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  Review Article Management Address correspondence to Dr Gregory K. Bergey, Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 2-147, Department of Neurology, Baltimore, MD 21287, gbergey@jhmi.edu. of a First Seizure Relationship Disclosure: Dr Bergey has received Gregory K. Bergey, MD, FAAN personal compensation for serving as an associate editor of Neurotherapeutics and has received research support from the National Institutes of Health. ABSTRACT Purpose of Review: Assessment of the patient with a first seizure is a common and important neurologic issue. Less than 50% of patients who have a first unprovoked Unlabeled Use of Products/Investigational Use Disclosure: Dr Bergey reports no disclosure. seizure have a second seizure; thus, the evaluation should focus on determining the patient’s risk of seizure recurrence. Recent Findings: A number of population studies, including some classic reports, * 2016 American Academy have identified the relative risk factors for subsequent seizure recurrence. The 2014 of Neurology. update of the International League Against Epilepsy definition of epilepsy incorporates these findings, and in 2015, the American Academy of Neurology published a guide- line that analyzed the available data. Summary: Provoked or acute symptomatic seizures do not confer increased risk for subsequent unprovoked seizure recurrence. Multiple seizures in a given 24-hour period do not increase the risk of seizure recurrence. Remote symptomatic seizures, an epileptiform EEG, a significant brain imaging abnormality, and nocturnal seizures are risk factors for seizure recurrence. Antiepileptic drug therapy delays the time to second seizure but may not influence long-term remission. Continuum (Minneap Minn) 2016;22(1):38–50. INTRODUCTION of 2014, the International League Patients presenting with a first seizure, Against Epilepsy (ILAE) defines epi- whether as a child or adult, are often lepsy as at least two unprovoked sei- quite distressed. When one considers zures occurring more than 24 hours that about 10% of the population will apart, one unprovoked seizure and a have a seizure at some time in their probability of further seizures similar lives but less than half of these patients to the general recurrence risk (approx- will have multiple  seizures, the impor- imately 60% or more) over the subse- tance of proper assessment is brought quent 10 years after two unprovoked into focus. The article “Diagnosis of Epi- seizures, or the diagnosis of an epilep- lepsy and Related Episodic Disorders” tic syndrome.2 The components of this by Erik K. St. Louis, MD, MS, FAAN, and definition are drawn from published Gregory D. Cascino, MD, FAAN,1 in this studies that are discussed in this article. issue of Continuum discusses the Accurately making an early assess- process of making the diagnosis and ment avoids unnecessary treatment of proper evaluation, so for the purpose patients unlikely to have a second un- of this article, it will be assumed that provoked seizure. Indeed, because of the patient has had an epileptic seizure the importance of this early evaluation, (either convulsive or nonconvulsive), a number of epilepsy centers have es- and the evaluation will only be men- tablished first seizure clinics. In these tioned in the context of findings that clinics, patients who have experienced influence the risk of seizure recurrence. a first seizure are seen promptly by an It is worth repeating, however, that as experienced epileptologist with the 38 www.ContinuumJournal.com February 2016  KEY hope that this early expert assessment seizures. Seizures due to a preexisting will more appropriately guide treat- brain abnormality or disorder (eg, trau- ment. Decisions about treatment after a matic brain injury [TBI]) are considered single seizure include considerations of remote symptomatic seizures. While some the chance of having a second seizure, authors6 group provoked and acute POINTS h The diagnosis of epilepsy is appropriately used even after a single unprovoked seizure if the risk of a the consequences of having a second symptomatic seizures together, some second unprovoked seizure, efficacy of medications in pre- benefit exists in separating these two seizure is significant venting future seizures, and the poten- categories, as will be discussed further. (approximately 60% tial toxicity of antiepileptic drugs (AEDs). Sometimes a first seizure and the asso- or more). The chance of seizure recurrence is one ciated EEG findings allow a syndromic h A very important part of the most important determinations classification that indicates likely recur- of the history from that will guide treatment decisions. rence. Obviously, not all patients fit into patients with a “first While one must still deal with proba- these categories; in some, the cause of the bilities, fortunately, a number of pop-  seizures is unknown even after evaluation. ulation studies exist that can assist in In assessing the patient with a “first” this determination. Of more than 180 seizure, the neurologist must also de- seizure” is determining whether they have, in fact, had other unrecognized seizures. practice parameters published by the termine whether the patient has actually American Academy of Neurology (AAN), had multiple seizures. It is common for six deal with initiation of AED therapy, patients to seek medical care after the including evaluation of a first seizure in first generalized tonic-clonic seizure, children,3 treatment of the child with a but they may not have appreciated the first unprovoked seizure,4 assessment of significance of myoclonic jerks after a first seizure in adults,5 and the 2015 awakening, nocturnal tongue biting, guideline for the management of an un- or brief staring spells (absence or focal provoked first seizure in adults.6 The seizures with dyscognitive features). A 2015 guideline is the most relevant to careful history will often determine that the discussion in this article. (Refer to many patients with newly diagnosed Appendix A for a summary of the AAN seizures have actually had multiple evidence-based guideline for clinicians.) events. This is particularly true in pa- In framing the discussion, it is worth- tients with complex partial seizures and while to review the classification of a children with absence seizures. first seizure (Table 2-1).
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