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Practice Parameter: Evaluating an apparent unprovoked first seizure in adults (an evidence-based review)

Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society

From the University of Maryland School of Medicine (A.K., T.T., J.H.), Baltimore; University of Calgary Foothills Medical Centre (S.W.), Calgary, Alberta, Canada; University of Kansas Medical Center (G.G.), Kansas City, KS; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Children's Hospital (P.L.), Denver, CO; Beth Israel Deaconess Medical Center (P.S.), Boston, MA; Fletcher Allen Health Care/University of Vermont College of Medicine (H.M.), Burlington; Peachtree Neurological Clinic (L.S.), Atlanta, GA; Henry Ford Medical Hospital (G.B.), Detroit, MI; and Department of Neurology (J.F.), New York University School of Medicine, New York.

Address correspondence and reprint requests to the American Academy of Neurology, 1080 Montreal Avenue, St. Paul, MN 55116 guidelines{at}aan.com

Objective: The Quality Standards Subcommittee of the American Academy of Neurology develops practice parameters as strategies for patient care based on analysis of evidence. For this practice parameter the authors reviewed available evidence relevant to evaluating adults presenting with an apparent unprovoked first seizure.

Methods: Relevant questions were defined and addressed by multiple searches of medical literature. Each article was then reviewed, abstracted, and classified using an established evidence scoring system. Conclusions and recommendations were based on a standard three-tiered scheme of evidence classification.

Results: For adults presenting with a first seizure, a routine EEG revealed epileptiform abnormalities in approximately 23% of patients, and these were predictive of seizure recurrence. A brain imaging study (CT or MRI) was significantly abnormal in 10% of patients, indicating a possible seizure etiology. Laboratory tests such as blood counts, blood glucose, and electrolyte panels were abnormal in up to 15% of individuals, but abnormalities were minor and did not cause the seizure. Overt clinical signs of infection such as fever typically predicted significant CSF abnormalities on lumbar puncture. Toxicology screening studies were limited, but report some positive tests.

Recommendations: EEG should be considered as part of the routine neurodiagnostic evaluation of adults presenting with an apparent unprovoked first seizure (Level B). Brain imaging with CT or MRI should be considered as part of the routine neurodiagnostic evaluation of adults presenting with an apparent unprovoked first seizure (Level B). Laboratory tests, such as blood counts, blood glucose, and electrolyte panels (particularly sodium), lumbar puncture, and toxicology screening may be helpful as determined by the specific clinical circumstances based on the history, physical, and neurologic examination, but there are insufficient data to support or refute recommending any of these tests for the routine evaluation of adults presenting with an apparent first unprovoked seizure (Level U).

Supplemental data at www.neurology.org

Approved by the Quality Standards Subcommittee on October 28, 2006; by the Practice Committee on July 16, 2007; and by the AAN Board of Directors on July 19, 2007.

Disclosure: The authors report no conflicts of interest.

Received February 20, 2007. Accepted in final form June 7, 2007.

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				J. A. French and T. A. Pedley Initial Management of Epilepsy N. Engl. J. Med., July 10, 2008; 359(2): 166 - 176. [Full Text] [PDF]

				L. Hamiwka, N. Singh, S. Kozlik, and E. Wirrell Feasibility and Clinical Utility of Early Electroencephalogram (EEG) in Children With First Seizure J Child Neurol, July 1, 2008; 23(7): 762 - 765. [Abstract] [PDF]