Utility of Tilt Table Testing in Management of Seizure-like Activity After Inconclusive Epilepsy Monitoring Unit Admission
Krystyna Cios1, Surbhi Mathur1, Marc Wish2, Mohankumar Kurukumbi3
1University of Virginia School of Medicine, 2Cardiology, Inova Fairfax Hospital, 3Neurology, UVA Inova Fairfax Hospital Campus
Objective:
Protocolized tilt table test (TTT) evaluation for patients with loss of consciousness (LOC) who have diagnostic uncertainty following evaluation with epilepsy monitoring unit (EMU).
Background:
Many patients suffer from unexplained LOC or altered state of consciousness (aka “episodes”) and remain without a diagnosis after extensive neurological and cardiological work-up. Even the gold standard of diagnosis for epilepsy, EMU studies, leave 12-24% of patients without definitive diagnosis. Lack of definitive diagnosis burdens patients with anxiety and practical restrictions like driving. TTT can help distinguish between epilepsy and dysautonomia (i.e. Neurocardiogenic syncope or Postural Orthostatic Tachycardia Syndrome, POTS) as causes of LOC, and is an inexpensive, low risk intervention. We hypothesize that inclusion of TTT in the diagnostic protocol improves medical management of patients suffering from recurrent unexplained episodes of LOC following nondiagnostic EMU admissions.
Design/Methods:
Retrospective data are collected on 22 patients who underwent TTT following non-diagnostic EMU between 03/2022 and 09/2023. A non-diagnostic EMU was one that did not reveal the cause of LOC or inconclusively explained the patients’ symptoms.
Results:
Twenty two patients were evaluated by TTT; 19 had inconclusive EMU and 3 had positive EMU but concern for coexisting dysautonomia. Of the 19 patients with negative EMU, 73.7 % (14) had positive TTT and benefited from dysautonomia management. All 3 who had positive EMU but concern for dysautonomia had a negative tilt table test. TTT also improved management through pre-epilepsy surgery evaluation, discontinuation of antiepileptic drugs, and transition from neurologic to primarily cardiologic management.
Conclusions:
EMU has utility in ruling out seizures as the etiology of LOC. In a subset of patients with diagnostic uncertainty following EMU, TTT provides definitive diagnosis, which results in multifactorial improvement in patient well-being. We strongly recommend that patients with inconclusive EMU undergo TTT.