clinical evaluation of a 1st seizure 1

8/13/2019 Clinical Evaluation of a 1st Seizure 1

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AnEvidenceBasedPractice


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Theaimofthispresentationistohighlightthestandardinitialhistory,physicalandneurologicalexaminationandthemethodsandprocedureswhichcomplementtheevaluation

ofafirstseizureinanadult.

Neurology.2007;69:19962007


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Seizuresareacommonpresentationintheemergency

care

setting

EpilepsyisdefinedasarecurrentunprovokedseizureUpto28%ofallepilepsypatientsrequiretreatmentin

emergencydepartment(EDs)annually.

AnnEmerg Med.2004;43:605625


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ClassificationofSeizures:AccordingtoPresentation


AmFam Physician2007;75:13421347

GeneralizedSeizures:Involvesallareasofthe

brain(bothhemisphere) Generalizedtonicclonic Tonic Clonic Absence Myoclonic

PartialSeizures:Involvespartofbrain(focal).

Furtherclassifiedas:Simple:NolossofconsciousnessComplex:Lossofconsciousness

Afirstseizureistwiceaslikelytobegeneralizedseizuresasapartialseizure.

Mostgeneralizedseizuresoccurwhentheyareawake,

but

one

in

four

occur

when

they

are

asleep.


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Classificationof

Seizures:

According

to

Etiology

SymptomaticSeizures:TheyhaveaRecognizableCause

AcuteSymptomatic Causedbyarecentorcurrentevent

RemoteSymptomatic Causedbyachronicabnormality like

stroke,trauma

or

anoxia

IdiopathicSeizures:Thereisnoabnormalityfound




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NewOnsetEpilepsyisthemostcommoncause

of

a

first

Seizure



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SomeMoreTermsforClassifyingSeizures:ProvokedSeizures:Resultofanacute

precipitating disorderviz. Meningitis IntoxicationsTrauma

Metabolicderangement:

(e.g.Hypoglycemia)

These

may

require

prompt

interventiontoreversepotentiallydamaging

dangerouscondition

UnprovokedSeizures:Seizureswithoutanapparentcauseor causesthatarenot

acuteprecipitating

conditions

requiringimmediateaction.

Theirbasis

may

be

Cryptogenic(noknowncause) Remotesymptomatic:duetoa

braininjury

,lesion,

tumor

or

stroke Idiopathic(genetic)

Neurology.2007;69:19962007


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Recurrence&MortalityAssociatedwithSeizures

Inayearfollowinganacutesymptomaticseizurediagnosis,patientshaveaninefoldhigherriskofdeath

in

the

first

30

days

after

seizure,

thanthosewithoutthisdiagnosis.

Idiopathicseizuresarenotassociatedwithincreasedriskof

death.

Acutesymptomaticseizureswere80%lesslikely to

havesubsequent

unprovoked

seizures

over

thefollowing10yearscomparedwithpatientswith

firstunprovokedseizure


F1000MedicineReports2010,2:51


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GoalsofImmediateEvaluationofaFirstSeizureAfter

apatient

who

presents

with

afirst

seizure

is

stabilizedandreturnstobaselinefunction,acarefuland

complete,physicalandneurologicalexaminationare

criticallyimportant

at

the

initial

presentation.

Thegoalsofimmediateevaluationare:

o Toknowwhetheritwasaseizureoracondition

mimickingseizure(Pseudoseizure orSyncope).oToknowwhetheritwasthefirstseizure.oTo

determine

the

possible

cause

of

the

seizure.

o Classifyingseizuretype&possibleseizuresyndromeo Assessingrecurrencerisk

Neurology.2007;69:19962007


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OutlinesforSeizureAssessment:Featuresofaseizure

Associatedfactors Age

Medicalhistory previoushistoryofsimilarepisodes,

prior

stroke,

brain

tumor,

systemic

illness,

mental

illness,drugoralcoholabuse Familyhistory

Developmentalstatus

Behavior Healthatseizureonset febrile,ill,exposedtoillness,

symptomsof

infection

viz.

stiff

neck,

fever,

headache.

Precipitatingeventsotherthanillness trauma,alcohol,medications,illicitdrugs,toxins,sleepdeprivation

AdaptedfromHertzetal.Neurology.2000;55:616623


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OutlinesforSeizureAssessment:Featuresofaseizure(Contd)

Symptomsduringseizure(ictal)

Aura:Subjective

sensations

Behavior: Moodorbehavioralchangesbeforetheseizure

Preictal symptoms: Describedby

patient

or

witnessed

Vocal: Cryorgasp,slurringofwords,garbledspeech Motor: Headoreyeturning,eyedeviation,posturing,

jerking(rhythmic),

stiffening,

automatisms

(purposeless

repetitivemovementssuchaspickingatclothing,

lipsmacking);generalizedorfocalmovements



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Symptomsduringseizure(ictal)

Respiration: Changein

breathing

pattern,

cessation

of

breathing,cyanosis Autonomic: Pupillary dilation,drooling,changein

respiratoryor

heart

rate,

incontinence,

pallor,

vomiting

Lossofconsciousness orinabilitytounderstandorspeak



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Symptomsfollowingaseizure(postictal)

Amnesiafor

events

ConfusionLethargy

SleepinessHeadachesandmuscleachesTransientfocalweakness(Toddsparesis)

Nauseaor

vomiting

Bitingoftongue



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DifferentialDiagnosis

of

a

Seizure

Pseudoseizure Syncope

MigraineDrugReactionorIntoxication

Neurology.2007;69:19962007


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Nonepileptic

seizures

(NES)

are

events

resembling

epilepticattacks,butlackingtheircharacteristicclinicalandelectrographicfeatures.

Theyhave

been

referred

to

as

pseudoseizures,

hystericalseizuresandpsychogenicseizures.

Nonepileptic

attack

disorder

(NEAD) has

also

been

used,butnonepilepticseizuresisnowgenerallypreferred.

20%ofpatientsdiagnosedwithepilepsyactuallyhavepseudoseizures

Seizure(2005)14,293303


Seizures&Pseudoseizures


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EEG/video isthegoldstandardfordiscriminatingbetweenepilepticandnonepilepticattacks.

AccordingtotheAmericanAcademyofNeurology(AAN),serumprolactin measurement,ifobtainedwithin

1020

mins of

the

event,

is

useful

in

differentiating

seizurefrompseudoseizure.(Sensitivityofanelevatedprolactin levelis60%forgeneralized

tonicclonicseizuresand46%forcomplexpartialseizures).

DifferentiatingSeizuresfromPseudoseizures


Neurology,2005;65:668675

Duetononavailabilityofthetesttoallclinicians,routine

diagnosis

largely

remains

restricted

to

clinical

judgment

onthebasisofhistorical featuressuggestiveofseizures.

Somehistoricalfeaturesofseizures:tonguebiting,

presenceof

an

aura,

sensation

of

epigastric

fullness,

postictalconfusionandfocalneurologicalsigns.

Tonguebiting

especially

lateral

is

highly

specific

but

not

sensitiveforgeneralizedseizures.


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Seizures&SyncopeSyncope

may

be

difficult

to

differentiate

from

seizures,

particularlyiftheeventwasunwitnessed.

Up

to

90%

of

patients

with

syncope

have

myoclonic or

other

seizurelikemovementswhileunconscious.

Events

precipitated

by

an

emotional

stressful

event

or

precededbylightheadedness,sweating,prolonged

standing,chestpain,palpitationsorslowheartratearemore

likelytobesyncopal.

AccordingtoAAN,serumprolactin levelcannotbeusedto

differentiatebetweenseizureandsyncope


Neurology,2005;65:668675


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Somedisorderscausingseizuresrequirepromptdiagnosis

and

acute

treatment.

Also,

some

causes

of

seizures

influence

the

prognosis

andthedecisionsregardinginitiationandmaintenanceofantiepilepticdrugtherapy.

Goalofimmediateevaluation:To

know

the

Cause

of

the

Seizure

Neurology.2007;69:19962007


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CriticalQuestionsRegardingAppropriateDiagnostic

Tools

While

Evaluating

first

Seizure

inanAdult

Neurology.2007;69:19962007


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Question1:ShouldanEEGberoutinelyorderedinanadultpresentingwithan

apparentunprovoked

first

seizure?

Neurology.2007;69:19962007


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AccordingtotheAmericanAcademyofNeurology

(AAN)

EEGsweresignificantlyabnormalin8%to50%

(average29%)

of

the

patients

(n=1766).However,itisalsoclearfromtheevidencesthatanormal

EEGdoesnotexcludethepresenceofaseizuredisorder

(Onan

average

about

50%

of

individuals

clinically

diagnosed

with

a

seizurehaveanormalEEG)

Also,it

was

estimated

that

the

probability

of

seizure

recurrenceinpatientswithepileptiformEEG

abnormalitiesisof49.5%comparedtoonly27.4%in

individualswhose

EEGs

are

completely

normal

RecommendationsbyAAN:1. The

EEG

(routine)

should

be

considered

as

part

of

theneurodiagnosticevaluationoftheadultwithanapparentunprovokedfirstseizurebecauseithasa

substantialyield.

2.TheEEG(routine)shouldbeconsideredaspartoftheneurodiagnostic evaluationoftheadultwithan

apparentunprovoked

first

seizure

because

it

has

valueindeterminingtheriskforseizurerecurrence.

Neurology.2007;69:19962007


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Also,

EmergentEEGisindicatedifthereisconcern

about

status

epilepticus.

Non

convulsive

or

subtle

convulsivestatusepilepticus maybedifficultto

diagnoseclinicallyandmaybemistakenfora

prolongedpostictal

state.

Onefourthofpatientswithtreatedstatusepilepticus whoappeartobe

seizure

free

continue

to

have

seizure

activity

that

is

only

detectablewithEEG.



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Question2:Shouldabrainimagingstudy(CTorMRI)beroutinelyorderedinanadult

presentingwith

an

apparent

unprovoked

firstseizure?

Neurology.2007;69:19962007


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Patientsatanincreasedriskofacuteintracranialpathologyneedimmediateneuroimaging.

AjointconsensusstatementfromtheAmericanCollegeofEmergencyPhysicians(ACEP)andAmericanAcademyofNeurology(AAN)statesthatimmediateneuroimaging is

indicatedwhen

aserious

structural

brain

lesion

is

suspected

and

alsoshouldbeconsideredforpatientswithpartialonsetseizuresandforthosewhoareolderthan40years


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MRIisthepreferredimagingmethodbecauseithas

greatersensitivityfordetectingabnormalitiesthanCT.

However,patientswithacuteseizuresinitiallyshouldundergoCTbecauseitmoreaccuratelydetectsacute

bleedingand

is

reasonably

sensitive

in

detecting

other

abnormalities



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AccordingtotheAmericanAcademyofNeurology CT

or

MRI

were

significantly

abnormal

in

1%

to

47%

(average10%)ofthepatients(n=1092).

Thesignificant

abnormalities

affected

patient

managementandincludedpreviouslyunrecognizedbraintumors,vascularlesionsandcerebralcysticercosis

orotherstructurallesion.

Recommendations:BrainimagingusingCTorMRIshouldbeconsideredas

part

of

the

neuro

diagnostic

evaluation

of

adults

presentingwithanapparentunprovokedfirstseizure

Neurology.2007;69:19962007


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Question3: Shouldbloodcounts,bloodglucose,electrolytepanelsandothertest

beroutinely

ordered

in

an

adult

with

an

apparentunprovokedfirstseizure?

Neurology.2007;69:19962007

A di t th A i A d f N l


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AccordingtotheAmericanAcademyofNeurologyData

from

studies

showed

that

in

adults

presenting

withanapparentunprovokedfirstseizure,

althoughsomeabnormallaboratoryresultsare

reported,there

is

not

sufficient

evidence

to

support

orrefuterecommendingroutinetestingofblood

glucose,blood

counts,

or

electrolyte

panels.

Thenecessityforsuchstudiesshouldbeguidedby

specificclinical

circumstances

based

on

the

history,

physical,andneurologicexamination.

Neurology.2007;69:19962007

Recommendations:

In

the

adult

initially

presenting

with

an

apparent

unprovokedfirstseizure,bloodglucose,bloodcounts,andelectrolytepanels(particularlysodium)maybe

helpfulin

specific

clinical

circumstances,

but

there

are

insufficientdatatosupportorrefuteroutine

recommendationofanyoftheselaboratorytests


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Question4:Shouldalumbarpunctureberoutinelyperformedinanadultpresenting

withan

apparent

unprovoked

first

seizure?

Neurology.2007;69:19962007


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Alumbar

puncture

is

indicated

for

patients

with

a

historyorexaminationresultssuggestiveofcentral

nervous

system

infection

and

in

patients

who

are

immunocompromised.

Newonset

seizures

may

be

the

only

symptom

of

centralnervoussysteminfectioninpatientswith

humanimmunodeficiencyvirus.


A di t th A i A d f N l


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Datafromthestudiesrevealedsignificant

abnormalitiesinupto8%ofamixedgroupofpatientspresentingtoanemergency

departmentwith

afirst

seizure.

Neurology.2007;69:19962007

Recommendations:

Inthe

adult

initially

presenting

withanapparentunprovokedfirstseizure,lumbarpuncturemaybehelpfulinspecificclinical

circumstances,such

as

patients

who

are

febrile,

but

thereareinsufficientdatatosupportorrefuterecommendingroutinelumbarpuncture

AccordingtotheAmericanAcademyofNeurology


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Question4:Shouldtoxicologic screeningberoutinelyorderedinanadultpresentingwith

anapparent

unprovoked

first

seizure?

Neurology.2007;69:19962007


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Seizuresarereportedasaconsequencesofdrug

intoxication

particularly

with

tricyclicantidepressants,cocaineandotherstimulants.

Inaseries

of

event

with

acute

medical

complicationsofcocaineintoxication,seizures,

often

first

seizures,

accounted

for

10%

of

the

presentingsymptoms.

Severalstudies

of

emergency

department

admissionforfirstseizures,indicatedthatabout3%

ofseizures

may

relate

to

drug

toxicity

or

abuse.

RecommendationsbyAAN:Intheadultpresentingwithan

apparentunprovokedseizure,toxicologyscreening

may

be

helpful

in

specific

clinical

circumstances,butthereareinsufficientdatato

supportorrefutearoutinerecommendationfor

toxicologyscreening

Neurology.2007;69:19962007

clinical evaluation of a 1st seizure 1

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