approach to first seizure

1. Dr Mohit Shah
M.D., D.M.(Neurology)
Consultant Neurologist
Baroda Neuro Hospital, Vadodara

2. APPROACH TO PATIENT WITH FIRST
SEIZURE

3. Why 1st seizure is Important?
• 10% of population will have at least 1 episode of
seizure sometime in their lives.
• Only about 2% to 3% go on to develop epilepsy

4. QUESTIONS WE SHOULD ASK
The stepwise approach should be the following:
• Is it a seizure?
• Is it epilepsy (likely to recur)?
• What kind of epilepsy?
• What is the cause?

5. • Seizure - A clinical event presumed to
result from an abnormal and excessive
neuronal discharge.
The clinical symptoms are paroxysmal and
may include impaired consciousness and
motor, sensory, autonomic, or psychic events
perceived by the subject or an observer.
Convulsion – Motor manifestation

6. Epilepsy –
• At least two unprovoked seizures occurring more
than 24 hours apart;
• One unprovoked seizure and a probability of
further seizures similar to the general recurrence
risk (approximately 60% or more) over the
subsequent 10 years after two unprovoked
seizures,
• or the diagnosis of an epileptic syndrome.

7. In adolescents and young adults
1. Syncope
2. Psychological disorders
3. Sleep disorders
4. Paroxysmal movement disorders
5. Migraine
6. Miscellaneous neurologic events
In the elderly
1. Transient ischemic attack

9. IS IT REALLY THE FIRST?
• significance of myoclonic jerks after
awakening
• nocturnal tongue biting,
• brief staring spells (absence or focal seizures
with dyscognitive features).

10. History and physical examination
• Diagnosis is highly dependent on the patient history
and physical examination.
• PATIENT’s experience, recollection, and awareness of
the event.
• Subjective symptoms –preceding – auras – localizing.
• Prior events that may represent seizure symptoms:
-staring spells,
-myoclonic jerks out of wakefulness
-stereotypic events (such as auras)

11. Classification of First seizure:
1. Provoked seizure (toxin, medication,
metabolic factors)
2. Acute symptomatic seizures (stroke,
encephalitis, head injury)
3. Remote symptomatic seizure (pre
existing underlying seizure)
4. Seizure associated with Epileptic
syndrome (juvenile myoclonic epilepsy).

13. 1. Fever or signs suggestive of infection.
2. Prolonged seizure for more than 5 minutes.
3. Recurrent seizure, Eg - 2 seizures in
24 hrs.
4. Incomplete recovery after a seizure, Eg-
drowsiness for >2 hrs.
5. Persistent post-ictal focal neurological
deficit.

14. • MRI brain
Abnormalities believed to contribute to a
patient’s occurrence of seizures was closer to
30%.
An epilepsy protocol:
-thin 1- to 3-mm slices of coronal FLAIR
-detection of subtle lesions, particularly focal
cortical dysplasia and hippocampal sclerosis.

15. E.E.G.
• can confirm diagnosis if positive
• determine the likely seizure type (focal vs generalized)
• determine the risk of recurrence after a first event.
• higher yield if performed in patients within 24 to 48
hours of new-onset seizure.

16. I
i
is the diagnosis correct?
 Are seizures likely to recur?
 Is treatment likely to be successful?
 Does the risk of more seizures outweigh the
negative aspects of treatment?

17. Risk Of Recurrence
• After a first unprovoked seizure, the overall risk
for a second seizure was only 33%.
• After a second seizure, however, the risk of a
third unprovoked seizure rose to 76%.
• Most recurrences are within 1 year of the
second or third seizure.

18.  Antiepileptic drug (AED) therapy is generally
reserved for patients who are at increased
risk for recurrent seizures.

20. PROPHYLACTIC AEDs
• The only evidence supporting AED prophylaxis
is in patients with high-risk head injury in the
early post-traumatic period.
• No evidence exists for AED in brain tumours,
cerebral cavernous haemangiomas,
cerebrovascular events, or craniotomy before a
first seizure occurs.

21. Case 1
• 34 years old male, FACTORY WORKER,
CHRONIC ALCOHOLIC
While working, suddenly develops generalised tonic
clonic seizures – becomes unconscious, has tongue
bite, with up-rolling of eyeballs and after some first
aid, gets better in 15-20 minutes.
Comes to us for consultation next day
Mri brain, EEG normal
What to do?

22. Case 2
• A 27-year-old man presented with right focal seizure
with secondary generalisation
• past medical history - depressed skull fracture 2 years
• He was treated with prophylactic antiepileptic drugs
(AEDs) at the time of the trauma but he had no
seizures, and his levetiracetam had been discontinued
shortly thereafter.
• His neurologic examination was normal.
• Brain MRI showed an area of gliosis in the anterior left
frontal lobe consistent with his previous injury.
• EEG revealed no epileptiform activity,

23. Case 3
• A 13-year-old girl presented with recurrent spells of
lightheadedness without vertigo. These occurred more
commonly when she stood up too quickly.
• Her examination was normal.
• Her EEG was interpreted as showing independent
bitemporal sharp waves in drowsiness and sleep.
• She was diagnosed with focal epilepsy and was started on
oxcarbazepine. Her lightheadedness persisted, and she had
two more spells;
• The EEG was found to be consistent with syncope, Careful
review of her initial EEG showed 14 and 6 positive spikes,
which are a normal variant and not epileptiform

25. Case 4
• A 19-year-old woman presented with her first generalized
convulsive seizure.
• Her examination, Mri brain and her basic metabolic panel was
normal.
• On EEG, she was found to have generalized polyspike-and
wave discharge.
• On asking - She admitted to episodes of hand-twitching in the
morning that caused her to spill her tea but had attributed
that to nervousness.
• Based on the history and EEG, she was diagnosed with
juvenile myoclonic epilepsy, and antiseizure medication was
initiated.

27. Case 5
• A 9-year-old boy, presented to the emergency
department with his first witnessed generalized
tonic-clonic seizure in sleep
• His neurologic examination on arrival showed
paresis of the left arm and face, which rapidly
resolved within 30 minutes.
• Brain MRI was normal.
• His EEG in wakefulness showed occasional right
centro-temporal discharges; however, these
became significantly more frequent in sleep
• Diagnosis - BECTS

29. THANK YOU