Beyond Withdrawal: Metabolic and Structural Causes of Seizures in Adults With Alcohol Use Presenting to the Emergency Department

Background In adults with a history of alcohol use who present with a seizure, alcohol withdrawal is often presumed, but alternative and immediately treatable causes are common. We tried to quantify the proportion of alcohol-withdrawal-related seizures versus other causes, and to identify bedside features that help differentiate them. Methods We conducted a single-centre observational cohort study of adults presenting to the Emergency Department with a seizure and any history of alcohol use. Cases were classified as alcohol-withdrawal-related or due to other causes using prespecified clinical criteria that incorporated hours since last drink; a structured withdrawal assessment (Clinical Institute Withdrawal Assessment for Alcohol-Revised, or CIWA-Ar); laboratory data (glucose, ketones or anion-gap acidosis, electrolytes including magnesium); neuroimaging, whenever performed; and clinical documentation. We described presentation characteristics, laboratory profiles, and in-hospital course, including ICU care, seizure recurrence, length of stay, and death. Results Among 500 participants, 190 (38.0%) were alcohol-withdrawal-related, and 310 (62.0%) were due to other causes. Within the non-withdrawal group, proximate causes were metabolic derangements with ketoacidosis (80, 16.0%), low blood sugar (70, 14.0%), primary electrolyte disturbance (50, 10.0%), structural brain disease (45, 9.0%), and other or combined causes (65, 13.0%). Timing strongly discriminated groups: withdrawal cases clustered at 6-48 hours after the last drink (46.3% at 6-24 hours; 36.8% at 24-48 hours), whereas other causes were more dispersed in time, including 17.7% beyond 72 hours. At triage, the median withdrawal score was higher in the withdrawal group (CIWA-Ar: 18 vs. 6), with more frequent seizure clustering. Metabolic abnormalities were substantially more common in other causes (low blood sugar, ketones or anion-gap acidosis, low blood sodium, low blood potassium, low blood magnesium). Overall, 12.0% required ICU/HDU (High Dependency Unit) care, 11.0% had in-hospital seizure recurrence, the median length of stay was four days (interquartile range, 2-6), and in-hospital death occurred in 2.4%. Conclusions Most seizures in adults with alcohol use were not due to alcohol withdrawal. A simple triage approach - time since last drink, structured withdrawal assessment, and rapid bedside testing for glucose and electrolytes - reliably separates withdrawal from other causes and directs early, reversible treatment.