Evaluation of the first seizure patient

Tomasz A. Nowacki and Jeffrey D. Jirsch.  Evaluation of the first seizure patient: Key points in the history and physical examination.  Seizure.  In press.

Highlights

• The first seizure evaluation rests primarily on the clinical history.

• An accurate description of the spell is necessary to confirm the diagnosis.

• Identifying prior unrecognized seizures may change the diagnosis to epilepsy.

• The interview aims to find specific acute or remote symptomatic seizure etiologies.

• The clinical findings influence further investigations, prognostication, and therapy.

Abstract

Purpose

This review will present the history and physical examination as the launching point of the first seizure evaluation, from the initial characterization of the event, to the exclusion of alternative diagnoses, and then to the determination of specific acute or remote causes. Clinical features that may distinguish seizures from alternative diagnoses are discussed in detail, followed by a discussion of acute and remote first seizure etiologies.

Methods

This review article is based on a discretionary selection of English language articles retrieved by a literature search in the PubMed database, and the authors’ clinical experience.

Results

The first seizure is a dramatic event with often profound implications for patients and family members. The initial clinical evaluation focuses on an accurate description of the spell to confirm the diagnosis, along with careful scrutiny for previously unrecognized seizures that would change the diagnosis more definitively to one of epilepsy. The first seizure evaluation rests primarily on the clinical history, and to a lesser extent, the physical examination.

Conclusions

Even in the era of digital EEG recording and neuroimaging, the initial clinical evaluation remains essential for the diagnosis, treatment, and prognostication of the first seizure.

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From the article

A study of 94 patients referred for evaluation of T-LOC identified factors that favoured a diagnosis of seizure over syncope. Pre-ictal factors were the absence of nausea, diaphoresis, spinning sensation, and diminution of vision. Ictal factors that favoured seizure were cyanosis, frothing at the mouth, and the absence of pallor. Post-ictal factors were unconsciousness for greater than five minutes, disorientation (self-reported or witnessed), sleepiness, aching muscles, and tongue bite. Clinical features that did not distinguish seizure from syncope were pre-ictal light-headedness or paresthesias, injuries, urinary incontinence, and body position at onset (e.g. sitting or standing). A study of 671 patients previously diagnosed with either seizure or syncope created a point score based on clinical features that distinguished syncope from seizures. Features that supported a diagnosis of seizure included waking with tongue bite, amnesia, witnessed unresponsiveness, unusual posturing or limb jerking, LOC with emotional stress, head turning to one side during LOC, prodromal déjà vu or jamais vu, and the absence of diaphoresis, light-headedness, or onset during prolonged standing or sitting. In summary, there was good agreement between the two studies about features that differentiate seizures from syncope, such as tongue bite, prolonged unresponsiveness, and the absence of typical syncopal features at onset; pre-ictal light-headedness was not consistently found to be a reliable clinical feature, however…

PNES are episodes of altered movement, emotion, sensation, or experience, resembling epileptic seizures, but which arise from emotional causes. They often arise in a particular context in response to external (place, time, witness) or internal triggers (flashbacks, emotions). “Red flag” clinical features that should raise a suspicion of PNES include resistance to anti-epileptic drugs (AEDs), very high event frequency (e.g. multiple times daily), atypical event triggers (stress, emotional upset, pain, certain movements or sounds), tendency to occur around an audience (such as in the clinic, during the examination), co-morbidities such as fibromyalgia or chronic pain, and presenting to health care providers with overly numerous symptoms, suggestive of somatization. Patient demeanour, effort, and co-operation with the interview and physical examination should be observed. Over-dramatization, histrionic features, give-way weakness or exaggeration of perceived deficits may raise suspicion of PNES. There is often a history of prior psychological trauma, physical abuse, or sexual abuse, with three quarters of PNES patients reporting traumatic antecedents in one case series  [ to be vigilant for these “red flags” during the first seizure evaluation, as a prior history of PNES may not have been recognized at the time of referral.

Unlike the typical progression and brief duration of a GTCS.  PNES are often longer-lasting, and variable in their presentation and course. Common features include a gradual onset or termination, with discontinuous, irregular, or asynchronous limb movements. Side to side head movements, pelvic thrusting, opisthotonic posturing, stuttering, persistent eye closure, and weeping are common. Oftentimes purposeful movements are maintained during periods of unresponsiveness such as holding onto hand rails, pushing away extraneous devices or persons, and self-guarding against injury. Patients may lapse into quiet unresponsiveness or “pseudosleep” or “pseudocoma” during a PNES in which even deep painful stimuli cannot elicit a response.