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First Adult Seizure Clinical Presentation

  • Author: Eissa Ibrahim AlEissa, MD, MBBS; Chief Editor: Selim R Benbadis, MD  more...
 
Updated: Jul 06, 2016
 

History

History remains the key in obtaining a correct diagnosis in patients with first seizure in adulthood. The detailed description of the actual episode in question is particularly important. The description should be obtained separately from the patient and from a caregiver who has witnessed the event.

The patient may be able to report a warning or aura and the feeling after the seizure. The presence of an aura, by definition, makes the diagnosis of a localization-related epilepsy, because auras are “simple partial” seizures with subjective symptoms. However, not every warning symptom is an aura.

Generally speaking, in order to be considered auras, the symptoms should be brief (seconds) and followed, at least some of the time, by more definite seizure. Auras widely vary but tend to be stereotyped in a given patient. Some (eg, déjà-vu, fear, epigastric sensation, lateralized somatosensory or visual phenomena) are very specific and even localizing; others are not (eg, indescribable sensation, whole body sensations, other vague symptoms like dizziness). The patient may not be able to describe the symptoms during the seizure, which speaks to loss of awareness, but says that the “next thing I know is coming to.”

The caregivers or witnesses should then describe what they observe; having the caregivers mimic the types of movements or behaviors they see during the attacks may be helpful. Occasionally, the best witnesses are not present; this may require a telephone call.

The following information should be obtained in the history:

  • Record the patient's age.
  • If a family history of seizures is noted, determine the clinical epilepsy syndrome of the affected family member.
  • Ask about a history of any previous provoked seizure.
  • Determine if the first seizure was status epilepticus.
  • Ask the time of day of the seizure occurrence.
  • Determine whether there is a history of postictal confusion, incontinence, and occurrence out of sleep.
  • Psychogenic nonepileptic attacks (PNEAs) are the most common nonepileptic events seen in referral epilepsy centers but should only be considered in the setting of recurrent episodes. [2]
  • Seek a possible cause (see Etiology).
  • Consider other paroxysmal neurologic events and identify seizure mimics, such as syncope, transient ischemic attack, transient global amnesia, migraine, sleep disorder, movement disorder, and vertigo. [27]

In syncope, several historical features can be helpful. When an accurate description is missing (eg, unwitnessed event), the distinction between syncope and seizures can be difficult, because it is based on history alone; however, several symptoms are helpful in aiding the diagnosis.[26, 28] These include the circumstances of the attacks, because the most common mechanism for syncope (vasovagal response) is typically triggered by known precipitants (eg, pain such as inflicted by medical procedures, emotions, cough, micturition, hot environment, prolonged standing, exercise).

Other historical features that favor syncope include “presyncopal” prodromes (eg, vertigo, dizziness, lightheadedness, chest pain, nausea), as well as age and a history of cardiovascular disease. Historical features that favor seizures include tongue biting, head turning, posturing, urinary incontinence, cyanosis, prodromal déjà-vu, and postictal confusion.[26, 28] A point system using most of these features was designed, with a reported 94% sensitivity and specificity for the diagnosis of seizures.[28]

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Physical Examination

The neurologic examination should be directed at finding clinical evidence of a focal brain lesion, and a general physical examination should be performed to exclude a non-neurologic cause of the seizure.[29]

Pay attention to the presence of signs traumatic injuries to any part of the body, especially a tongue bite, which is highly specific in epileptic seizures.[30, 31]

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Contributor Information and Disclosures
Author

Eissa Ibrahim AlEissa, MD, MBBS Consultant Neurologist and Epileptologist, King Salman Hospital, Saudi Arabia

Eissa Ibrahim AlEissa, MD, MBBS is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society

Disclosure: Nothing to disclose.

Coauthor(s)

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cyberonics; Eisai; Lundbeck; Sunovion; UCB; Upsher-Smith<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cyberonics; Eisai; Glaxo Smith Kline; Lundbeck; Sunovion; UCB<br/>Received research grant from: Cyberonics; Lundbeck; Sepracor; Sunovion; UCB; Upsher-Smith.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jose E Cavazos, MD, PhD, FAAN, FANA, FACNS Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, Assistant Dean for the MD/PhD Program, Program Director of the Clinical Neurophysiology Fellowship, University of Texas School of Medicine at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center, University Hospital System; Director, San Antonio Veterans Affairs Epilepsy Center of Excellence and Neurodiagnostic Centers, Audie L Murphy Veterans Affairs Medical Center

Jose E Cavazos, MD, PhD, FAAN, FANA, FACNS is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Neurological Association, Society for Neuroscience, American Epilepsy Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Brain Sentinel, consultant.<br/>Stakeholder (<5%), Co-founder for: Brain Sentinel.

Chief Editor

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cyberonics; Eisai; Lundbeck; Sunovion; UCB; Upsher-Smith<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cyberonics; Eisai; Glaxo Smith Kline; Lundbeck; Sunovion; UCB<br/>Received research grant from: Cyberonics; Lundbeck; Sepracor; Sunovion; UCB; Upsher-Smith.

Additional Contributors

Anthony M Murro, MD Professor, Laboratory Director, Department of Neurology, Medical College of Georgia, Georgia Regents University

Anthony M Murro, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author William J Nowack, MD, to the development and writing of the source article.

References
  1. [Guideline] Anderson P. New AAN/AES guideline on first unprovoked seizure in adults. Medscape Medical News. Available at http://www.medscape.com/viewarticle/843442. Accessed: April 20, 2015.

  2. Annegers JF, Shirts SB, Hauser WA, Kurland LT. Risk of recurrence after an initial unprovoked seizure. Epilepsia. 1986 Jan-Feb. 27(1):43-50. [Medline].

  3. Beghi E, Berg AT, Hauser WA. Treatment of Single Seizures. Engel J Jr, Pedley TA, eds. Epilepsy: A Comprehensive Textbook. Lippincott-Raven; 1997. 1287-94.

  4. Benbadis SR. Differential diagnosis of epilepsy. Continuum Lifelong Learn Neurol. 2007. 13:48-70.

  5. Benbadis SR. Errors in EEGs and the misdiagnosis of epilepsy: importance, causes, consequences, and proposed remedies. Epilepsy Behav. 2007 Nov. 11(3):257-62. [Medline].

  6. Benbadis SR. Provocative techniques should be used for the diagnosis of psychogenic nonepileptic seizures. Arch Neurol. 2001 Dec. 58(12):2063-5. [Medline].

  7. Benbadis SR. The differential diagnosis of epilepsy: A critical review. Epilepsy Behav. 2009. 15:15-21.

  8. Benbadis SR, Lin K. Errors in EEG interpretation and misdiagnosis of epilepsy. Which EEG patterns are overread?. Eur Neurol. 2008. 59(5):267-71. [Medline].

  9. Benbadis SR, Tatum WO. Overintepretation of EEGs and misdiagnosis of epilepsy. J Clin Neurophysiol. 2003 Feb. 20(1):42-4. [Medline].

  10. Benbadis SR, Wolgamuth BR, Goren H, Brener S, Fouad-Tarazi F. Value of tongue biting in the diagnosis of seizures. Arch Intern Med. 1995 Nov 27. 155(21):2346-9. [Medline].

  11. Berg AT, Berkovic SF, Brodie MJ, et al. Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, 2005-2009. Epilepsia. 2010 Apr. 51(4):676-85. [Medline]. [Full Text].

  12. Berg AT, Shinnar S. The risk of seizure recurrence following a first unprovoked seizure: a quantitative review. Neurology. 1991 Jul. 41(7):965-72. [Medline].

  13. Bora I, Seckin B, Zarifoglu M, Turan F, Sadikoglu S, Ogul E. Risk of recurrence after first unprovoked tonic-clonic seizure in adults. J Neurol. 1995 Feb. 242(3):157-63. [Medline].

  14. Camfield PR, Camfield CS, Dooley JM, Tibbles JA, Fung T, Garner B. Epilepsy after a first unprovoked seizure in childhood. Neurology. 1985 Nov. 35(11):1657-60. [Medline].

  15. Chadwick D, Smith D. Epileptology of the first-seizure presentation. Lancet. 1998 Dec 5. 352(9143):1855; author reply 1856. [Medline].

  16. Chandra B. First seizure in adults: to treat or not to treat. Clin Neurol Neurosurg. 1992. 94 suppl:S61-3. [Medline].

  17. [Guideline] Commission on Epidemiology and Prognosis, International League Against Epilepsy. Guidelines for epidemiologic studies on epilepsy. Epilepsia. 1993. 34(4):592-6. [Medline].

  18. [Guideline] Commission on Epidemiology and Prognosis, International League Against Epilepsy. Proposal for revised classification of epilepsies and epileptic syndromes. Epilepsia. 1989. 30(4):389-99. [Medline].

  19. [Guideline] Engel J Jr. Report of the ILAE classification core group. Epilepsia. 2006 Sep. 47(9):1558-68. [Medline].

  20. Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota: 1935-1984. Epilepsia. 1993 May-Jun. 34(3):453-68. [Medline].

  21. Hauser WA, Beghi E. First seizure definitions and worldwide incidence and mortality. Epilepsia. 2008. 49 Suppl 1:8-12. [Medline].

  22. Hauser WA, Rich SS, Annegers JF, Anderson VE. Seizure recurrence after a 1st unprovoked seizure: an extended follow-up. Neurology. 1990 Aug. 40(8):1163-70. [Medline].

  23. Heller AJ, Chesterman P, Elwes RD, et al. Phenobarbitone, phenytoin, carbamazepine, or sodium valproate for newly diagnosed adult epilepsy: a randomised comparative monotherapy trial. J Neurol Neurosurg Psychiatry. 1995 Jan. 58(1):44-50. [Medline].

  24. Hesdorffer DC, Benn EK, Cascino GD, Hauser WA. Is a first acute symptomatic seizure epilepsy? Mortality and risk for recurrent seizure. Epilepsia. 2009 May. 50(5):1102-8. [Medline].

  25. Hesdorffer DC, Logroscino G, Benn EK, Katri N, Cascino G, Hauser WA. Estimating risk for developing epilepsy: a population-based study in Rochester, Minnesota. Neurology. 2011 Jan 4. 76(1):23-7. [Medline]. [Full Text].

  26. Hopkins A, Garman A, Clarke C. The first seizure in adult life. Value of clinical features, electroencephalography, and computerised tomographic scanning in prediction of seizure recurrence. Lancet. 1988 Apr 2. 1(8588):721-6. [Medline].

  27. King MA, Newton MR, Jackson GD, et al. Epileptology of the first-seizure presentation: a clinical, electroencephalographic, and magnetic resonance imaging study of 300 consecutive patients. Lancet. 1998 Sep 26. 352(9133):1007-11. [Medline].

  28. Kotsopoulos IA, van Merode T, Kessels FG, de Krom MC, Knottnerus JA. Systematic review and meta-analysis of incidence studies of epilepsy and unprovoked seizures. Epilepsia. 2002 Nov. 43(11):1402-9. [Medline].

  29. Krumholz A, Wiebe S, Gronseth GS, Gloss DS, Sanchez AM, Kabir AA, et al. Evidence-based guideline: Management of an unprovoked first seizure in adults: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology. 2015 Apr 21. 84(16):1705-13. [Medline]. [Full Text].

  30. Labovitz DL, Hauser WA, Sacco RL. Prevalence and predictors of early seizure and status epilepticus after first stroke. Neurology. 2001 Jul 24. 57(2):200-6. [Medline].

  31. Marson AG, Al-Kharusi AM, Alwaidh M, et al, for the SANAD Study group. The SANAD study of effectiveness of carbamazepine, gabapentin, lamotrigine, oxcarbazepine, or topiramate for treatment of partial epilepsy: an unblinded randomised controlled trial. Lancet. 2007 Mar 24. 369(9566):1000-15. [Medline].

  32. Marson AG, Al-Kharusi AM, Alwaidh M, et al, for the SANAD Study group. The SANAD study of effectiveness of valproate, lamotrigine, or topiramate for generalised and unclassifiable epilepsy: an unblinded randomised controlled trial. Lancet. 2007 Mar 24. 369(9566):1016-26. [Medline].

  33. Martinovic Z, Jovic N. Seizure recurrence after a first generalized tonic-clonic seizure, in children, adolescents and young adults. Seizure. 1997 Dec. 6(6):461-5. [Medline].

  34. Meador KJ, Baker GA, Browning N, et al for the NEAD Study Group. Cognitive function at 3 years of age after fetal exposure to antiepileptic drugs. N Engl J Med. 2009 Apr 16. 360(16):1597-605. [Medline].

  35. Moore-Sledge CM. Evaluation and management of first seizures in adults. Am Fam Physician. 1997 Sep 15. 56(4):1113-20. [Medline].

  36. Musicco M, Beghi E, Bordo B. Randomized clinical trial on the efficacy of antiepileptic drugs in reducing the risk of relapse after a first unprovoked tonic-clonic seizure. First Seizure Trial Group (FIR.S.T. Group). Neurology. 1993 Mar. 43(3 pt 1):478-83. [Medline].

  37. Musicco M, Beghi E, Solari A, Viani F. Treatment of first tonic-clonic seizure does not improve the prognosis of epilepsy. First Seizure Trial Group (FIRST Group). Neurology. 1997 Oct. 49(4):991-8. [Medline].

  38. Nowack WJ. Epilepsy: a costly misdiagnosis. Clinical Electroencephalogr. 1997. 28(4):225-228. [Medline].

  39. Olafsson E, Ludvigsson P, Gudmundsson G, Hesdorffer D, Kjartansson O, Hauser WA. Incidence of unprovoked seizures and epilepsy in Iceland and assessment of the epilepsy syndrome classification: a prospective study. Lancet Neurol. 2005 Oct. 4(10):627-34. [Medline].

  40. Pohlmann-Eden B, Beghi E, Camfield C, Camfield P. The first seizure and its management in adults and children. BMJ. 2006 Feb 11. 332(7537):339-42. [Medline].

  41. van Donselaar CA, Schimsheimer RJ, Geerts AT, Declerck AC. Value of the electroencephalogram in adult patients with untreated idiopathic first seizures. Arch Neurol. 1992 Mar. 49(3):231-7. [Medline].

  42. Zaidi A, Clough P, Cooper P, Scheepers B, Fitzpatrick AP. Misdiagnosis of epilepsy: many seizure-like attacks have a cardiovascular cause. J Am Coll Cardiol. 2000 Jul. 36(1):181-4. [Medline].

  43. Privitera MD, Brodie MJ, Mattson RH, et al, for the EPMN 105 Study Group. Topiramate, carbamazepine and valproate monotherapy: double-blind comparison in newly diagnosed epilepsy. Acta Neurol Scand. 2003 Mar. 107(3):165-75. [Medline].

  44. Scheepers B, Clough P, Pickles C. The misdiagnosis of epilepsy: findings of a population study. Seizure. 1998 Oct. 7(5):403-6. [Medline].

  45. Schreiner A, Pohlmann-Eden B. Value of the early electroencephalogram after a first unprovoked seizure. Clin Electroencephalogr. 2003 Jul. 34(3):140-4. [Medline].

  46. Sheldon R, Rose S, Ritchie D, et al. Historical criteria that distinguish syncope from seizures. J Am Coll Cardiol. 2002 Jul 3. 40(1):142-8. [Medline].

  47. Simpson CS, Barlow MA, Krahn AD, et al. Recurrent seizure diagnosed by the insertable loop recorder. J Interv Card Electrophysiol. 2000 Oct. 4(3):475-9. [Medline].

  48. Stein MA, Kanner AM. Management of newly diagnosed epilepsy: a practical guide to monotherapy. Drugs. 2009. 69(2):199-222. [Medline].

  49. Tardy B, Lafond P, Convers P, et al. Adult first generalized seizure: etiology, biological tests, EEG, CT scan, in an ED. Am J Emerg Med. 1995 Jan. 13(1):1-5. [Medline].

  50. Tudur Smith C, Marson AG, Chadwick DW, Williamson PR. Multiple treatment comparisons in epilepsy monotherapy trials. Trials. 2007 Nov 5. 8:34. [Medline]. [Full Text].

 
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An electroencephalogram (EEG) recording of a temporal lobe seizure. The ictal EEG pattern is shown in the rectangular areas.
An electroencephalogram (EEG) recording from a patient with primary generalized epilepsy. A burst of bilateral spike and wave discharge is shown in the rectangular area.
An electroencephalogram (EEG) recording of a seizure from a subdural array in a patient evaluated for epilepsy surgery. The subdural electrodes record from the left anterior temporal (LAT), left middle temporal (LMT), and left posterior temporal (LPT) regions. The EEG seizure pattern is seen best in bipolar EEG channels LAT 3-4 and LMT 3-4 (rectangular areas).
 
 
 
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