Initiation of Antiseizure Medications by US Board-Certified Neurologists After a First Unprovoked Seizure Based on EEG Findings

Hernan Nicolas Lemus; Mauricio F Villamar; Julie Roth; Steven Tobochnik

doi:10.1212/CPJ.0000000000200249

Initiation of Antiseizure Medications by US Board-Certified Neurologists After a First Unprovoked Seizure Based on EEG Findings

Neurol Clin Pract. 2024 Feb;14(1):e200249. doi: 10.1212/CPJ.0000000000200249. Epub 2024 Jan 4.

Authors

Hernan Nicolas Lemus¹, Mauricio F Villamar¹, Julie Roth¹, Steven Tobochnik¹

Affiliation

¹ Department of Neurology (HNL), The University of Alabama at Birmingham; Department of Neurology (MFV, JR), The Warren Alpert Medical School of Brown University, Providence, RI; and Department of Neurology (ST), Brigham and Women's Hospital, Boston, MA.

PMID: 38204587
PMCID: PMC10775163 (available on 2025-02-01)
DOI: 10.1212/CPJ.0000000000200249

Abstract

Background and objectives: To investigate neurologists' practice variability in antiseizure medication (ASM) initiation after a first unprovoked seizure based on reported EEG interpretations.

Methods: We developed a 15-question multiple-choice survey incorporating a standardized clinical case scenario of a patient with a first unprovoked seizure for whom different EEG reports were provided. The survey was distributed among board-certified neurologists practicing in the United States. Associations between categorical variables were evaluated using the Fisher Exact test. Multivariate analysis was performed using logistic regression.

Results: A total of 106 neurologists responded to the survey. Most responders (75%-95%) would start ASM for definite epileptiform features on EEG, with similar rates between subgroups differing in years of practice, presence of subspecialty EEG training, and self-reported confidence in EEG interpretation. There was greater variability in practice for nonspecific EEG abnormalities, with sharply contoured activity, sharp transients, and focal delta slowing associated with the highest variability and uncertainty. Neurologists with >5 years of practice experience (21% vs 44%, OR 0.35 [95% CI 0.13-0.89], p = 0.021), subspecialty EEG training (15% vs 50%, OR = 0.17 [95% CI 0.06-0.48], p < 0.001), and greater confidence in EEG interpretation (21% vs 52%, OR 0.24 [95% CI 0.09-0.62], p = 0.001) were less likely to start ASM for ≥2 nonspecific EEG abnormalities and reported greater uncertainty. In multivariate analysis, seniority (p = 0.039) and subspecialty EEG training (p = 0.032) were associated with decreased ASM initiation for nonspecific EEG features.

Discussion: There was substantial variability in ASM initiation practices between board-certified neurologists after a first unprovoked seizure with nonspecific EEG abnormalities. These findings clarify specific areas where EEG reporting may be optimized and reinforces the importance of implementing evidence-based practice guidelines.