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Evaluation and management of the first seizure in adults

Author
Steven C Schachter, MD
Section Editor
Paul Garcia, MD
Deputy Editor
April F Eichler, MD, MPH

INTRODUCTION

Seizures are a common occurrence, affecting an estimated 8 to 10 percent of the population over a lifetime [1,2]. Seizures account for 1 to 2 percent of all emergency department visits, and approximately one-quarter of these will be a first seizure [3].

The primary goal in evaluating a patient's first seizure is to identify whether the seizure resulted from a treatable systemic process or intrinsic dysfunction of the central nervous system and, if the latter, the nature of the underlying brain pathology. This evaluation will determine the likelihood that a patient will have additional seizures, assist in the decision whether to begin antiseizure drug therapy, and direct appropriate treatment to the underlying cause, if known.

The differential diagnosis and clinical features of seizures and the diagnostic evaluation of the first seizure in adults are reviewed here. Other paroxysmal events that can mimic seizure in adults, including syncope, migraine, transient ischemic attack, and psychogenic nonepileptic seizures, are reviewed separately. (See "Nonepileptic paroxysmal disorders in adolescents and adults" and "Syncope in adults: Clinical manifestations and diagnostic evaluation" and "Pathophysiology, clinical manifestations, and diagnosis of migraine in adults" and "Definition, etiology, and clinical manifestations of transient ischemic attack" and "Psychogenic nonepileptic seizures".)

The evaluation and management of convulsive and nonconvulsive status epilepticus, which are occasionally the first presentations of seizure, as well as the management of chronic epilepsy are reviewed separately. (See "Convulsive status epilepticus in adults: Classification, clinical features, and diagnosis" and "Nonconvulsive status epilepticus" and "Overview of the management of epilepsy in adults" and "Initial treatment of epilepsy in adults".)

DEFINITIONS

A seizure is a sudden change in behavior caused by electrical hypersynchronization of neuronal networks in the cerebral cortex.

                                      

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Literature review current through: Aug 2017. | This topic last updated: Sep 08, 2017.
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References
Top
  1. Annegers JF, Hauser WA, Lee JR, Rocca WA. Incidence of acute symptomatic seizures in Rochester, Minnesota, 1935-1984. Epilepsia 1995; 36:327.
  2. Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota: 1935-1984. Epilepsia 1993; 34:453.
  3. Huff JS, Morris DL, Kothari RU, et al. Emergency department management of patients with seizures: a multicenter study. Acad Emerg Med 2001; 8:622.
  4. Beghi E, Carpio A, Forsgren L, et al. Recommendation for a definition of acute symptomatic seizure. Epilepsia 2010; 51:671.
  5. Hart YM, Sander JW, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: recurrence after a first seizure. Lancet 1990; 336:1271.
  6. Fisher RS, Acevedo C, Arzimanoglou A, et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia 2014; 55:475.
  7. Riggs JE. Neurologic manifestations of electrolyte disturbances. Neurol Clin 2002; 20:227.
  8. Schold C, Yarnell PR, Earnest MP. Origin of seizures in elderly patients. JAMA 1977; 238:1177.
  9. Sander JW, Hart YM, Johnson AL, Shorvon SD. National General Practice Study of Epilepsy: newly diagnosed epileptic seizures in a general population. Lancet 1990; 336:1267.
  10. Loiseau J, Crespel A, Picot MC, et al. Idiopathic generalized epilepsy of late onset. Seizure 1998; 7:485.
  11. Marini C, King MA, Archer JS, et al. Idiopathic generalised epilepsy of adult onset: clinical syndromes and genetics. J Neurol Neurosurg Psychiatry 2003; 74:192.
  12. Cutting S, Lauchheimer A, Barr W, Devinsky O. Adult-onset idiopathic generalized epilepsy: clinical and behavioral features. Epilepsia 2001; 42:1395.
  13. Theodore WH. The postictal state: effects of age and underlying brain dysfunction. Epilepsy Behav 2010; 19:118.
  14. Fisher RS, Harding G, Erba G, et al. Photic- and pattern-induced seizures: a review for the Epilepsy Foundation of America Working Group. Epilepsia 2005; 46:1426.
  15. Pittau F, Tinuper P, Bisulli F, et al. Videopolygraphic and functional MRI study of musicogenic epilepsy. A case report and literature review. Epilepsy Behav 2008; 13:685.
  16. Takada H, Aso K, Watanabe K, et al. Epileptic seizures induced by animated cartoon, "Pocket Monster". Epilepsia 1999; 40:997.
  17. Harding G, Wilkins AJ, Erba G, et al. Photic- and pattern-induced seizures: expert consensus of the Epilepsy Foundation of America Working Group. Epilepsia 2005; 46:1423.
  18. Firkin AL, Marco DJ, Saya S, et al. Mind the gap: Multiple events and lengthy delays before presentation with a "first seizure". Epilepsia 2015; 56:1534.
  19. Jallon P, Loiseau P, Loiseau J. Newly diagnosed unprovoked epileptic seizures: presentation at diagnosis in CAROLE study. Coordination Active du Réseau Observatoire Longitudinal de l' Epilepsie. Epilepsia 2001; 42:464.
  20. King MA, Newton MR, Jackson GD, et al. Epileptology of the first-seizure presentation: a clinical, electroencephalographic, and magnetic resonance imaging study of 300 consecutive patients. Lancet 1998; 352:1007.
  21. Hamiwka LD, Singh N, Niosi J, Wirrell EC. Diagnostic inaccuracy in children referred with "first seizure": role for a first seizure clinic. Epilepsia 2007; 48:1062.
  22. Schachter SC. Iatrogenic seizures. Neurol Clin 1998; 16:157.
  23. Dallos V, Heathfield K. Iatrogenic epilepsy due to antidepressant drugs. Br Med J 1969; 4:80.
  24. Earnest MP, Feldman H, Marx JA, et al. Intracranial lesions shown by CT scans in 259 cases of first alcohol-related seizures. Neurology 1988; 38:1561.
  25. Rosati A, Guerrini R, Cimaz R. Lupus, antiphospholipid syndrome and epilepsy: an update. Lupus 2017; 26:3.
  26. Noureldine MH, Harifi G, Berjawi A, et al. Hughes syndrome and epilepsy: when to test for antiphospholipid antibodies? Lupus 2016; 25:1397.
  27. Ottman R, Barker-Cummings C, Leibson CL, et al. Accuracy of family history information on epilepsy and other seizure disorders. Neurology 2011; 76:390.
  28. Brigo F, Storti M, Lochner P, et al. Tongue biting in epileptic seizures and psychogenic events: an evidence-based perspective. Epilepsy Behav 2012; 25:251.
  29. Brigo F, Nardone R, Bongiovanni LG. Value of tongue biting in the differential diagnosis between epileptic seizures and syncope. Seizure 2012; 21:568.
  30. Brigo F, Nardone R, Ausserer H, et al. The diagnostic value of urinary incontinence in the differential diagnosis of seizures. Seizure 2013; 22:85.
  31. Krumholz A, Wiebe S, Gronseth G, et al. Practice Parameter: evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007; 69:1996.
  32. Shukla G, Bhatia M, Vivekanandhan S, et al. Serum prolactin levels for differentiation of nonepileptic versus true seizures: limited utility. Epilepsy Behav 2004; 5:517.
  33. Chen DK, So YT, Fisher RS, Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Use of serum prolactin in diagnosing epileptic seizures: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2005; 65:668.
  34. Willert C, Spitzer C, Kusserow S, Runge U. Serum neuron-specific enolase, prolactin, and creatine kinase after epileptic and psychogenic non-epileptic seizures. Acta Neurol Scand 2004; 109:318.
  35. Pritchard PB 3rd, Wannamaker BB, Sagel J, Daniel CM. Serum prolactin and cortisol levels in evaluation of pseudoepileptic seizures. Ann Neurol 1985; 18:87.
  36. Shah AK, Shein N, Fuerst D, et al. Peripheral WBC count and serum prolactin level in various seizure types and nonepileptic events. Epilepsia 2001; 42:1472.
  37. Hung TY, Chen CC, Wang TL, et al. Transient hyperammonemia in seizures: a prospective study. Epilepsia 2011; 52:2043.
  38. Petramfar P, Yaghoobi E, Nemati R, Asadi-Pooya AA. Serum creatine phosphokinase is helpful in distinguishing generalized tonic-clonic seizures from psychogenic nonepileptic seizures and vasovagal syncope. Epilepsy Behav 2009; 15:330.
  39. Angus-Leppan H. First seizures in adults. BMJ 2014; 348:g2470.
  40. Fountain NB, Van Ness PC, Swain-Eng R, et al. Quality improvement in neurology: AAN epilepsy quality measures: Report of the Quality Measurement and Reporting Subcommittee of the American Academy of Neurology. Neurology 2011; 76:94.
  41. van Donselaar CA, Schimsheimer RJ, Geerts AT, Declerck AC. Value of the electroencephalogram in adult patients with untreated idiopathic first seizures. Arch Neurol 1992; 49:231.
  42. Shinnar S, Kang H, Berg AT, et al. EEG abnormalities in children with a first unprovoked seizure. Epilepsia 1994; 35:471.
  43. Leach JP, Stephen LJ, Salveta C, Brodie MJ. Which electroencephalography (EEG) for epilepsy? The relative usefulness of different EEG protocols in patients with possible epilepsy. J Neurol Neurosurg Psychiatry 2006; 77:1040.
  44. ACEP Clinical Policies Committee, Clinical Policies Subcommittee on Seizures. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med 2004; 43:605.
  45. Practice parameter: neuroimaging in the emergency patient presenting with seizure--summary statement. Quality Standards Subcommittee of the American Academy of Neurology in cooperation with American College of Emergency Physicians, American Association of Neurological Surgeons, and American Society of Neuroradiology. Neurology 1996; 47:288.
  46. Harden CL, Huff JS, Schwartz TH, et al. Reassessment: neuroimaging in the emergency patient presenting with seizure (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007; 69:1772.
  47. Hakami T, McIntosh A, Todaro M, et al. MRI-identified pathology in adults with new-onset seizures. Neurology 2013; 81:920.
  48. Ramirez-Lassepas M, Cipolle RJ, Morillo LR, Gumnit RJ. Value of computed tomographic scan in the evaluation of adult patients after their first seizure. Ann Neurol 1984; 15:536.
  49. Betting LE, Mory SB, Lopes-Cendes I, et al. MRI reveals structural abnormalities in patients with idiopathic generalized epilepsy. Neurology 2006; 67:848.
  50. Fields MC, Labovitz DL, French JA. Hospital-onset seizures: an inpatient study. JAMA Neurol 2013; 70:360.
  51. Berg AT, Shinnar S. The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. Neurology 1991; 41:965.
  52. Berg AT. Risk of recurrence after a first unprovoked seizure. Epilepsia 2008; 49 Suppl 1:13.
  53. Krumholz A, Wiebe S, Gronseth GS, et al. 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; 84:1705.
  54. Huff JS, Melnick ER, Tomaszewski CA, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med 2014; 63:437.
  55. Choquet C, Depret-Vassal J, Doumenc B, et al. Predictors of early seizure recurrence in patients admitted for seizures in the Emergency Department. Eur J Emerg Med 2008; 15:261.
  56. Krauss GL, Ampaw L, Krumholz A. Individual state driving restrictions for people with epilepsy in the US. Neurology 2001; 57:1780.
  57. Breen DP, Dunn MJ, Davenport RJ, Gray AJ. Epidemiology, clinical characteristics, and management of adults referred to a teaching hospital first seizure clinic. Postgrad Med J 2005; 81:715.