A Synopsis of AFP's "Evaluation of First Nonfebrile Seizures"

A synopsis of-Evaluation of First Nonfebrile Seizures
JESSICA A. WILDEN, MD, and AARON A. COHEN-GADOL, MD, Indiana University School of Medicine, Indianapolis, Indiana
Am Fam Physician. 2012 Aug 15;86(4):334-340.
http://www.aafp.org/afp/2012/0815/p334.pdf

     The three components of an epileptic seizure are the clinical signs, the specific onset and offset, and the  electrical brain activity. The three types of epileptic seizures are provoked, unprovoked, and progressive.  Provoked (or situational) seizures are usually due to an underlying cause which affects brain and/or metabolic activity. Causes include alcohol, DM, viral infections, cancer, dehydration, liver or kidney disease, progressive headaches, or drug use. Unprovoked seizures do not have a precipitant. The possible causes include mental retardation, preeclampsia, prior TIA, CP, family history of seizure, or an old head injury. It is more common in older men. 
     Nonepileptic seizures have transient symptoms and no electrical brain disturbances. The two types are psychogenic and syncope. Psychogenic nonepileptic seizures may present with resistance to medications, multiple seizures per day, depression, or anxiety. Causes include physical or sexual abuse, childhood trauma, PTSD, history of self harm, and others.  Syncope may present with lightheadedness, chest pain, palpitations or nausea, followed by a loss of consciousness and motionlessness. There may be a brief jerking motion which may resolve within seconds. Causes include CAD, HTN, PVD, chest pain, cardiomyopathy, and others. 
     Evaluation of a patients' first seizure should include the events right before the seizure, the number of seizures over the last day, focal aspects,  length of time the patient is postictal, and how long the seizure lasted. A full neuro exam should be completed as well. A CT with and without contrast should be done in all patients experiencing a first seizure. If the patient has returned to baseline, or did not present in the ER, the CT can be done as an outpatient. It may not be needed if the patient is older than one, without any risk factors, and did not go to the ER.  Depending on the history and exam, a glucose, LP, serum sodium, or pregnancy test may be drawn. An elevated serum prolactin may be seen 10-20 minutes after a seizure if the etiology is tonic-clonic or focal, rather than psychogenic. 
     An EEG can be performed on all patients with seizures of unknown cause. It should be done within 24-48 hours. It should also be done during sleep and while awake. Sleep deprived EEG (up to 3 days) may be helpful as well. The EEG may find focal lesions not seen on CT or MRI. Such lesions may be associated with a high recurrence risk. 
     Treatment of epilepsy may help slow down the recurrence rate, but will not affect the time to remission. Patients with a high risk of recurrence should be considered for treatment.  Treatment may also be helpful for patients who become too stressed from the thought of a second seizure in public.The may be in a position of high public scrutiny. Driving privileges may be affected from a seizure.