eMedicine Specialties > Neurology > Seizures and Epilepsy

First Seizure in Adulthood, Diagnosis and Treatment: Differential Diagnoses & Workup

Author: Eissa Ibrahim AlEissa, MBBS, MD, Fellow in EEG and Epilepsy, Tampa General Hospital
Coauthor(s): Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Contributor Information and Disclosures

Updated: Aug 21, 2009

Differential Diagnoses

Cardioembolic Stroke
Hemifacial Spasm
Chorea Gravidarum
Huntington Disease
Chorea in Adults
Hyperammonemia
Complex Partial Seizures
Migraine Variants
Epilepsia Partialis Continua
Narcolepsy
Epilepsy, Juvenile Myoclonic
Posttraumatic Epilepsy
Epileptiform Discharges
Psychogenic Nonepileptic Seizures
Essential Tremor
Reflex Epilepsy
First Seizure: Pediatric Perspective
REM Sleep Behavior Disorder
Frontal Lobe Epilepsy
Restless Legs Syndrome

Other Problems to Be Considered

See Causes.

Workup

Laboratory 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.24
  • Other laboratory investigations may be indicated for specific clinical situations.

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. Using clinical and EEG data alone, King et al were able to identify 23% of patients as having primary generalized epilepsy, 54% as having partial epilepsy, and 23% as having unclassified seizures.13 Using clinical, EEG, and MRI data, they were able to determine that 23% of patients had primary generalized epilepsy, 58% had partial epilepsy, and 19% had unclassified seizures.
  • CT scanning might miss surgically 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.13
  • Neuroimaging is unlikely to detect brain lesions in patients with clinical and EEG features of idiopathic generalized epilepsy or benign rolandic 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 rolandic epilepsy.13
  • 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.25

Other Tests

  • EEG should be performed within 24 hours of the seizure because it is significantly more sensitive when obtained during that period.13 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.10
  • EEG significantly improves diagnostic accuracy in patients with a first seizure. Using clinical data alone, King et al were able to determine that 8% of patients had primary generalized epilepsy, 39% had partial epilepsy, and 53% had unclassified seizures.13 Using clinical and EEG data, they were able to determine that 23% of patients had primary generalized epilepsy, 53% had partial epilepsy, and 23% had unclassified seizures.
  • Simpson et al described a case in which the placement of an insertable loop recorder, an important new tool in the diagnostic evaluation of patients with syncope, led to an unexpected diagnosis of a seizure.26 Whenever cardiovascular causes are considered as the cause of a patient's spells but cannot be proven with conventional investigations, the use of the insertable loop recorder should be considered.
  • Schreiner and Pohlman-Eden studied the value of an EEG taken within 48 hours of the first seizure in an adult.27 They found that 38% of patients without seizure recurrence had normal EEGs, while only 10.2% of patients with seizure recurrence had normal EEGs. Focal epileptiform activities were found significantly more frequently (26.5% vs 13%) in patients with seizure recurrence than in patients without seizure recurrence.
  • Unfortunately, although EEG can be helpful, it is often harmful because normal EEGs are frequently overread as epileptiform, leading to the misdiagnosis of seizures.22,28  The tendency to overread normal EEGs is common and has numerous causes.29 The most common reason for misdiagnosis is that the history is not suggestive of seizures but the entire diagnosis is essentially based on the EEG.

More on First Seizure in Adulthood, Diagnosis and Treatment

Overview: First Seizure in Adulthood, Diagnosis and Treatment
Differential Diagnoses & Workup: First Seizure in Adulthood, Diagnosis and Treatment
Treatment & Medication: First Seizure in Adulthood, Diagnosis and Treatment
Follow-up: First Seizure in Adulthood, Diagnosis and Treatment
Multimedia: First Seizure in Adulthood, Diagnosis and Treatment
References
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References

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Further Reading

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Keywords

first seizure in adulthood, first fit, paroxysmal clinical events, epileptic seizure, epilepsy, status epilepticus, idiopathic epilepsy, epilepsy syndromes, cryptogenic seizure, seizure of unknown etiology, symptomatic seizure, stroke, traumatic brain injury, syncope, nonepileptic event, tonic-clonic seizures, syncope, transient ischemic attack, transient global amnesia, migraine, sleep disorder, movement disorder, vertigo, tongue biting, head turning, posturing, urinary incontinence, cyanosis, prodromal deja-vu, head trauma, meningitis, encephalitis, neurodegenerative diseases, brain neoplasm, uremia, hypoglycemia, hyponatremia, hypocalcemia, PNEAs, psychogenic nonepileptic attacks, treatment, diagnosis

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Contributor Information and Disclosures

Author

Eissa Ibrahim AlEissa, MBBS, MD, Fellow in EEG and Epilepsy, Tampa General Hospital
Eissa Ibrahim AlEissa, MBBS, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Coauthor(s)

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Anthony M Murro, MD, Laboratory Director, Professor, Department of Neurology, Medical College of Georgia
Anthony M Murro, MD is a member of the following medical societies: American Academy of Neurology and American Epilepsy Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jose E Cavazos, MD, PhD, FAAN, Associate Professor with Tenure, Departments of Neurology, Pharmacology, and Physiology, University of Texas Health Science Center at San Antonio; Co-Director, South Texas Comprehensive Epilepsy Center; Director of the Epilepsy Center, Audie L Murphy Veterans Affairs Medical Center
Jose E Cavazos, MD, PhD, FAAN is a member of the following medical societies: American Academy of Neurology, American Clinical Neurophysiology Society, American Epilepsy Society, and Society for Neuroscience
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

 
 
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