The Role of Emergent Brain CT Scans in the Management of Epilepsy Patients Presenting With Breakthrough Seizures

Background and purpose Approximately 1-3% of global emergency department (ED) visits are for acute seizures. The role of neuroimaging with non-contrast computed tomography (CT) has been well described for first-time unprovoked seizures. However, current guidelines provide limited or non-specific recommendations for the utility of routine neuroimaging in patients with a known history of epilepsy presenting with breakthrough seizures. This study evaluated the clinical utility of brain CT imaging in adults with a previously confirmed diagnosis of epilepsy who presented to the ED with breakthrough seizures. Methods We conducted a retrospective review of electronic medical records from 2019 to 2023. Seizure-specific diagnostic codes were used to identify patients who presented to the ED during the study period. Patients meeting all inclusion criteria were selected for review of CT imaging results and clinical management. Results A total of 207 seizure-related ED encounters were identified. After applying inclusion and exclusion criteria, 121 encounters involving adults with known epilepsy presenting with breakthrough seizures who underwent emergent non-contrast head CT were included in the final analysis. Indications for imaging included falls (47, 38.8%), altered mental status (24, 19.8%), lethargy (19, 15.7%), recurrent seizures (20, 16.5%), and headache (11, 9.09%). Among those imaged, CT findings were normal in 92 (76.0%), showed prior stroke in 11 (9.1%), postoperative changes in 9 (7.4%), small-vessel disease in 5 (4.1%), remote trauma in 2 (1.7%), and ambiguous findings in 2 (1.7%). No CT findings represented new pathology compared with prior imaging, and none of these findings altered acute clinical management. Conclusions The diagnostic yield of emergent brain CT in epilepsy patients with breakthrough seizures is low. Given the financial burden, exposure to radiation, and limited clinical impact, future studies should focus on developing evidence-based imaging guidelines that minimize unnecessary CT use while maintaining patient safety.