Initial Management of Seizure in Adults
The New England Journal of Medicine (NEJM): Published on July 15, 2021
The incidence rate of a single unprovoked seizure among adults is 23 to 61 cases per 100,000 person-years.
After a first unprovoked seizure, the overall risk of recurrence may be as high as 60%, and this risk is highest within the first 2 years.
Epilepsy is diagnosed after two unprovoked seizures that occur more than 24 hours apart or after a single event that occurs in a person who is considered to have a high risk of recurrence (>60% risk in a 10-year period).
Key Clinical Points
Diagnosis of Seizure in Adults
The clinical diagnosis of an epileptic seizure requires a detailed history taking and, ideally, an eyewitness account of the seizure.
Evaluation with 12-lead electrocardiography is essential in a patient who has had a first seizure or an unexplained blackout spell.
In children and teenagers, interictal electroencephalography, ideally within 24 hours after a first seizure, is particularly important.
All patients who have had a suspected focal-onset seizure should undergo detailed magnetic resonance imaging (MRI) of the head.
The risk of recurrent seizures, and therefore the need for antiepileptic medication, depends on the number of seizures and the presence of neurologic conditions and/or EEG abnormalities.
Initial Management of Seizure in Adults
Abnormal findings on electroencephalography (EEG), an abnormal neurologic status, and a second seizure all increase the probability of seizure recurrence. These three factors allow clinicians to stratify low, medium, and high risks and help in guiding decisions about the initiation of antiseizure medication.
Factors Guiding Medication Choice
The choice of medication should be guided by the type of seizure and epilepsy syndrome (broadly, valproate or levetiracetam is used in patients with generalized-onset seizures and lamotrigine or levetiracetam is used in those with focal-onset seizures) as well as by the effectiveness, adverse-event profile, and pharmacodynamic and pharmacokinetic properties of a given drug. Coexisting conditions must also be considered.
The first-line medication of seizures:
for patients with focal-onset seizures is either lamotrigine or levetiracetam;
for patients with generalized-onset seizures, the first choice is sodium valproate, except for women of childbearing potential, in whom the first-line medication is usually levetiracetam.
Notes:
The main disadvantage of lamotrigine is its low starting dose, with increases to the full treatment dose over a period of several weeks. This gradual dose adjustment is necessary to reduce the risk of the Stevens–Johnson syndrome and toxic epidermal necrolysis; initial coverage with another antiseizure medication may be warranted.
The main adverse effects of levetiracetam are irritability and anxiety, especially in patients with preexisting anxiety.Doctors Liked to Read More
This case vignette (case report) illustrates the practical approach to a common problem in neurology: the initial management of a first seizure in an adult.
An 18-year-old woman is brought to the emergency department after having had a seizure. She was up late with friends the night before and drank some alcohol. Shortly after waking this morning, she collapsed without warning, injuring her face.
Her boyfriend witnessed her having a generalized tonic–clonic seizure with cyanosis during which she bit the side of her tongue. Her first memory was waking in the ambulance.
She has had no previous seizures; specifically, she has not had any involuntary jerks of the arms and legs on awakening, blank spells, or sensitivity to flashing lights (e.g., sunlight flashing through trees, as seen while riding in a car).
How should this patient be further evaluated and treated?
Conclusions and Recommendations
In the patient described in the vignette, the first generalized tonic–clonic seizure developed after sleep loss and alcohol use. Careful questioning revealed that this was an isolated event, with no previous myoclonic jerks or absences.
Evaluation should include MRI of the head, interictal EEG, and 12-lead ECG. I would discuss with the patient lifestyle factors such as the importance of regular sleep and limiting alcohol consumption, the risks associated with seizures (including drowning and SUDEP), and driving eligibility.
Antiseizure medications are not routinely recommended for patients who have had a single seizure; however, if interictal EEG showed spike-and-wave activity, indicating a high risk of recurrent seizure, Author would recommend initiation of an antiseizure medication.
Provided that this patient did not have depression or anxiety, Author would favor levetiracetam administered with a folate supplement since the patient is of childbearing potential.
Also would arrange follow-up in 2 months to review the patient’s response and adherence to the medication regimen and any adverse effects.
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