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Comprehensive Approach to First Seizure Evaluation: Guidelines & Recommendations

Understand the definitions, epidemiology, risk factors, and management of first seizures in adults. Learn how to recognize, investigate, and treat seizures effectively. Special thanks to Laura Baxter for the slides provided.

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Comprehensive Approach to First Seizure Evaluation: Guidelines & Recommendations

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  1. Approach to First Seizure • Kelvin Au • University of Calgary • Adult Neurology • September 2016

  2. Outline • Seizure definition and epidemiology • Recognize and characterize seizures • Seizure history • Seizure examination • Red flags, risk factors • How and when to investigate first seizure • How and when to start treatment • First seizure counseling • Special thanks to Laura Baxter for her slides

  3. Definitions • Seizure & Epilepsy

  4. Definitions • Seizure • Occurrence of signs and symptoms due to abnormal excessive or synchronous neuronal activity in the brain • Epilepsy • Condition of enduring predisposition to generate epileptic seizures and the associated biological, cognitive, psychological, and social consequences

  5. Definitions • Status Epilepticus

  6. Definitions • Status Epilepticus • (practical definition) 5 min or more of either: • continuous seizure • two or more seizures between which there is in- complete recovery of consciousness. • Requires prompt recognition and management • SE associated with significant morbidity and mortality • Nonconvulsive SE affects up to 10% inpatients with altered LOC • Approx. ½ of SE occur in patients w/o a seizure Hx

  7. Epidemiology • In the population • Up to 10% will have a seizure in their lifetime • Only 0.5-1% have Epilepsy • Seizure etiology varies with age • An estimated 150,000 adults present annually with an unprovoked first seizure in the United States. • Even 1 seizure is an event that can pose difficult diagnostic and treatment challenges and can have major social consequences (e.g., loss of driving privileges, limitations for employment).

  8. History • Collateral • Aura? Pre-event symptoms • Characterization of event & duration • Previous episodes? • Postictal state • Cardiac ROS • Associated symptoms • Neurological Hx & Neurological ROS* • TRIGGERS:sleep deprivation, drugs, stress, illness, menstrual cycles, substances, medication noncompliance, individual reflex triggers (e.g., flashing lights)

  9. History • PMHx • Previous seizures • Head injury/brain surgery • Perinatal/obstetrical events • Childhood febrile seizures (?prolonged, recurrent,etc) • Other neurologic Hx (CNS infection, stroke, tumour, dementia) • Cognitive disability • Medical conditions • Chronic pain or chronic fatigue disorder • Psychiatric disorder • Meds – Changes? New? Withdrawal? • FHx – seizures, neurologic diseases • SHx– drug use, addictions, withdrawal, ?potential material gain • Occupational risks, driving status • Living alone? • Medical coverage (if starting AEDs)

  10. Cause • Most common causes of seizures?

  11. Provoked Seizures • Neurologic: trauma, infection, tumour, vascular • Hypoxia/ischemia 2ry to CV/Resp failure • Medications: antibiotics, antivirals, theophylline, antidepressants (TCA), Lithium • EtOH/Benzo withdrawal • Cocaine, stimulants • Metabolic/Electrolyte • Na, Ca, Mg, glucose, Urea • Hypertension (PRES) • Fulminant liver failure • Hyperthyroidism

  12. Differential Diagnosis of a “Spell”

  13. Seizure versus Syncope

  14. Risk • What are some risk factors for having a seizure?

  15. Risk of Seizure Recurrence • For the adult who presents with an unprovoked first seizure, what are the risks for seizure recurrence?

  16. Krumholz et al. 2015

  17. Risk of Seizure Recurrence • Within the first 2 years (21%-45%), and especially in the first year • Lower in those treated with AEDs • Risk of seizure increases • prior brain lesion or insult causing the seizure • EEG with epileptiform abnormalities • significant brain-imaging abnormality • nocturnal seizure

  18. Types of Seizures

  19. Exam • ABC’s, Vitals • Survey for trauma, injuries • Tongue/mouth bites • incontinence • Auscultate chest • ?aspiration • General exam • ?signs of provoked seizure • E.g., infection, toxodrome • Assess LOC, GCS • Neuro exam as appropriate for pt’s LOC • E.g. comatose exam vs full exam if alert • Observe: abnormal posturing, movements, vocalizations, confusion, signs that patient may be seizing

  20. Post Ictal State • Transient period of brain recovery lasting seconds to hours • Can be prolonged in those with poor neurologic reserve…several days • ?Due to prolonged hyperpolarization of post ictal tissue, ischemia, etc. • Commonly: • Altered LOC (confusion, drowsiness, agitation) • Focal neurologic deficits • Upgoing toes • Hyperreflexia, increased tone • Todd’s paralysis • Less commonly – aphasia, vision loss, sensory deficits

  21. Investigations • What investigations to order?

  22. Investigations • Extended lytes • Bedside glucose • Troponin • CBC, Creatinine, Urea, Coag’s, U/A • LFTs, CK, ammonia • Tox screen • ECG • Consider: • CT head* • Lumbar Puncture • Cultures • CXR • EEG • TSH, B12 • AED levels, etc. • Serum prolactin**

  23. EEG • Routine 30 minute EEG • Sensitivity: 30-40% • How can you increase sensitivity • EEG within 24h or seizure ~50% sensitive • Increase EEG duration • Multiple EEGs • Photic stimulation • Sleep deprivation (20-40% increase)

  24. EEG • Adults with first seizure • 25% will have abnormal EEG • Epilepsy • 20-50% will have abnormality on first routine EEG • 20-40% with initial normal EEG will have epileptic activity on sleep deprived EEG

  25. Neuroimaging • When to scan? • What modality?

  26. Neuroimaging • Indicated whenever there is not a clear history of provoked seizure • CT – mass lesion, hemorrhage, large infarct • Suitable for ED work up • Changes management in ED 10-15% of the time • MRI – subtle structural abnormalities (e.g., cortical dysplasia, mesial temporal sclerosis, sequela of head injury, subtle tumour or vascular malformations)

  27. Management • ABC’s, frequent vitals • Remove nearby dangerous objects • SpO2 monitoring & apply O2 • Two large bore IV’s, start NS • Treat the cause • Consider IV thiamine, dextrose, cardiac monitoring • If multiple seizures, localizing seizure focus, enduring seizure risk – start AED (Dilantin load, Keppra, etc)

  28. Doctor, can I drive? • Single, provoked seizure – private no driving x 3m • EtOH provoked seizure – stable and abstinent for 6m • If AED change/withdrawal or seizure recurrence: • No private driving x 3 m • No commercial driving x 6m • No duty to report in Alberta

  29. Lifestyle & Risk Reduction • Avoid EtOH, substances, fatigue • Counseling re: injury, mortality • High Risk activities • Swimming • Bathing • Heights (ladders, roofing) • Heavy machinery and equipment

  30. When to start AEDs? • Not usually indicated in first seizure with normal work up, especially if provoked seizure • Often AEDs are discussed after 2 seizures • Not necessarily life long • Consider: • Patient preferences & compliance • Cost • Medical comorbidities (renal function, hepatic impairment, psychiatric conditions) • Interactions • Side effects • Drug effectiveness for patient seizure type • Childbearing, contraception, and risks of AEDs in pregnancy should be discussed

  31. Recommendations • Adults presenting with an unprovoked first seizure should be informed that the chance for a recurrent seizure is greatest within the first 2 years after a first seizure (21%45%) (Level A). • Clinicians should also advise such patients that clinical factors associated with an increased risk for seizure recurrence include a prior brain insult such as a stroke or trauma (Level A),an EEG with epileptiform abnormalities (Level A), a significant brain-imaging abnormality (Level B), or a nocturnal seizure (Level B).

  32. Recommendations • Clinicians should advise patients that, although immediate AED therapy, as compared with delay of treatment pending a second seizure, is likely to reduce the risk for a seizure recurrence in the 2 years subsequent to a first seizure (Level B), it may not improve QOL (Level C). • Clinicians should advise patients that over the longer term (> 3 years) immediate AED treatment is unlikely to improve the prognosis for sustained seizure remission (Level B). • Patients should be advised that their risk for AED AEs ranges from 7% to 31% (Level B) and that these AEs are predominantly mild and reversible.

  33. Thanks!

  34. References • 1.Krumholz A1, Wiebe S1, Gronseth GS1, Gloss DS1, Sanchez AM1, Kabir AA1, Liferidge AT1, Martello JP1, Kanner AM1, Shinnar S1, Hopp JL1, French JA1. Evidence-based guideline: Management of an unprovoked first seizure in adults: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015 Apr 21;84(16):1705-13. • 2. Canadian Medical Association Driver’s Guide 8th Edition: Determining Medical Fitness to Operate Motor Vehicles. 2012.

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