Title: Practice Assessment: The Use of Serum Prolactin in Diagnosing Epileptic Seizures
1Practice 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
2Introduction
- 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
3Objective
- To review the use of serum prolactin assay in
epileptic seizure diagnosis, and present
evidence-based practice recommendations.
4Description 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
5Description 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
6AAN Strength of Evidence
7AAN Strength of Evidence
8Translation of Evidence to Recommendation Level
9Translation of Evidence to Recommendation Level
10Guidelines Clinical Questions
- Question 1
- Is serum PRL assay useful in differentiating
epileptic seizures from psychogenic non-epileptic
seizure ?
11Analysis of the Evidence
- Table Prospective controlled studies
investigating PRL changes following either ES or
psychogenic NES
12Analysis of the Evidence
13Analysis of the Evidence
14Analysis of the Evidence
- Table Validity measures of serum prolactin assay
in differentiating ES and NES
15Analysis of the Evidence
16Analysis of the Evidence
17Analysis of the Evidence
18Conclusion
- 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.
19Guidelines Clinical Questions
- Question 2
- Does serum PRL measure change following other
neurological conditions?
20Analysis of the Evidence
- Table Methodologic characteristics of studies
evaluating serum prolactin changes following
tilt-induced syncope
21Analysis of the Evidence
22Analysis of the Evidence
- Table Methodologic characteristics of studies
evaluating serum prolactin changes following
status epilepticus, or repetitive seizures (not
SE).
23Analysis of the Evidence
24Conclusion
- 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.
25Conclusion
- 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
26Evidence-based Recommendations
27Evidence-based Recommendations
28Recommendations 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.
29Recommendations 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.
30Acknowledgement
- 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
31To view the entire guideline and additional AAN
guidelines visit www.aan.com/professionals/prac
tice/index/cfm
- Published in Neurology 200565668-675
32Disclaimer
- 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.