepsy
Original research
Pragmatic computerised perfusion diagnostics for non-convulsive status epilepticus: a prospective observational study
  1. Elena Merli1,
  2. Michele Romoli2,
  3. Simone Galluzzo3,
  4. Lorenzo Bevacqua1,
  5. Emanuele Saverio Cece1,
  6. Gabriele Ricci1,
  7. Stefania Testoni1,
  8. Anna Zaniboni1,
  9. Maria Maddalena Viola1,
  10. Luigi Simonetti3,
  11. Francesca Bisulli4,5,
  12. Sara Contardi1,
  13. Paolo Tinuper4,5,
  14. Andrea Zini1
  1. 1 IRCCS Istituto Delle Scienze Neurologiche di Bologna, Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy
  2. 2 Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Italy
  3. 3 IRCSS Istituto delle Scienze Neurologiche di Bologna, Neuroradiologia, Ospedale Maggiore, Bologna, Italy
  4. 4 IRCSS Istituto delle Scienze Neurologiche di Bologna, Department of Neurological Sciences, University of Bologna, Bologna, Italy
  5. 5 Dipartimento di Scienze Biomediche e Neuromotorie, University of Bologna, Bologna, Italy
  1. Correspondence to Dr Michele Romoli, Neurology and Stroke Unit, Maurizio Bufalini Hospital, Cesena, Italy; michele.romoli{at}auslromagna.it; Dr Andrea Zini, IRCCS Istituto delle Scienze Neurologiche di Bologna, Neurologia e Rete Stroke Metropolitana, Ospedale Maggiore, Bologna, Italy; a.zini{at}ausl.bologna.it

Abstract

Background Non-convulsive status epilepticus (NCSE) is a time-dependent neurological disorder often misdiagnosed in the emergency setting. Electroencephalography (EEG) is often not available on a 24/7 basis, and Salzburg criteria may at times miss the diagnosis. Here, we tested the accuracy of hyperperfusion on CT perfusion imaging (CTP) in the identification of NCSE against Salzburg criteria, to define its potential role in a pragmatic diagnostic workflow.

Methods We enrolled consecutive patients with suspected acute seizure or seizure disorder undergoing brain imaging with CTP and EEG from January 2021 to March 2023. EEG recordings, Salzburg criteria and CTP hyperperfusion were rated and adjudicated by two independent experts blinded to patient status. A reference standard including all clinical, lab, imaging, EEG and therapeutic data was used to adjudicate NCSE diagnosis. Sensitivity, specificity, diagnostic accuracy, positive and negative predictive values (NPV) were calculated for CTP hyperperfusion and Salzburg criteria versus NCSE adjudicated according to reference standard.

Results Seventy-seven patients were enrolled. Among 21 NCSE cases, 17 were adjudicated according to Salzburg criteria (81%) and 4 received NCSE diagnosis according to reference standard. Agreement between EEG and CTP emerged in 16/21 NCSE cases, reaching sublobar level in 37.5% of cases. Receiver operator curve analysis suggested good accuracy for CTP hyperperfusion for the diagnosis of NCSE (AUROC 0.79, 95% CI 0.69 to 0.89). CTP hyperperfusion had a high NPV for NCSE (NPV 0.97, 95% CI 0.86 to 1).

Conclusion CTP hyperperfusion may be implemented in the emergency fast-track to rule out NCSE, given very high NPV. Further validation studies are needed to evaluate CTP application in real-world setting for NCSE codes.

  • CLINICAL NEUROLOGY
  • EEG
  • EPILEPSY
  • STROKE

Data availability statement

Data are available on reasonable request. Anonymised data can be made available on reasonable request to the corresponding author.

https://doi.org/10.1136/jnnp-2023-332152

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    Data availability statement

    Data are available on reasonable request. Anonymised data can be made available on reasonable request to the corresponding author.

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    Footnotes

    • EM and MR are joint first authors.

    • X @micheleromoli, @ZiniAndrea

    • Contributors EM, MR and AZ designed the study. MR performed statistical analysis and developed reverse map concept; EM, MR, SG and AZ collected and analysed data. All other authors participated in data collection and manuscript revision for content. AZ is the guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.