American Journal of Emergency Medicine 31 (2013) 1525-1534

Correspondence

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Pulmonary embolism as a cause of seizure?,??,?

To the Editors,

Pulmonary embolism (PE) is not rare, with an overall annual incidence of 60 to 70 cases per 100 000 [1]. Pulmonary embolism presents typically with cardiopulmonary symptoms. In some cases, however, patients present with neurologic symptoms such as syncope and a convulsion [2], which makes clinical evaluation compromised and results in delayed diagnosis. There are only a few case reports about seizures related to PE. The clinical characteristics of such cases remain unclear. The objective of this study is to elucidate them.

The clinical records of consecutive cases of PE that were treated in our hospital from April 2006 to March 2011 were retrospectively reviewed. The early symptoms of each case were analyzed.

Three hundred nineteen consecutive cases of PE were identified. Clinical details were available in 285 cases. Early symptoms included seizures in 2 cases (0.7%). The seizure was considered to be caused by PE in 1 of these cases, which is described below. In the other case, the cause of the seizure was controversial because of the detection of an asymptomatic subacute lacunar infarction. In 164 cases (58%), PE was suspected because of cardiopulmonary symptoms. In 75 cases (26%), the early symptom was only swelling or tenderness of the leg. Suspicion of Deep venous thrombosis led to the diagnostic examination of PE. In 44 cases (15%), there were no symptoms.

The patient, an 87-year-old woman, was taken to our hospital with generalized tonic seizures with conjugate deviation of the eyes to the left. The seizures occurred 4 times within 4 hours. She had complained of discomfort on the previous day. She had no history of seizures or cardiopulmonary disease. After the seizures, the arterial partial pressure of oxygen (PaO2) was 87.2 mm Hg on a fraction of inspired oxygen of 0.5. The D-dimer value was higher than 10 ug/mL (reference range, 0.0-1.0 ug/mL). Computed tomography (CT) and magnetic resonance imaging (MRI) studies of the brain showed little leukoar- aiosis consistent with age. electroencephalogram showed intermittent diffuse irregular slow activity. Despite gradual recovery from the confused state, Oxygen desaturation persisted, which led to the suspicion of PE. Bilateral PE and DVT in the right leg were finally detected by contrast-enhanced CT. She was treated successfully with heparin and warfarin.

This is the first case series of PE-related seizures since 1950. There are 11 cases including our case described above reported in the English literature (Table) [2-9]. The other case with an asymptomatic subacute lacunar infarction in this report is excluded from the analysis because the cause of the seizure was not clear. The patients are from their 20s to their 80s, without a history of seizure.

? Source of support: None.

?? A part of this article has been presented at American Epilepsy Society 65th annual

meeting (December 2-6, 2011).

? This study was approved by the institutional ethics committee of Kurashiki Central

Hospital.

Severe PE can lead to seizures, and the pathophysiology is considered to be transient global cerebral hypoperfusion or hypoxia. As is widely accepted, cerebral ischemia sometimes causes a seizure [10]. Cardiogenic syncope is sometimes associated with a seizure, which is considered to be caused by transient cerebral hypoperfusion [11]. It is indicated that PE-related seizures have a similar pathophys- iologic mechanism.

Interestingly, PE-related seizures sometimes have a lateralized neurologic sign in addition to the generalized nature. There are a few cases with eye deviation, head twitching, or short-lasting hemiparesis, including the patient in this report [2,3,5,9]. All of these cases showed no responsible brain lesion by either autopsy or MRI. This indicates the relationship between PE and focal neurologic signs. There may be a difference of vulnerability to hypoxia owing to factors such as focal arterial stenosis. Although transient ischemic attack caused by paradoxical emboli is an alternative explanation, the lack of a finding of acute cerebral infarction in all the cases makes this less likely.

Electroencephalogram was recorded in 3 cases including our case. It showed intermittent diffuse irregular slow activity in our case, which is considered to be caused by to postictal state. The other 2 cases showed normal EEG result.

The disease course of PE can involve several abrupt changes of condition, such as recurrence of convulsions, exacerbation of dyspnea, and hypotension. The oxygen desaturation may fluctuate, as in the case reported by Meyer [5]. The coexistence of new and older pulmonary emboli is pathologically revealed in the second case reported by Hamilton and Thompson [9]. These findings suggest that PE attacks occur several times with a short interval of hours to days, at least in some cases.

Pulmonary embolism is a potentially fatal condition, especially when presenting with a seizure. Six (55%) of 11 patients died of PE. This indicates the significance of early diagnosis. With a seizure, however, clinical evaluation may be compromised by the postictal state. Typical cardioPulmonary signs of PE such as tachypnea, tachycardia, and hypoxia may be attributed to the seizure. These take our eyes away from the primary cardiopulmonary disorder. In fact, PE was not suspected at first after the seizure in 8 cases (73%). In 4 of these 8 cases, the possibility of PE was considered only after the change of the condition, such as exacerbation of dyspnea, hypoxia, and hypotension. In another case, it was considered with sustained hypoxia. In the other 3 cases, the diagnosis was made upon postmortem examination.

Accurate diagnosis can be delayed when presenting with a seizure, unless PE is taken into account. One important point is to recognize the initial symptom. Cardiopulmonary symptoms preceded a seizure in 3 cases (27%). Evaluating D-dimer value may be also important, although there was 1 case with a value around the upper normal limit [2].

A limitation of this study is that it is a hospital-based retrospective study.

In conclusion, there were 2 cases with a seizure as an early symptom among 285 cases of PE. Pulmonary embolism-related seizures have high mortality, which makes early diagnosis and prompt initiation of treatment necessary. With a seizure, however, clinical

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Correspondence / American Journal of Emergency Medicine 31 (2013) 1525-1534

Table

Summary of PE-related seizures: current one patient and those reported in the literature

symptoms leading to the suspicion of PE

CPA, cardiopulmonary arrest; CTA, computed tomography angiogram; F, female; GTCS, generalized tonic-clonic seizure; LMWH, low-molecular-weight heparin; M, male; NA, not available; tPA, tissue plasminogen activator; UCG, ultrasonic cardiogram; V-P scan, ventilation-perfusion scan.

^a Appendectomy.

Correspondence / American Journal of Emergency Medicine 31 (2013) 1525-1534 1527

evaluation may be compromised. We should always be alert to clinical features, which are not easily attributed to a seizure. Recognition of the preceding cardiopulmonary symptoms and evaluation of the D-dimer value may be important for suspicion of PE. Further research is needed to evaluate the clinical use of these findings.

Kimitoshi Kimura MD Hitoshi Mori MD

Hiroshi Kitaguchi MD, PhD

Fusae Yamao MD Katsuro Shindo MD, PhD

Department of Neurology Kurashiki Central Hospital

1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan E-mail addresses: [email protected], [email protected] [email protected], [email protected], [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.06.024

References

1. British Thoracic Society Standards of Care Committee Pulmonary Embolism Guideline Development Group. British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003;58:470-83.
2. Fred HL, Willerson JT, Alexander JK. neurological manifestations of pulmonary thromboembolism. Arch Intern Med 1967;120:33-7.
3. Wang JW, Xu MW, Luo BY. Pulmonary embolism presenting as recurrent transient loss of consciousness: syncope and seizure. Chin Med J 2013;126:193-4.
4. Shah AK, Darwent M. Acute pulmonary embolism presenting as seizures. Emerg Med J 2009;26:299-300.
5. Meyer MA. Seizure as the presenting sign for massive pulmonary embolism: case report and review of the literature. Seizure 2009;18:76-8.
6. Kupnik D, Grmec S. pulmonary thromboembolism presenting as epileptiform Generalized seizure. Eur J Emerg Med 2004;11:346-7.
7. Marine JE, Goldhaber SZ. Pulmonary embolism presenting as seizures. Chest 1997;112:840-2.
8. Fred HL, Yang M. Sudden loss of consciousness, dyspnea, and hypoxemia in a previously healthy young man. Circulation 1995;91:3017-9.
9. Hamilton M, Thompson EN. Unusual manifestations of pulmonary embolic disease. Postgrad Med J 1963;39:348-53.
10. Beghi E, D’Alessandro R, Beretta S, et al. Incidence and predictors of acute symptomatic seizures after stroke. Neurology 2011;77:1785-93.
11. Alboni P, Brignole M, Menozzi C, et al. Diagnostic value of history in patients with syncope with or without heart disease. J Am Coll Cardiol 2001;37:1921-8.

    Physical examination combined with focused assessment with sonography for trauma examination to clear hemodynamically stable blunt abdominal trauma patients

    To the Editor,

    The use of the focused assessment with sonography for trauma examination has become standard practice over the past 10 years in the evaluation of patients with suspected abdominal trauma. It is generally accepted in trauma algorithms as an extension of the physical examination. Currently, it is used primarily to identify the need for an expedited emergency laparotomy in the hemodynami- cally unstable patient, unable to tolerate a computed tomographic (CT) scan. In Hemodynamically stable patients, however, especially those with low-risk injury by history and physical examination, the role of the FAST examination to exclude further diagnostic testing is less studied. As a result, for most trauma centers, the standard practice is to follow a normal FAST examination with abdominal and pelvic CT imaging to exclude missed injuries, even in the clinically low-risk patient. In our study, we wanted to determine if CT scanning of the abdomen/pelvis could safely be excluded in hemodynamically stable, blunt abdominal trauma patients with normal neurologic status, no complaint of abdominal pain or tenderness to palpation, a normal FAST examination, and the absence of clinical findings suspicious for major Abdominal injury.

    This was a retrospective chart review of all trauma alerted patients at a Level 1 trauma center evaluated for possible blunt abdominal trauma who had a documented negative FAST examination, met inclusion criteria, and received a CT scan of the abdomen and pelvis during 1 calendar year. This study was approved by our local institutional review board committee. The records of all alerted trauma patients during the study period were reviewed to identify patients 18 to 89 years old, with systolic blood pressure greater than 100 mm Hg, heart rate less than 110 and greater than 60 beats per minute, and a Glasgow Coma Scale greater than or equal to 14. In addition, these patients had to have an adequate FAST examination that was negative for the evidence of free fluid in the 4 standard views and a normal clinical abdominal and pelvic examination that was free of tenderness and without anatomic deformities. Results of the FAST examination were compared with the results of the CT scan of the abdomen/pelvis and discrepancies noted.

    A total of 1738 patients were alerted for trauma during the study period; 467 patients met inclusion criteria. Forty-three patients had CT scans demonstrating trauma-related Intra-abdominal injuries, and 19 patients demonstrated intra-abdominal soft tissue injury. Of the 19 patients with soft tissue injury, 12 were noted to have injuries not typically identified by sonography, including bowel wall contusions; serosal tears; small hepatic, splenic, or renal lacerations; or contusions without active extravasation. None of these 12 patients had Clinically significant injuries requiring intervention. Of the 19 patients with intra-abdominal soft tissue injury on CT scan, 6 had CT scans showing hematoma or free fluid, only one of whom was deemed to have a clinically significant injury. The negative predictive value (NPV) of these inclusion criteria for any intra-abdominal soft tissue injury identified on CT was 96.1%. For injuries associated with free fluid or hematoma, the NPV was 98.7%, and for those injuries deemed clinically significant, the NPV was 99.8%.

    Our findings are consistent with those of large retrospective studies of blunt abdominal trauma patients that found similar sensitivity (85%-87%), specificity (97%-99%), positive predictive value (86%-88%), and NPV (98%-99%) for free fluid on FAST examination [1-4].

    There are several advantages to safely excluding CT scanning in a subpopulation of blunt trauma patients. The first is the reduction in unnecessary radiation exposure to such patients. One retrospective review by Brenner and Elliston [5] showed that half of trauma patients who received a CT scan had no significant injury. Similarly, cost containment, without sacrificing quality, is becoming increasingly important. We need to be proactive in conducting studies that examine if certain tests can be safely eliminated in the workup of patients. A third advantage would be the use of such inclusion criteria when faced with a mass casualty situation. Reliable criteria could be very helpful in triaging patients appropriately when normal resources are overwhelmed. Finally, the use of such inclusion criteria could be beneficial in austere medical conditions, when advanced imaging is frequently unavailable in some third-world countries.

    Our study suggests the CT scanning of the abdomen/pelvis could be safely eliminated in a certain subpopulation of blunt trauma patients. More studies with a larger number of patients would be helpful in definitively answering this question.

    Sincerely,

    Donald Byars MD Alicia Devine MD Christopher Maples MD Alexander Yeats MD Krista Greene MD

    Department of Emergency Medicine Eastern Virginia Medical School, Norfolk, VA 23507, USA

    E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2013.06.042