First-time seizure
Background
Seizure Types
Classification is based on the international classification from 1981[1]; More recent terms suggested by the ILAE (International League Against Epilepsy) task Force.[2]
Focal seizures
(Older term: partial seizures)
- Without impairment in consciousness– (AKA Simple partial seizures)
- With motor signs (ex. facial twiching or rhythmic ipsilateral extremity movements)
- With sensory symptoms (ex. tingling or pereiving a certain smell)
- With autonomic symptoms or signs (ex. tachycardia or diaphoresis)
- With psychic symptoms (including aura, ex. sense of déjà-vu)
- With impairment in consciousness - (AKA Complex Partial Seizures--Older terms: temporal lobe or psychomotor seizures)
- Simple partial onset, followed by impairment of consciousness
- With impairment of consciousness at onset
- These seizures may be accompanied by automatism (such as lip smacking and chewing, hand wringing, patting and rubbing)
- Focal seizures evolving to secondarily generalized seizures
- Simple partial seizures evolving to generalized seizures
- Complex partial seizures evolving to generalized seizures
- Simple partial seizures evolving to complex partial seizures evolving to generalized seizures
Generalized seizures
- Absence seizures (Older term: petit mal; brief dissociative states without postural changes)
- Typical absence seizures
- Atypical absence seizures (last longer and often include more motor involvement)
- Myoclonic seizure (violent muscle contractions)
- Clonic seizures (rhythmic jerking)
- Tonic seizures (stiffening)
- Tonic–clonic seizures (Older term: grand mal)
- Atonic seizures (loss of muscle tone -> drop attacks)
SUDEP[3]
- Sudden Unexpected Death in Epilepsy
- Generalized tonic-clonic seizure is the major risk factor for SUDEP, and seizure freedom is strongly associated with decreased risk
- Annual incidence of SUDEP in children is 1 in 4500
- Incidence in adults is 1 in 1000
Clinical Features
- Abrupt onset, may be unprovoked
- Brief duration (typically <2min)
- AMS
- Jerking of limbs
- Postictal drowsiness/confusion (typically lasting <30 minutes)
- Todd paralysis
- Temporary focal deficit up to 36 hr post-seizure
- Lateral tongue biting - 100% specificity
- Incontinence
Differential Diagnosis
Causes of first-time seizure
- Idiopathic
- Trauma (recent or remote)
- Intracranial hemorrhage (subdural, epidural, subarachnoid, intraparenchymal)
- Structural CNS abnormalities
- Vascular lesion (aneurysm, AVM)
- Mass lesions (primary or metastatic neoplasms)
- Degenerative neurologic diseases
- Congenital brain abnormalities
- Infection (meningitis, encephalitis, abscess)
- Metabolic disturbances
- Hypoglycemia or hyperglycemia
- Hyponatremia or hypernatremia
- Hyperosmolar states
- Uremia
- Hepatic failure
- Hypocalcemia, hypomagnesemia (rare)
- Toxins and drugs
- Cocaine, lidocaine
- Antidepressants
- Theophylline
- Alcohol withdrawal
- Drug withdrawal
- Eclampsia of pregnancy (may occur up to 8wks postpartum)
- Hypertensive encephalopathy
- Anoxic-ischemic injury (cardiac arrest, severe hypoxemia)
Seizure
- Epileptic seizure
- First-time seizure
- Seizure with known seizure disorder
- Status epilepticus
- Temporal lobe epilepsy
- Non-compliance with anti-epileptic medications
- Hyponatremia
- INH toxicity
- Non-epileptic seizure
- Meningitis
- Encephalitis
- Brain abscess
- Intracranial hemorrhage
- Alcohol withdrawal
- Benzodiazepine withdrawal
- Barbiturate withdrawal
- Baclofen withdrawal
- Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia, hepatic failure, uremia
- Eclampsia
- Neurocysticercosis
- Posterior reversible encephalopathy syndrome
- Impact seizure (head trauma)
- Acute hydrocephalus
- Arteriovenous malformation
- Seizure with VP shunt
- Toxic ingestion (amphetamines, anticholinergics, cocaine, INH, organophosphates, TCA, salicylates, lithium, phenothiazines, bupropion, camphor, clozapine, cyclosporine, fluoroquinolones, imipenem, lead, lidocaine, metronidazole, synthetic cannabinoids, theophylline, Starfruit)
- Psychogenic nonepileptic seizure (pseudoseizure)
- Intracranial mass
- Syncope
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
- Post-hypoxic myoclonus (Status myoclonicus)
Diagnosis
Work-up
- Glucose
- CBC
- Chemistry
- Pregnancy test
- Utox
- Head CT
- LP (if SAH or meningitis/encephalitis is suspected)
Indications for Head CT due to Seizure[4]
- If patient has returned to a normal baseline:
- When feasible, perform a neuroimaging of the brain in the ED on patients with a first-time seizure
- Deferred outpatient neuroimaging may be used when reliable follow-up is available
Evaluation
Management
Several states have mandatory DMV reporting requirements
- No anticonvulsant treatment necessary if patient has[5][6]:
- Normal neuro exam
- No acute or chronic medical comorbidities
- Normal diagnostic testing (including normal imaging)
- Normal mental status
- Treatment generally indicated if seizure due to an identifiable neurologic condition
Disposition
See Also
External Links
References
- ↑ Proposal for revised clinical and electroencephalographic classification of epileptic seizures. From the Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 1981; 22:489.
- ↑ Epilepsia 2015; 56:1515-1523.
- ↑ Harden C et al. American Academy of Neurology and the American Epilepsy Society. Practice guideline summary: Sudden unexpected death in epilepsy incidence rates and risk factors. Neurology April 25, 2017 vol. 88 no. 17 1674-1680.
- ↑ ACEP Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med 2004; 43:605-625
- ↑ Cite error: Invalid
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- ↑ Krumholz A, et al. Evidence-based guideline: Management of an unprovoked first seizure in adults. Neurology 2015; 84(16):1705-1713.