First Seizure: Should or Should not be treated?

1. First Seizure: Should or
Should not be treated?
Dr Abhijeet Jain
Guide Dr Atishay Jain Sir
From Medicine Update 2018
Chapter 63

2. Introduction
• About 10% of the population has seizure once
in their lives
• Less than half of these patients has multiple
seizures
• Classification of first seizure–

3. • International League of Epilepsy, 2014 defines
Epilepsy as atleast 2 unprovoked seizures
occurring more than 24 hours apart
• Factors guiding treatment decisions-
1. Chance of second seizure
2. Consequence following a second seizure
3. Preventing future seizure
4. Toxicities of Antiepileptic Drugs
• Occurrence of multiple seizures during
analysis of first seizure has to looked

4. Role of Antiepileptic Drug Prophylaxis
• Only evidence of Antiepileptic Drug
prophylaxis is in early post traumatic period of
high risk head injury
• No evidence of Antiepileptic Drug prophylaxis
for-
 Brain Tumour
 Cavernous Hemangioma
 Cerebrovascular Accident
 Craniotomy

5. When to Initiate Antiepileptic Drug?
• Factors to be considered before starting
treatment-
1. Whether the seizure is provoked or
unprovoked
Causes of Provoked Seizures

6. 2. Type of Seizure-
– Simple partial seizures are less disabling then
complex partial seizures
– Decision to treat seizures should be
individualized depending on EEG changes,
recurrence of focal seizures, risk of secondary
generalization or seizure causing psychological
distress
– Febrile seizures do not require antiepileptic drug
treatment

7. 3. Patient’s Age-
– Elderly patients with unprovoked seizures do not
have idiopathic seizures
– Unprovoked Seizure in elderly should be
considered focal with or without secondary
generalization
– Cerebrovascular disease is the most common
cause of seizure in elderly
– Seizures that begin in childhood are more likely to
be idiopathic than adults

8. 4. Acute vs. Remote Symptomatic Seizures-
• Prognosis of first acute symptomatic seizure is
not good if the etiology is
– Stroke
– Traumatic Brain Injury
– Encephalitis or Meningitis
• Mortality is higher with acute symptomatic
seizures during the first month but risk for
subsequent seizure is low

9. 5. Risk of Recurrence-
 Factors related to increased risk of recurrence
of seizures

10. Approach to a case of first Seizure
• Differential Diagnosis of a Single Seizure

11. Investigations
• Routine laboratory tests- Electrolytes, Blood
Glucose, Calcium levels, Kidney function tests
and others based on clinical suspicion like
toxicology profile
• Lumbar Puncture- Sometimes new onset
seizures may be the only manifestation of
underlying CNS infection, especially in
patients co-infected with HIV

12. • Routine EEG- EEG is essential in diagnostic
workup because
– Abnormal EEG is the most significant predictor of
seizure recurrence
– EEG points to focal lesions
– EEG may also indicate specific epilepsy syndrome
• Neuroimaging-
– MRI is preferred over CT because it has greater
sensitivity for detecting structural lesions
– After a first seizure, abnormalities detected by
MRI are more common in Adults than Children

13. Management of first seizure
• American Academy of Neurology and
American Epilepsy Society in 2015, states,
immediate anti epileptic drug therapy, as
compared delay of treatment pending a
second seizure, likely to reduce recurrence risk
in first 2 years but may not improve quality of
life
• So, Anti epileptic drug therapy is started based
on individualized assessment of risk of
recurrence against adverse effects of Drugs

14. Conclusion
• Immediate Anti epileptic drug therapy reduce
likelihood of recurrence but have no effect on
long-term prognosis.
• The consensus is that Anti epileptic treatment
is needed after 2 seizures, and after 1 seizure
if associated with other risk factors
• The chosen Anti epileptic should have high
efficacy, long-term safety, good tolerability
and low interaction potential
• Treatment should be started with
monotherapy