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Single Seizure Evaluation
Aka: Single Seizure Evaluation, Seizure Evaluation, First Seizure Evaluation
- See Also
- Seizure
- Status Epilepticus
- Febrile Seizure
- Exam
- Vital Signs including Temperature
- Complete Neurologic Exam
- Evaluate for localizing deficits (e.g. Cerebrovascular Accident)
- History: Present Ilness
- Interview patient and witnesses for their recollections of event
- Careful review of events leading up to Seizure
- Provoked (e.g. Alcohol Withdrawal, Head Trauma, drug-induced Seizure) or unprovoked Seizure?
- Number of Seizures in the prior 24 hours
- Presence of prodromes or auras
- Deja Vu Sensation
- Mood Changes
- Hallucinations
- Description of Seizure by reliable witness including focal aspects
- Unilateral movements
- Eye Deviation
- Head turning
- Twisting
- Limb Jerking
- Duration
- Time from onset to cessation of motor activity
- Postictal duration and observations
- Post-Ictal Confusion
- Amnesia
- Associated Findings
- Tongue Biting
- Urinary Incontinence
- Findings suggesting alternative diagnosis
- Chest Pain
- Nausea
- Dyspnea
- Palpitations
- Presyncopal symptoms (e.g. light headedness, Dizziness or tunnel Vision)
- Provoked Seizure Causes
- See Seizure Causes (includes Drug Induced Seizure and Seizure Differential Diagnosis)
- Medications (e.g. Bupropion, Diphenhydramine, Tramadol)
- Drug Withdrawal (e.g. Alcohol Withdrawal) or Drug Intoxication (e.g. Cocaine)
- History: Past Medical History
- Febrile Convulsions
- Head Injury
- Vascular disease
- Cerebrovascular Accidents
- Coronary Artery Disease
- Cancer
- Infectious disease
- Sleep Disorder
- Medications (including over the counter, and Herbals)
- History: Family
- Febrile Convulsions
- Epilepsy in siblings, parents, or close relatives
- History of neurogenic disorders
- History: Social
- Travel
- Occupation
- Substance Abuse
- 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 (Todd Paralysis versus Cerebrovascular Accident)
- Neuropsychological evaluation
- Labs: First-line indicated in most patients
- Fingerstick Glucose (all patients)
- Serum Sodium
- Urine Pregnancy Test (in women of child-bearing age)
- Labs: As indicated by presentation (e.g. Dehydration, toxic ingestion)
- Complete Blood Count
- Serum Electrolytes (especially Serum Sodium), Calcium, Magnesium, and Phosphorus
- Indicated for gastrointestinal losses, poor oral intake or other suspected cause
- Especially consider in infants with new onset Seizure
- Serum Glucose
- At minimum, check a fingerstick Glucose as above
- Renal Function tests
- Creatinine
- Blood Urea Nitrogen
- 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 (but not increased in 15 to 20% of patients)
- However, increased in 25% of non-epileptic Seizures
- Serum Prolactin is also increased in Vasovagal Syncope
- Abukar (2016) Neurol Clin Pract 6(2): 116-9 [PubMed]
- Lusic (1999) Seizure 8(4): 218-22 [PubMed]
- Diagnostics
- Electroencephalogram (EEG) Indications
- Emergent EEG if Status Epilepticus (even if treated)
- Routine EEG (preferably within 48 hours)
- Recommended for most cases of new onset Seizures that are unprovoked
- Attempt to schedule EEG soon after event (i.e. within 7 days of event)
- EEG has highest Test Sensitivity in first 24 hours after Seizure
- EEG abnormalities double the risk of Seizure recurrence and change management
- EEG is normal in 10 to 50% of true Epilepsy cases
- Repeat as a sleep-deprived EEG if high level of suspicion, but negative EEG
- Lumbar Puncture indications
- CNS Infection suspected (fever, Meningitis)
- Seizure not consistent with simple Febrile Seizure
- Unlikely to be useful in awake, alert patients without significant infectious findings
- Immunocompromised patient
- Age under 6 months
- Severe, Thunderclap Headache (evaluate for Subarachnoid Hemorrhage)
- Unvaccinated
- Altered Mental Status
- Consider cardiovascular evaluation in older patients (for Syncope)
- Chest XRay
- Electrocardiogram
- Echocardiogram
- Holter Monitor
- Carotid Ultrasound
- Consider Sepsis evaluation if signs toxicity or SIRS criteria (or qSOFA Score)
- Lumbar Puncture
- Urinalysis and Urine Culture
- Blood Culture
- Other source evaluation (Chest XRay)
- Imaging: Structural study
- See Seizure Indications for Neuroimaging
- Differential Diagnosis
- See Seizure Causes
- Syncope
- Febrile Seizure
- Infantile Spasms
- Pediatric Spells
- Psychogenic Nonepileptic Seizure
- Evaluation
- Indications for Electrolyte and metabolic testing
- Age under 6 months (aside from simple Febrile Seizure)
- Encephalopathy or coma
- Developmental Delay
- Persistent acidosis
- Findings out of proportion to level of Dehydration or other predisposing factors
- Indications for Sepsis or CNS Infection evaluation
- Fever AND
- Other signs of more significant infection
- Toxicity or SIRS criteria
- Meningismus
- Persistent Altered Mental Status (beyond post-ictal period)
- Other indications for extensive evaluation (labs, imaging, diagnostics)
- Status Epilepticus
- Management: General
- See Status Epilepticus for acute Seizure management
- First-time Seizures do not require admission in most cases
- Exceptions are described below
- Provoked Seizures typically require no antiepileptic medications if returned to baseline
- Treat underlying cause (e.g. Alcohol Withdrawal)
- However, some Provoked Seizures (e.g. Intracranial Hemorrhage) receive Seizure Prophylaxis
- 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
- Breen (2005) Postgrad Med J 81(961): 725-8 [PubMed]
- Seizure Prophylaxis reduces recurrence risk by 35% within first 2 years after first Seizure
- Seizure Prophylaxis does improve the chances of driving at 2 years
- However, benefit of Seizure Prophylaxis falls over time until marginal benefit at 3 to 5 years
- Seizure Prophylaxis has adverse effects, and does not improve quality of life or reduce mortality
- Krumholz (2015) Epilepsy Curr 15(3): 144-52 [PubMed]
- Driving restriction after Seizure
- Typically 3 to 6 month driving suspension required following most recent Seizure
- Mandatory reporting varies by U.S. State
- Epilepsy foundation
- http://www.efa.org
- Anticipatory Guidance
- Risk of recurrent Seizure (see below)
- Subsequent Seizure management
- Avoid driving (see above)
- Avoid swimming or bathing alone
- In some cases, rectal Diazepam may be provided for a recurrent episode
- Management: Disposition
- Hospitalization Indications
- Acute anticonvulsant management required at presentation (Status Epilepticus management)
- Prolonged postictal phase or Altered Mental Status >1 hour following Seizure
- Abnormal diagnostic evaluation (e.g. labs, neuroimaging)
- Infants with non-Febrile Seizure
- Injuries sustained during the Seizure
- Limited access to outpatient care
- Discharge Indications
- Return to baseline mental status
- Normal Neurologic Exam
- Prognosis
- Recurrence risk after first, unprovoked, non-Febrile Seizure in children
- Recurrence at one year: 20-30%
- Recurrence at 10 years: 50%
- Recurrence after a second non-Febrile Seizure: 75%
- Major (2007) Pediatr Rev 28(11): 405-14 [PubMed]
- 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)
- Nocturnal Seizures
- Febrile Seizure history
- Abnormal brain imaging
- Neurologic abnormalities
- Focal deficits or underlying congenital or acquired chronic disorders
- Severe Head Trauma
- Cerebral Palsy
- Encephalopathy
- Space occupying CNS Lesion
- Todd's Paralysis history
- Predictors of no recurrence of Seizure
- Normal EEG (recurrence risk 20-25% by 2 years)
- No Seizure within 1 year of first Seizure
- Acute provocative factors (e.g. metabolic disturbance)
- References
- Hart (1990) Lancet 336(8726): 1271-4 [PubMed]
- Chin (2006) Lancet 368(9531): 222-9 [PubMed]
- References
- Nocera, Valente, Amanullah (2018) Crit Dec Emerg Med 32(11): 3-9
- (2014) Ann Emerg Med 63(4): 437-47 [PubMed]
- Adams (2007) Am Fam Physician 75:1342-48 [PubMed]
- Rowland (2022) Am Fam Physician 105(5): 507-13 [PubMed]
- Wilden (2012) Am Fam Physician 86(4): 334-40 [PubMed]