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Title: 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.

2
Introduction
3
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.

4
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.

5
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?

6
Pathophysiology
7
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.

8
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.

9
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.

10
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

11
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.

12
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.

13
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.

14
Pathophysiology - Definitions
  • Seizures are also classified as
  • Provoked an acute symptomatic seizure
  • Unprovoked a cryptogenic or remote symptomatic
    seizure

15
Frequency
16
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.

17
Mortality / Morbidity
18
Mortality / Morbidity
  • The patient who develops recurrent unprovoked
    seizures has the same mortality and morbidity
    rates as other patients with epilepsy.

19
Race
20
Race
  • Racial differences have not been studied.

21
Sex
22
Sex
  • Most authors report a small-to-moderate
    preponderance of men in their studies of a first
    seizures in adults.

23
Age
24
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

25
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).

26
Clinical Aspects
27
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.

28
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).

29
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).

30
Physical Exam
31
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.

32
Causes
33
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

34
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

35
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

36
Causes
  • Nonepileptic events
  • Transient ischemic attack
  • Migraine
  • Sleep disorders
  • Transient global amnesia
  • Movement disorder
  • Paroxysmal vertigo
  • Malingering

37
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)

38
Differentials
39
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

40
Work Up
41
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.

42
Imaging Studies
43
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.

44
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.)

45
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.

46
Other Tests
47
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.

48
EEG
49
EEG
50
Normal EEG
51
Abnormal EEG
52
EEG Lead Placement
53
EEG Lead Placement
54
Medical Care
55
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.

56
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.

57
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

58
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

59
Risk Factors
  • CT scan that shows a brain tumor
  • EEG that shows epileptiform discharges

60
Epileptiform Discharges
61
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.

62
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.

63
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).

64
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).

65
Follow-Up
66
Further Inpatient Care
67
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.

68
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.

69
Medical / Legal Pitfalls
70
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.

71
Medical / Legal Pitfalls
  • Counseling patients about driving after a first
    seizure revolves around 2 issues
  • The diagnosis
  • The chance of recurrence

72
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.

73
Special Concerns
74
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.

75
Competency Exam
76
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

77
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

78
Question Two
  • 1) All can be causes of epileptic seizures,
    except
  • Prenatal complications of pregnancy
  • Cerebral infarction
  • Brain neoplasm
  • Movement disorder
  • Hypocalcemia

79
Question Two
  • 1) All can be causes of epileptic seizures,
    except
  • Prenatal complications of pregnancy
  • Cerebral infarction
  • Brain neoplasm
  • Movement disorder
  • Hypocalcemia

80
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

81
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

82
End of Lecture
  • Thank you for your attendance.
  • This lecture will be made available at the
    Internal Medicine Residency website
  • http//IM.official.ws
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