II. History: Present Ilness
- Careful review of events leading up to Seizure
- Provoked (e.g. Alcohol Withdrawal, Head Trauma) or unprovoked Seizure?
- Number of Seizures in the prior 24 hours
- Presence of prodromes or auras
- Description of Seizure by reliable witness including focal aspects
- Unilateral movements
- Eye Deviation
- Head turning
- Time from onset to cessation of motor activity
- Postictal duration and observations
III. History: Past Medical History
- Febrile Convulsions
- Head Injury
- Vascular disease
- Cancer
- Infectious disease
- Sleep Disorder
- Medications (including over the counter, and Herbals)
IV. History: Family
- Febrile Convulsions
- Epilepsy in siblings, parents, or close relatives
- History of neurogenic disorders
V. History: Social
- Travel
- Occupation
- Substance Abuse
VI. Exam
- Injury pattern
- Oral Lacerations (especially lateral Tongue bites)
- Urinary Incontinence
- Burn injuries are common
- Cardiovascular exam
- Skin exam
-
Neurologic Exam
- Focal postictal deficits
- Focal neurologic deficits after recovery
- Neuropsychological evaluation
VII. Labs: First-line indicated in most patients
- Serum Glucose
- Serum Sodium
- Urine Pregnancy Test (in women of child-bearing age)
VIII. Labs: As indicated by presentation
- Complete Blood Count
- Serum electrolytes (especially Serum Sodium), calcium, Magnesium, and phosphorus
- Serum Glucose
- Renal Function tests
- Liver Function Tests
- Erythrocyte Sedimentation Rate (ESR)
- Ammonia level (in Cirrhosis history)
- Urine Toxicology Screening
- Serum drug levels (as indicated)
-
Serum Prolactin is not typically helpful
- Increased in 40-60% within 20 minutes of Seizure
IX. Diagnostics
-
Electroencephalogram (EEG) Indications
- Emergent EEG if Status Epilepticus (even if treated)
- Routine EEG (preferably within 48 hours)
-
Lumbar Puncture indications
- CNS Infection suspected (fever, Meningitis)
- Immunocompromised patient
- Age under 6 months
- Severe, Thunderclap Headache (evaluate for Subarachnoid Hemorrhage)
- Consider cardiovascular evaluation in older patients (for Syncope)
X. Imaging: Structural study
XI. Differential Diagnosis
XII. Management
- See Status Epilepticus for acute Seizure management
- First-time Seizures do not require admission
- Provoked Seizures typically require no antiepileptic medications if returned to baseline
- Treat underlying cause (e.g. Alcohol Withdrawal)
- Unprovoked first Seizures are typically not given prophylaxis unless high risk for recurrence (if returned to baseline)
- See Seizure Prophylaxis
- Discuss with neurology
- Only 9% of first-time Seizures have recurrence in first 6 weeks while awaiting clinic follow-up
- Driving restriction after Seizure
XIII. Prognosis
- Recurrence risk after first, unprovoked, non-Febrile Seizure in children
- Recurrence at one year: 20%
- Recurrence at 10 years: 50%
- Recurrence risk of Seizure in adults
- Recurrence at one year: 65%
- Recurrence at two years: 76%
- Predictors of recurrent Seizure
- EEG with epileptiform changes
- Unprovoked or remote provocative factor (e.g. prior CVA)
- Neurologic abnormalities
- Focal deficits or underlying congenital or acquired chronic disorders
- Severe Head Trauma
- Cerebral Palsy
- Predictors of no recurrence of Seizure
- References
