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First seizure in adults

A seizure is a transient occurrence of symptoms and/ or signs
 due to abnormal or synchronous neuronal activity in the brain 
( ILAE- International League Against Epilepsy )

Estimated that about 10 % of the population would experience atleast one epileptic seizure ( 3 % risk of epilepsy ) In US about 150 000 adults present each year with an unprovoked first seizure ( less than ½ have a readily apparent cause ) WHO estimates that about 70 % of people with epilepsy could live seizure free if properly diagnosed and treated Despite a decrease in disease burden ( from 1990-2016 ) epilepsy remains an important cause of disability and mortality ( Lancet -Neurology Feb 2019 ) UK active epilepsy estimate is 5-10 cases/1000 ( NICE )

International League Against Epilepsy-ILAE recommends making a diagnosis of epilepsy if the patient meets 
any 1 of the following conditions-Atleast 2 unprovoked seizures occurring 24 hrs apart 1 unprovoked seizure and a probability of further seizures over next 10 yrs is greater than 60 % Diagnosis of an epilepsy syndrome

Provoked seizure – seizure due to an underlying acute symptomatic condition ( eg a metabolic or toxic disturbance , cerebral trauma , stroke ) Unprovoked – absence of precipitating factors -are further classified ( American Academy of Neurology ) into (1) seizure of unknown aetiology or (2) seizure in relation to a demonstrated preexisting brain lesion or progressive CNS disorder
( remote symptomatic seizure )

risk factors-Family h/o epilepsy Male sex Brain trauma Intracranial infections e.g Meningitis Age > 60 yrs Previous febrile seizure Previous neurological surgery Genetic conditions as childhood epilepsy syndromes or neurocutaneous syndromes ( e.g tuberous sclerosis , neurofibromatosis ) Use of illicit drugs
Cocaine -epileptogenic psychostimulant
Heroine abuse Sedative-hynotics drug withdrawal Alzheimers disease Intellectual and learning disabilities Autism spectrum disorder Stroke

Was it a seizure ? First seizures are rarely witnessed by clinicians Patient account and collateral history are vital Patient may describe a ” spell ” of uncertain nature with a wide differential diagnosis Patient description may be unreliable – he/she may have had altered consciousness at the time of the event About 40-50 % of patients with an apparent 1st seizure have had other minor seizures i.e the diagnosis is Epilepsy A seizure diagnosis would have a profound impact on patients life
○ driving
○ employment
○ relationships
○ insurance / finance

Differentials- Seizure Pre-syncope Transient ischaemic attacks Migraine auras Paroxysmal movement disorders Sleep disorders Intracranial hypertension Psychogenic non-epileptic seizures 
( PNES ) Narcolepsy/ cataplexy Hypoglycemia Nocturnal myoclonus Cardiac arrhythmia

was it a syncopal event-Syncope is a transient loss of consciousness with complete return to pre-existing neurological function discriminating between epileptic seizure and syncope can be challenging Often heralded by lightheadedness , diaphoresis , nausea or decreased hearing and vision or palpitations Vasovagal syncope typically has a situational trigger as fear, pain , medical procedures , coughing , micturition, defaecation or Valsalva manuovere No fatigue or confusion following the episode Seizure diagnosis is supported by –

waking with tongue bite amnesia witnessed unresponsiveness unusual posturing or limb jerking LOC with emotional stress head turning to one side during LOC prodromal deja vu or jamais vu absence of diaphoresis , light-headedness onset during prolonged sitting or standing

History-Patient’s experience , recollection , awareness
and an eyewitness account – its interpretation constitutes the most important aspect of the diagnostic process
○ ask for video of the event if recorded 
○ consider calling an eye-witness for collateral history ( if not accompanied ) Prior events- previous episodes are often missed ask e.g any childhood events Risk factors – assess and relate clinically Medical history Drug history Alcohol , drug abuse etc Any precipitating event ? eg
○ sleep deprivation
○ alcohol use
○ medications
○ drugs

Focal cause-Warning or unusual feelings just before the
 event e.g
 Aura – brief subjective symptoms ( cannot be appreciated by an outside observer ) described as a minimally disabling phenomena due to a discretely localized seizure predicted by the functionality of the cortex involved e.g 
○ Temporal lobe seizures – epigastric rising sensation , unpleasant olfactory sensation , palpitations , deja vu or jamais vu, fear elation
○ Occipital and parietal lobe – somatosensory 
( paraesthetic painful , thermal disturbance of body image ) or visual ( amaurotic , elemantary and complex hallucinations , illusions ) Consciousness may be fully retained ( simple partial seizures ) or impaired ( complex partial seizures ) during an attack Focal clonic limb jerking ( eg starts from face and spreads to involve the limbs ” Jacksonian march “) Dystonic posturing – fencing position Dyscognitive features eg motionsless and staring unresponsive to external clues Automatism – repetitive behaviour that do not meaningfully interact with the environment eg swallowing , chewing , lip-smacking , plucking at clothings or objects. Can also involve complex behaviors as running , walking or undressing

Generalised-Ask for an eye-witness account
( unless simple partial with preserved consciousness – patient would not be able to answer ) Generalised seizures specific pointers include
GTCS -called grand mal earlier ( generalised tonic clonic seizures ) – consistent pattern of 5 phases
Tonic ( stiffening ) cause impairment of consciousness and stiffening, trunk may be straight or flexed at the waist. Tonic phase comes first.
Clonic – means rhythmical jerking + impairment of consciousness
Tonic-Clonic → stiffening and jerking + impaired consciousness
Myoclonic – < 1 s muscular jerk without apparent impairment of consciousness
Atonic – seizures that cause sudden brief attacks of loss of tone with falls and impaired consciousness Ask about
tongue biting- lateral tongue bite
urinary incontinence ( neither sensitive nor specific to diagnose epileptic seizures versus PNES or syncope )
self injury eg contusions , wounds , fractures , abrasions , concussion , thermal injury
Post-shoulder dislocation rarely happens

Post-ictal period-Post-ictal period- may manifest as several neurological alterations This period starts when a seizure subsides and ends when the patient returns to the baseline It may be easier to decide when the post-ictal state starts in GTCS and harder in for e.g abscence seizures , focal seizures with impaired awareness and myoclonic seizures ie this will vary in nature based on type of seizure After a generalised seizure patient may go into a period of post ictal sleep Hemiparesis or hemiplegia following a seizure (Todd’s paralysis ) suggests a focal onset Aching limbs or headache Abscence seizures are typically associated with brief or no post-ictal disorientation

General appearance Vital signs – temp , BP, pulse Head and neck Oral mucosa- look for lateral tongue bite CVS – postural drop, rhythm Resp system GI – e.g chronic liver dis 
( ? alcohol ) Musculoskeletal system ? any injury # Neurological – ? focal deficits Skin- bruises, cuts Mental state. Bloods
FBC, Us-Es, LFT, TFT, glucose, Bone profile
Prlocatin- no convincing evidence of clinical benefit
Yeild of blood tests is usually low 12 lead ECG EEG Imaging eg MRI

References Management of an Unprovoked First seizure in Adults JAMA . 2016 ; 316 ( 15 ) : 1590-1591 Evidence-based guideline : Management of an unprovoked first seizure in adults Allan Krumholz, MD American Society of Neurology 2015 Risk factors associated with Epilepsy : A case controlled study Health Science Journal Vol 6 , Issue 3 ( July – September 2012 ) An approach to the Evaluation of a Patient for Seizure and Epilepsy Wisconian Medical Journal 2004 . Volume 103, No1 New-Onset Seizure in Adults and Adolescents A Review JAMA Review JAMA Dec 2016 Volume 316 , Number 24 Epilepsies : diagnosis and management NICE Clinical guideline 137 January 2012 International League Against Epilepsy via www.ilae.org- classification Seizure , Postictal State Waleed Abood et al StatPearls CKS NHS- Epilepsy


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