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Semin Neurol 2021; 41(05): 477-482
DOI: 10.1055/s-0041-1735143
Review Article

Evaluation and Management of First-Time Seizure in Adults

Myriam Abdennadher 
1   Department of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
,
Aneeta Saxena
1   Department of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
,
Milena K. Pavlova
2   Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
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Abstract

First seizures are often perceived as devastating events by patients and their families due to the fear of having a life-long disease. One in 10 people experiences one or more seizures during their lifetime, while 1 in 26 people develops epilepsy. Acute symptomatic seizures are often related to a provoking factor or an acute brain insult and typically do not recur. Careful history and clinical examination should guide clinicians' management plans. Electroencephalography and brain imaging, preferably with epilepsy-specific magnetic resonance imaging, may help characterize both etiology and risk of seizure recurrence. Antiepileptic drugs should be initiated in patients with newly diagnosed epilepsy. In patients without an epilepsy diagnosis, the decision to prescribe drugs depends on individual risk factors for seizure recurrence and possible complications from seizures, which should be discussed with the patient. Counseling about driving and lifestyle modifications should be provided early, often at the first seizure encounter.

Keywords

first seizure evaluation - antiepileptic drug - electroencephalography - epilepsy


Publication History

Article published online:
07 October 2021

© 2021. Thieme. All rights reserved.

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  • References

  • 1 England MJ, Liverman CT, Schultz AM, Strawbridge LM. Epilepsy across the spectrum: promoting health and understanding. A summary of the Institute of Medicine report. Epilepsy Behav 2012; 25 (02) 266-276
    CrossrefPubMedGoogle Scholar
  • 2 Tedrus GMAS, Pereira RB, Zoppi M. Epilepsy, stigma, and family. Epilepsy Behav 2018; 78: 265-268
    CrossrefPubMedGoogle Scholar
  • 3 Hauser WA. Status epilepticus: epidemiologic considerations. Neurology 1990;40(05, Suppl 2):9–13 (Review)
    PubMedGoogle Scholar
  • 4 Fisher RS, Acevedo C, Arzimanoglou A. et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia 2014; 55 (04) 475-482
    CrossrefPubMedGoogle Scholar
  • 5 Epilepsy Imitators. Accessed April 30, 2021 at: https://www.epilepsydiagnosis.org/epilepsy-imitators.html
    PubMedGoogle Scholar
  • 6 Gavvala JR, Schuele SU. New-onset seizure in adults and adolescents: a review. JAMA 2016; 316 (24) 2657-2668
    CrossrefPubMedGoogle Scholar
  • 7 Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia 1993; 34 (04) 592-596
    CrossrefPubMedGoogle Scholar
  • 8 Hauser WA, Beghi E. First seizure definitions and worldwide incidence and mortality. Epilepsia 2008; 49 (Suppl. 01) 8-12
    CrossrefPubMedGoogle Scholar
  • 9 Loiseau J, Loiseau P, Guyot M, Duche B, Dartigues JF, Aublet B. Survey of seizure disorders in the French southwest. I. Incidence of epileptic syndromes. Epilepsia 1990; 31 (04) 391-396
    CrossrefPubMedGoogle Scholar
  • 10 Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota: 1935-1984. Epilepsia 1993; 34 (03) 453-468
    CrossrefPubMedGoogle Scholar
  • 11 Olafsson E, Ludvigsson P, Gudmundsson G, Hesdorffer D, Kjartansson O, Hauser WA. Incidence of unprovoked seizures and epilepsy in Iceland and assessment of the epilepsy syndrome classification: a prospective study. Lancet Neurol 2005; 4 (10) 627-634
    CrossrefPubMedGoogle Scholar
  • 12 MacDonald BK, Cockerell OC, Sander JW, Shorvon SD. The incidence and lifetime prevalence of neurological disorders in a prospective community-based study in the UK. Brain 2000; 123 (Pt 4): 665-676
    CrossrefPubMedGoogle Scholar
  • 13 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. Epilepsy Curr 2015; 15 (03) 144-152
    CrossrefPubMedGoogle Scholar
  • 14 Hauser WA, Rich SS, Lee JR, Annegers JF, Anderson VE. Risk of recurrent seizures after two unprovoked seizures. N Engl J Med 1998; 338 (07) 429-434
    CrossrefPubMedGoogle Scholar
  • 15 Shinnar S, Berg AT, Ptachewich Y, Alemany M. Sleep state and the risk of seizure recurrence following a first unprovoked seizure in childhood. Neurology 1993; 43 (04) 701-706
    CrossrefPubMedGoogle Scholar
  • 16 Fisher RS, Cross JH, French JA. et al. Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology. Epilepsia 2017; 58 (04) 522-530
    CrossrefPubMedGoogle Scholar
  • 17 Bergey GK. Management of a first seizure. Continuum 2016; 22 (1 Epilepsy): 38-50
    PubMedGoogle Scholar
  • 18 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 (9133): 1007-1011
    CrossrefPubMedGoogle Scholar
  • 19 Pohlmann-Eden B, Beghi E, Camfield C, Camfield P. The first seizure and its management in adults and children. BMJ 2006; 332 (7537): 339-342
    CrossrefPubMedGoogle Scholar
  • 20 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 (04) 464-475
    CrossrefPubMedGoogle Scholar
  • 21 Goodwin E, Kandler RH, Alix JJ. The value of home video with ambulatory EEG: a prospective service review. Seizure 2014; 23 (06) 480-482
    CrossrefPubMedGoogle Scholar
  • 22 Kho LK, Lawn ND, Dunne JW, Linto J. First seizure presentation: do multiple seizures within 24 hours predict recurrence?. Neurology 2006; 67 (06) 1047-1049
    CrossrefPubMedGoogle Scholar
  • 23 Cendes F, Andermann F. Do febrile seizures: promote temporal lobe epilepsy? Retrospective studies. In: Baram TZ, Shinnar S. eds. Febrile Seizures. Academic Press; 2002: 78-88
    Google Scholar
  • 24 Peljto AL, Barker-Cummings C, Vasoli VM. et al. Familial risk of epilepsy: a population-based study. Brain 2014; 137 (Pt 3): 795-805
    CrossrefPubMedGoogle Scholar
  • 25 Schreiner A, Pohlmann-Eden B. Value of the early electroencephalogram after a first unprovoked seizure. Clin Electroencephalogr 2003; 34 (03) 140-144
    CrossrefPubMedGoogle Scholar
  • 26 Ho K, Lawn N, Bynevelt M, Lee J, Dunne J. Neuroimaging of first-ever seizure: contribution of MRI if CT is normal. Neurol Clin Pract 2013; 3 (05) 398-403
    CrossrefPubMedGoogle Scholar
  • 27 Von Oertzen J, Urbach H, Jungbluth S. et al. Standard magnetic resonance imaging is inadequate for patients with refractory focal epilepsy. J Neurol Neurosurg Psychiatry 2002; 73 (06) 643-647
    CrossrefPubMedGoogle Scholar
  • 28 Duncan JS, Winston GP, Koepp MJ, Ourselin S. Brain imaging in the assessment for epilepsy surgery. Lancet Neurol 2016; 15 (04) 420-433
    CrossrefPubMedGoogle Scholar
  • 29 Bernasconi A, Bernasconi N, Bernhardt BC, Schrader D. Advances in MRI for ‘cryptogenic’ epilepsies. Nat Rev Neurol 2011; 7 (02) 99-108
    CrossrefPubMedGoogle Scholar
  • 30 Marson A, Jacoby A, Johnson A, Kim L, Gamble C, Chadwick D. Medical Research Council MESS Study Group. Immediate versus deferred antiepileptic drug treatment for early epilepsy and single seizures: a randomised controlled trial. Lancet 2005; 365 (9476): 2007-2013
    CrossrefPubMedGoogle Scholar
  • 31 Jacoby A, Gamble C, Doughty J, Marson A, Chadwick D. Medical Research Council MESS Study Group. Quality of life outcomes of immediate or delayed treatment of early epilepsy and single seizures. Neurology 2007; 68 (15) 1188-1196
    CrossrefPubMedGoogle Scholar
  • 32 S.T. Group). Randomized clinical trial on the efficacy of antiepileptic drugs in reducing the risk of relapse after a first unprovoked tonic-clonic seizure. First Seizure Trial Group (FIR. Neurology 1993; 43 (3, Pt 1): 478-483
    CrossrefPubMedGoogle Scholar
  • 33 Arcot Jayagopal L, Samson KK, Taraschenko O. Driving with drug-resistant and controlled seizures from a patient's perspective: assessment of attitudes and practices. Epilepsy Behav 2018; 81: 101-106
    CrossrefPubMedGoogle Scholar
  • 34 Stephen LJ, Brodie MJ. Selection of antiepileptic drugs in adults. Neurol Clin 2009; 27 (04) 967-992
    CrossrefPubMedGoogle Scholar
  • 35 Goldenberg MM. Overview of drugs used for epilepsy and seizures: etiology, diagnosis, and treatment. P&T 2010; 35 (07) 392-415
    PubMedGoogle Scholar
  • 36 Elliott RA, Tanajewski L, Gkountouras G. et al. cost effectiveness of support for people starting a new medication for a long-term condition through community pharmacies: an economic evaluation of the new medicine service (NMS) compared with normal practice. PharmacoEconomics 2017; 35 (12) 1237-1255
    CrossrefPubMedGoogle Scholar
  • 37 Perucca P, Jacoby A, Marson AG. et al. Adverse antiepileptic drug effects in new-onset seizures: a case-control study. Neurology 2011; 76 (03) 273-279
    CrossrefPubMedGoogle Scholar
  • 38 French JA, Kanner AM, Bautista J. et al; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology, Quality Standards Subcommittee of the American Academy of Neurology, American Epilepsy Society. Efficacy and tolerability of the new antiepileptic drugs II: treatment of refractory epilepsy: report of the Therapeutics and Technology Assessment Subcommittee and Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2004; 62 (08) 1261-1273
    CrossrefPubMedGoogle Scholar
  • 39 Ramsay E, Faught E, Krumholz A. et al; CAPSS-272 Study Group. Efficacy, tolerability, and safety of rapid initiation of topiramate versus phenytoin in patients with new-onset epilepsy: a randomized double-blind clinical trial. Epilepsia 2010; 51 (10) 1970-1977
    CrossrefPubMedGoogle Scholar
  • 40 Kanner AM, Ashman E, Gloss D. et al. Practice guideline update summary: efficacy and tolerability of the new antiepileptic drugs I: treatment of new-onset epilepsy: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2018; 91 (02) 74-81
    CrossrefPubMedGoogle Scholar
  • 41 Crawford P. Best practice guidelines for the management of women with epilepsy. Epilepsia 2005; 46 (Suppl. 09) 117-124
    CrossrefPubMedGoogle Scholar
  • 42 Jetté N, Wiebe S. Initial evaluation of the patient with suspected epilepsy. Neurol Clin 2016; 34 (02) 339-350 , vii
    CrossrefPubMedGoogle Scholar
  • 43 Brodie MJ, Barry SJ, Bamagous GA, Norrie JD, Kwan P. Patterns of treatment response in newly diagnosed epilepsy. Neurology 2012; 78 (20) 1548-1554
    CrossrefPubMedGoogle Scholar
  • 44 Kwan P, Arzimanoglou A, Berg AT. et al. Definition of drug resistant epilepsy: consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies. Epilepsia 2010; 51 (06) 1069-1077
    CrossrefPubMedGoogle Scholar
  • 45 Beghi E, Carpio A, Forsgren L. et al. Recommendation for a definition of acute symptomatic seizure. Epilepsia 2010; 51 (04) 671-675
    CrossrefPubMedGoogle Scholar
  • 46 Annegers JF, Hauser WA, Lee JR, Rocca WA. Incidence of acute symptomatic seizures in Rochester, Minnesota, 1935-1984. Epilepsia 1995; 36 (04) 327-333
    CrossrefPubMedGoogle Scholar
  • 47 Pal DK, Carpio A, Sander JW. Neurocysticercosis and epilepsy in developing countries. J Neurol Neurosurg Psychiatry 2000; 68 (02) 137-143
    CrossrefPubMedGoogle Scholar
  • 48 Hesdorffer DC, Benn EK, Cascino GD, Hauser WA. Is a first acute symptomatic seizure epilepsy? Mortality and risk for recurrent seizure. Epilepsia 2009; 50 (05) 1102-1108
    CrossrefPubMedGoogle Scholar
  • 49 Schuele SU. Evaluation of seizure etiology from routine testing to genetic evaluation. Continuum (Minneap Minn) 2019; 25 (02) 322-342
    PubMedGoogle Scholar
  • 50 Lv RJ, Wang Q, Cui T, Zhu F, Shao XQ. Status epilepticus-related etiology, incidence and mortality: a meta-analysis. Epilepsy Res 2017; 136: 12-17
    CrossrefPubMedGoogle Scholar
  • 51 Al-Faraj AO, Pang T. Management of status epilepticus. Semin Neurol 2021
    PubMedGoogle Scholar
  • 52 Salinsky M, Wong VSS, Motika P, Meuse J, Nguyen J. Emergency department neuroimaging for epileptic seizures. Epilepsia 2018; 59 (09) 1676-1683
    CrossrefPubMedGoogle Scholar
  • 53 Bank AM, Bazil CW. Emergency management of epilepsy and seizures. Semin Neurol 2019; 39 (01) 73-81
    Article in Thieme ConnectPubMedGoogle Scholar
  • 54 Claassen J, Mayer SA, Kowalski RG, Emerson RG, Hirsch LJ. Detection of electrographic seizures with continuous EEG monitoring in critically ill patients. Neurology 2004; 62 (10) 1743-1748
    CrossrefPubMedGoogle Scholar
  • 55 Alvarez V, Rodriguez Ruiz AA, LaRoche S. et al; Critical Care EEG Monitoring Research Consortium (CCEMRC). The use and yield of continuous EEG in critically ill patients: a comparative study of three centers. Clin Neurophysiol 2017; 128 (04) 570-578
    CrossrefPubMedGoogle Scholar
  • 56 Khan OI, Azevedo CJ, Hartshorn AL. et al. A comparison of continuous video-EEG monitoring and 30-minute EEG in an ICU. Epileptic Disord 2014; 16 (04) 439-448
    CrossrefPubMedGoogle Scholar
  • 57 Krumholz A, Hopp JL, Sanchez AM. Counseling epilepsy patients on driving and employment. Neurol Clin 2016; 34 (02) 427-442 , ix
    CrossrefPubMedGoogle Scholar
  • 58 Noe K. Counseling and management of the risks of living with epilepsy. Continuum (Minneap Minn) 2019; 25 (02) 477-491
    PubMedGoogle Scholar