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Practice Assessment: The Use of Serum Prolactin in Diagnosing Epileptic Seizures

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Title: Practice Assessment: The Use of Serum Prolactin in Diagnosing Epileptic Seizures


1
Practice Assessment The Use of Serum Prolactin
in Diagnosing Epileptic Seizures
  • Report of the Therapeutics and Technology
    Assessment Subcommittee of the American Academy
    of Neurology
  • David K. Chen, MD Yuen T. So, MD, PhD and
    Robert S. Fisher, MD, PhD
  • Published in Neurology 200565668-675

2
Introduction
  • Prolactin (PRL) released from the pituitary is
    under the control of the hypothalamus via the
    prolactin inhibitory factor, now believed to be
    dopamine
  • May alter the hypothalamic regulation of PRL
    release
  • Trimble first demonstrated that generalized
    tonic-clonic seizures could raise serum prolactin
  • The sensitivity and specificity of serum PRL
    assay for diagnosis of epileptic seizures remain
    uncertain

3
Objective
  • To review the use of serum prolactin assay in
    epileptic seizure diagnosis, and present
    evidence-based practice recommendations.

4
Description of Process
  • Searched MEDLINE, Science Citation Index, and the
    Cochrane Database
  • A total of 381 articles met the keywords search,
    as of October, 2003
  • Reviewed the abstracts of these articles, looking
    for controlled studies that reported on PRL
    changes following seizures or seizure-like events

5
Description of Process
  • Reviews without original data, letters, meeting
    abstracts, and case reports/series were excluded
  • Examined 39 articles in their entirety, along
    with 5 additional articles identified upon
    reviewing bibliographies of the retrieved
    articles

6
AAN Strength of Evidence
7
AAN Strength of Evidence
8
Translation of Evidence to Recommendation Level
9
Translation of Evidence to Recommendation Level
10
Guidelines Clinical Questions
  • Question 1
  • Is serum PRL assay useful in differentiating
    epileptic seizures from psychogenic non-epileptic
    seizure ?

11
Analysis of the Evidence
  • Table Prospective controlled studies
    investigating PRL changes following either ES or
    psychogenic NES

12
Analysis of the Evidence
13
Analysis of the Evidence
14
Analysis of the Evidence
  • Table Validity measures of serum prolactin assay
    in differentiating ES and NES

15
Analysis of the Evidence
16
Analysis of the Evidence
17
Analysis of the Evidence
18
Conclusion
  • On the basis of one class I and conflicting class
    II studies, an elevated PRL level when measured
    within 20 minutes of a suspected event is
    probably a useful adjunct to differentiate GTC or
    CPS from psychogenic NES among adults and older
    children.
  • On the basis of consistent class I and II
    studies, the low sensitivity and low negative
    predictive value of a normal serum PRL assay does
    not permit the diagnosis of psychogenic NES nor
    exclude the possibility of GTC or CPS.

19
Guidelines Clinical Questions
  • Question 2
  • Does serum PRL measure change following other
    neurological conditions?

20
Analysis of the Evidence
  • Table Methodologic characteristics of studies
    evaluating serum prolactin changes following
    tilt-induced syncope

21
Analysis of the Evidence
22
Analysis of the Evidence
  • Table Methodologic characteristics of studies
    evaluating serum prolactin changes following
    status epilepticus, or repetitive seizures (not
    SE).

23
Analysis of the Evidence
24
Conclusion
  • On the basis of limited class II studies, serum
    PRL probably increases at least two-fold from
    baseline level when measured within 10 minutes
    after syncope in adults.
  • On the basis of one negative class II study that
    did not show a significant change in PRL level,
    no conclusion can be established regarding serum
    PRL changes following termination of status
    epilepticus.

25
Conclusion
  • On the basis of conflicting class II studies, no
    conclusion can be established regarding serum PRL
    changes following repetitive seizures (not SE).
  • On the basis of conflicting class II studies, no
    conclusion can be established regarding serum PRL
    changes following epileptic seizures in neonates

26
Evidence-based Recommendations
27
Evidence-based Recommendations
28
Recommendations for future research
  • Standardization of abnormal PRL elevation A
    large sample size, gender-matched study of
    baseline PRL values in healthy and epileptic
    subjects, allowing for uninterrupted sleep, may
    provide more accurate standardization of
    gender-specific PRL threshold values.
  • Capillary PRL assays Future studies
    investigating the utility of an outpatient PRL
    kit kept at home to document capillary PRL
    changes shortly post-event may circumvent current
    practical limitations.

29
Recommendations for future research
  • PRL in other types of physiologic non-epileptic
    events Future studies are necessary to define
    the specificity of PRL assay in the setting of
    these events
  • Pediatric population Future prospective studies
    of postictal PRL measures in neonates and young
    children are needed
  • PRL in other epileptic disorders Further data
    are needed in order to interpret PRL value
    following status epilepticus and repetitive
    seizures.

30
Acknowledgement
  • Therapeutics and Technology Assessment
    Subcommittee Members Douglas S. Goodin, MD
    (Chair) Yuen T. So, MD, PhD (Vice-Chair) Carmel
    Armon, MD Richard M. Dubinsky, MD Mark Hallett,
    MD David Hammond, MD Cynthia Harden, MD Chung
    Hsu, MD, PhD (ex-officio) Andres M. Kanner, MD
    (ex-officio) David S. Lefkowitz, MD Janis
    Miyasaki, MD Michael A. Sloan, MD James C.
    Stevens, MD

31
To view the entire guideline and additional AAN
guidelines visit www.aan.com/professionals/prac
tice/index/cfm
  • Published in Neurology 200565668-675

32
Disclaimer
  • This assessment focused on the use of serum
    prolactin assay in epilepsy diagnosis. The
    utility of serum PRL assay in other indications
    is beyond the scope of this review. This
    statement is provided as an educational service
    of the American Academy of Neurology. It is
    based on an assessment of current scientific and
    clinical information. It is not intended to
    include all possible proper methods of care for a
    particular neurological problem or all legitimate
    criteria for choosing to use a specific
    procedure. Neither is it intended to exclude any
    reasonable alternative methodologies. The AAN
    recognizes that specific patient care decisions
    are the prerogative of the patient and the
    physician caring for the patient, based on all of
    the circumstances involved.
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