First Seizure in Adulthood Diagnosis and Treatment The

1
First Seizure in AdulthoodDiagnosis and
Treatment The bring your pillow to work
lecture

• Jim Czarnecki, D.O.

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Introduction
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Introduction

• Many diseases can cause paroxysmal clinical
  events. Correct diagnosis is necessary to provide
  correct treatment.
• If the event is an epileptic seizure, the seizure
  type and associated clinical, EEG, and
  neuroimaging findings assist in determining the
  risk of seizure recurrence and the possible need
  to begin anticonvulsant therapy.

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Introduction

• The correct diagnosis is often missed.
• An acute symptomatic seizure is one that occurs
  following a recent acute disorder such as a
  metabolic insult, toxic insult, CNS infection,
  stroke, brain trauma, cerebral hemorrhage,
  medication toxicity, alcohol withdrawal, or drug
  withdrawal. An example of an acute symptomatic
  seizure is a seizure that occurs within 1 week of
  a stroke or head injury.

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Introduction

• In 1988, Scheepers et al found 49 patients with
  an incorrect diagnosis and 26 patient with an
  uncertain diagnosis among 214 patients with a
  diagnosis of epilepsy.
• In a 1999 report, Davidson describes a similar
  approach to the patient with a first seizure.
• Is it epilepsy?
• What kind of epilepsy?
• What is the cause?

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Pathophysiology
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Pathophysiology - Definitions

• Definitions
• Nonepileptic event event presumed to be
  unrelated to abnormal and excessive neuronal
  discharge. An example is syncope. Decreased
  cardiac output causes decreased cerebral
  perfusion, and this results in loss of
  consciousness.

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Pathophysiology - Definitions

• Epileptic seizure event presumed to result from
  an abnormal and excessive neuronal discharge. The
  symptoms are paroxysmal and may include impaired
  consciousness and motor, sensory, autonomic, or
  psychic events perceived by the subject or an
  observer.

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Pathophysiology Definitions

• Epilepsy occurs when 2 more epileptic seizures
  occur unprovoked by any immediately identifiable
  cause. The seizures must occur more than 24 hours
  apart.
• In studies, an episode of status epilepticus is
  considered a single seizure. Febrile seizures and
  neonatal seizures are excluded from this category.

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Pathophysiology - Definitions

• Idiopathic epilepsy describes epilepsy syndromes
  with specific age-related onset, specific
  clinical and electrographic characteristics, and
  a presumes genetic mechanism.
• Epileptic seizures are classified as
• cryptogenic
• symptomatic

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Pathophysiology - Definitions

• Cyrptogenic seizure is a seizure of unknown
  etiology. This type of seizure is not associated
  with a prior CNS insult known to increase the
  risk of developing epilepsy. It does not conform
  to the criteria for the idiopathic or symptomatic
  categories.
• Previous studies use the term idiopathic to
  describe a seizure of unknown etiology.

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Pathophysiology - Definitions

• Symptomatic seizure is a seizure caused by a
  previously known or suspected disorder of the
  CNS. This type of seizure is associated with a
  prior CNS insult known to increase the risk of
  developing epilepsy.

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Pathophysiology - Definitions

• A remote symptomatic seizure occurs more than 1
  week following a disorder that is known to
  increase the risk of developing epilepsy. The
  seizure may occur a long time after the disorder.
  These disorders may produce static or progressive
  brain lesions. An example of a remote symptomatic
  seizure is a seizure that first occurs 6 months
  following a traumatic brain injury or stroke.

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Pathophysiology - Definitions

• Seizures are also classified as
• Provoked an acute symptomatic seizure
• Unprovoked a cryptogenic or remote symptomatic
  seizure

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Frequency
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Frequency

• In the US In 1997, it was reported that the
  annual incidence of adult-onset seizures in the
  United States is 84 per 100,000 population and
  that about 6 of the US population experience a
  nonfebrile seizure sometime during life.
• Estimates are approximately 50 of each 84
  patients develop epilepsy.

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Mortality / Morbidity
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Mortality / Morbidity

• The patient who develops recurrent unprovoked
  seizures has the same mortality and morbidity
  rates as other patients with epilepsy.

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Race
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Race

• Racial differences have not been studied.

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Sex
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Sex

• Most authors report a small-to-moderate
  preponderance of men in their studies of a first
  seizures in adults.

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Age
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Age

• In a study (Musicco, 1993) of consecutive
  patients aged 2 years or older, the age
  distribution for a first unprovoked seizure was
  the following
• Younger than 16 years 28
• Aged 16-60 years 66
• Older than 60 years 6

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Age

• Among adults, young adults are affected most
  often.
• Patients aged 15 years and older, the mean age of
  first unprovoked seizure was 38 years (Van
  Donselaar, 1992).
• In a study of patients 16 years and older, the
  most frequently affected group was aged 20 29
  years (Hopkins, 1988).

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Clinical Aspects
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History

• The following information should be obtained in
  the history
• Age
• If a family history of seizures is noted, the
  clinical epilepsy syndrome of the affected family
  members should be determined.
• Ask about a history of any previous provoked
  seizure.
• Determine if the first seizure was status
  epilepticus.

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History

• Ask the time of day of the seizure occurrence.
• Identify any symptoms that may indicate a
  nonepileptic event, such as convulsive syncope,
  syncope, transient ischemic attack, transient
  global amnesia, migraine, sleep disorder,
  movement disorder, vertigo, or nonepileptic
  psychogenic seizure (pseudoseizure).

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History

• Because of the frequency with which nonepileptic
  seizures occur, the first step should be to rule
  out nonepileptic events.
• Seek a possible etiology (will be covered in the
  Causes Section).

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Physical Exam
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Physical Exam

• The neurologic examination should be directed at
  finding clinical evidence of a focal brain
  lesion.
• A general physical examination should be
  performed to exclude a nonneurologic cause of the
  seizure.

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Causes
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Causes

• Epileptic seizure
• Prenatal, perinatal, or postnatal complications
  of pregnancy and delivery
• Febrile seizure Distinguish a complex febrile
  seizure from a simple febrile seizure.
• Cerebrovascular disease such as cerebral
  infarction, cerebral hemorrhage, and venous
  thrombosis
• CNS infections such as meningitis or encephalitis

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Causes

• Epileptic seizure (continued)
• Head Trauma Is the more significant when it
  occurs with loss of consciousness lasting longer
  than 30 minutes, post-traumatic amnesia lasting
  longer than 30 minutes, focal neurologic
  findings, or neuroimaging finding suggesting a
  structural brain injury.
• Neurodegenerative diseases
• Autoimmune disease

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Causes

• Epileptic seizure (continued)
• Brain neoplasm
• Genetic diseases
• Drug intoxication, drug withdrawal, or alcohol
  withdrawal
• Metabolic medical disorders such as uremia,
  hypoglycemia, hyponatremia, and hypocalcemia

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Causes

• Nonepileptic events
• Transient ischemic attack
• Migraine
• Sleep disorders
• Transient global amnesia
• Movement disorder
• Paroxysmal vertigo
• Malingering

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Causes

• Nonepileptic events (continued)
• Convulsive syncope Decreased cardiac output
  causes reduced cerebral perfusion with loss of
  consciousness and convulsive motor activity.
• Psychiatric disorders such as conversion disorder
  (psychogenic seizures, pseudoepileptic seizures,
  pseudoseizures)

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Differentials
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Differentials

• Cardioembolic Stroke
• Chorea Gravidarum
• Chorea in Adults
• Complex Partial Seizures
• Epilepsia Partialis Continua
• Epilepsy, Juvenile Myoclonic
• Epileptiform Discharges

• Essential Tremor
• First Seizure Pediatric Perspective
• Frontal Lobe Epilepsy
• Hemifacial Spasm
• Huntinging Disease
• Migrain Variants
• Narcolepsy

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Work Up
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Lab Studies

• Metabolic screening for uremia, hypoglycemia,
  drug intoxications, and electrolyte disorders
  should be conducted for patients with first
  seizure who present to the emergency department
• Other laboratory investigations may be indicated
  for specific clinical situations.

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Imaging Studies
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Imaging Studies

• Neuroimaging should be performed because
  discovery of an epileptogenic lesion can have an
  impact on the diagnosis, prognosis, and treatment
  of new-onset seizures.
• MRI improves diagnostic accuracy.
• CT scanning might miss surgical remedial brain
  lesions that would otherwise be detected by MRI.
  King et al found that CT scanning detected only
  12 of the 28 brain lesions that were detected by
  MRI 7 of the missed lesions were brain tumors.

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Imaging Studies

• Neuroimaging is unlikely to detect brain lesions
  in patients with clinical and EEG features of
  idiopathic generalized epilepsy or benign
  epilepsy. (King et al found that MRI did not
  detect any brain lesions in 49 patients with
  clinical and EEG features of idiopathic
  generalized epilepsy or in 11 patients with
  benign epilepsy.)

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Imaging Studies

• In 1998, Chadwick and Smith concluded that
  plausible arguments may be made for obtaining
  routine early CT scanning and reserving MRI for
  patients with epilepsy whose seizures are not
  controlled by antiepileptic drugs.

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Other Tests
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Other Tests

• EEG should be performed within 24 hours of the
  seizure because it is significantly more
  sensitive when obtained during the period. If the
  routine EEG findings are normal, a sleep-deprived
  EEG should be performed.
• Standard EEG detects epileptiform discharges in
  29 of patients. Standard EEG combined with
  sleep-deprived EEG shows epileptiform discharges
  in 48 of patients.

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EEG
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EEG
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Normal EEG
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Abnormal EEG
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EEG Lead Placement
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EEG Lead Placement
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Medical Care
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Medical Care

• Many patients who have a single seizure do not
  require therapy.
• The decision to be on therapy is based on a
  discussion of the risk of seizure recurrence, the
  effectiveness of treatment, and the adverse
  medical and socioeconomic effects of
  anticonvulsant treatment.

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Medical Care

• Among medically untreated patients in one study
  (Musicco, 1993), the cumulative 2-year risk of
  seizure recurrence was 51.
• Risk Factors for recurrent seizures include the
  following list.

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Risk Factors

• Age younger than 16 years
• Remote symptomatic seizure
• Seizures occurring between midnight and 859 am
• Prior provoked seizures
• Remote symptomatic seizure in a patient whose
  sibling is affect with epilepsy

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Risk Factors

• Status epilepticus or multiple seizures within 24
  hours as the initial remote symptomatic seizure.
• Partial seizures
• Todds paralysis in patients with a remote
  symptomatic seizure
• History of neurologic deficit from birth such as
  cerebral palsy or mental retardation.
• Abnormal examination findings in patients without
  a remote symptomatic seizure

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Risk Factors

• CT scan that shows a brain tumor
• EEG that shows epileptiform discharges

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Epileptiform Discharges
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Medical Therapy

• Immediate anticonvulsant treatment reduces the
  likelihood of a second seizure by half.
• Immediate anticonvulsant treatment does not
  effect the long-term prognosis for achieving 1-
  or 2-year seizure-free remission and exposes many
  patients who would never have a recurrent seizure
  to anticonvulsant side effects.

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Medical Therapy

• The need for anticonvulsant treatment after two
  seizures is generally agreed upon. The decision
  to provide anticonvulsant treatment after one
  seizure should be individualized.
• Two situations that are often encountered in
  clinical practice and should be distinguished are
  a first seizure and new-onset epilepsy with more
  than one unprovoked seizure.

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Medical Therapy

• Berg and Shinnar emphasized the need to
  distinguish between these two entities in
  clinical studies (Berg, 1991).
• Seizure recurrence risk is substantially higher
  after two or more unprovoked seizures than after
  just one (Hauser, 1990).

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Medical Therapy

• In a 1995 report, Heller et al found that
  phenytoin, carbamazepine, valproate, and
  phenobarbital were equally effective in treating
  newly diagnosed epilepsy and that phenobarbital
  had more adverse effects. Mattson and coworks
  found similar results (Mattson, 1985).

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Follow-Up
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Further Inpatient Care
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Further Inpatient Care

• Many patients who have a seizure recover
  spontaneously and fully with normal consciousness
  after a short time interval.
• Patients with incomplete recovery or a prolonged
  postictal state may require inpatient
  hospitalization.
• Inpatient management may be necessary if the
  clinical course is complicated by other medical
  problems requiring inpatient management.

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Further Inpatient Care

• A short hospitalization may be necessary for
  patients who are at risk of recurrent seizures
  and have no adequate supervision at home.
• Patients admitted from an emergency department
  had a 16.8 risk of an early recurrent seizure
  during their brief hospitalization.

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Medical / Legal Pitfalls
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Medical / Legal Pitfalls

• Patients who have had a single epileptic seizure
  are at increased risk of having a second seizure.
• These patients should be informed that they are
  at increased risk of injury to themselves or
  others if another seizure occurs.
• Risk of injury is especially important if
  patients are driving, operating dangerous
  machinery, or performing other activities that
  could put themselves or others at risk.

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Medical / Legal Pitfalls

• Counseling patients about driving after a first
  seizure revolves around 2 issues
• The diagnosis
• The chance of recurrence

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Medical / Legal Pitfalls

• Patients with a first epileptic seizure with risk
  factors such as remote symptomatic etiology or
  EEG with epileptiform discharges are at higher
  risk for a second seizure.
• Restrictions of hazardous activity should be more
  emphatic for these patients.

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Special Concerns
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Special Concerns

• The diagnosis of epilepsy refers to recurrent
  seizures and cannot be made on the basis of a
  single episode, even if anticonvulsant treatment
  is administered. This especially important
  because of the serious medical, social, and legal
  consequences surrounding the diagnosis of
  epilepsy.
• The annual cost of misdiagnosis of nonepileptic
  spells as epileptic seizures is estimated to be
  between 650 million and 4 billion.

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Competency Exam
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Question One

• 1) All are correct regarding a history of a
  patient with new onset seizure, except
• Family history of seizures should be noted
• History of any previous provoked seizure
• Determine if this first seizure was status
  epilepticus
• Age is noncontributory
• Time of day of the seizure

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Question One

• 1) All are correct regarding a history of a
  patient with new onset seizure, except
• Family history of seizures should be noted
• History of any previous provoked seizure
• Determine if this first seizure was status
  epilepticus
• Age is noncontributory
• Time of day of the seizure

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Question Two

• 1) All can be causes of epileptic seizures,
  except
• Prenatal complications of pregnancy
• Cerebral infarction
• Brain neoplasm
• Movement disorder
• Hypocalcemia

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Question Two

• 1) All can be causes of epileptic seizures,
  except
• Prenatal complications of pregnancy
• Cerebral infarction
• Brain neoplasm
• Movement disorder
• Hypocalcemia

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Question Three

• 1) Within one of the landmark neurology studies,
  King et al found that CT scanning caught most
  brain lesions not detected by MRI scanning, as
  well as catching more surgically remedial brain
  lesions. Is this statement true or false
• True
• False

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Question Three

• 1) Within one of the landmark neurology studies,
  King et al found that CT scanning caught most
  brain lesions not detected by MRI scanning, as
  well as catching more surgically remedial brain
  lesions. Is this statement true or false
• True
• False

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End of Lecture

• Thank you for your attendance.
• This lecture will be made available at the
  Internal Medicine Residency website
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