While the evaluation and treatment of patients with seizures or epilepsy is often challenging, modern therapy provides many patients with complete seizure control. After a first seizure, evaluation should focus on excluding an underlying neurologic or medical condition, assessing the relative risk of seizure recurrence and determining whether treatment is indicated. Successful management of patients with recurrent seizures begins with the establishment of an accurate diagnosis of epilepsy syndrome followed by treatment using an appropriate medication in a manner that optimizes efficacy. The goal of therapy is to completely control seizures without producing unacceptable medication side effects. Patients who do not achieve complete seizure control should be referred to an epilepsy specialist, since new medications and surgical treatments offer patients unprecedented options in seizure control.
Epileptic seizures are a common and important medical problem, with about one in 11 persons experiencing at least one seizure at some point.1 Epilepsy—the tendency to have recurrent, unprovoked seizures—occurs with a prevalence of about 0.5 percent and a cumulative lifetime incidence of 3 percent.2 The management of patients with epilepsy is often challenging, as evidenced by a recent report that over one half of all patients with epilepsy continue to experience at least occasional seizures despite treatment with antiepileptic medications.3 New clinical advances offer considerable hope to these patients. This article reviews the practical clinical implications of recent studies on the epidemiology, diagnosis and management of epilepsy.
Management of Patients with New Seizures
Despite numerous technologic advances in the evaluation of neurologic disorders, diagnosis of the first seizure is still based predominantly on the patient’s medical history. Many paroxysmal events may be confused with epileptic seizures, including syncope, movement disorders, parasomnias and psychogenic seizures.
Probably the most common entity that is confused with epileptic seizures is syncope. Studies in which volunteers were videotaped during induced syncopal events illustrate the common occurrence of repetitive clonic, myoclonic or dystonic movements on fainting.4 These movements, however, rarely persist beyond five to 10 seconds and do not exhibit the organized progression from tonic to clonic phase seen in a convulsive seizure. Thus, a detailed history of the motor activity, together with the usual questions regarding premonitory symptoms, postictal state, tongue-biting, incontinence and provoking factors, can often help distinguish between these two common entities.
Diagnostic studies must be tailored to individual patients. Basic laboratory evaluation focuses on detecting systemic disturbances potentially associated with seizures and includes a complete blood count and measurements of electrolytes, calcium, magnesium, phosphorus, blood urea nitrogen, creatinine and glucose. Consideration also should be given to obtaining a toxicology screen and evaluating hepatic function with synthetic and enzyme studies. Lumbar puncture is essential in patients in whom meningitis or encephalitis is suspected, as well as in immunocompromised patients, since occult meningitis is a common finding in this group.5
Most authorities recommend that all patients who experience an unprovoked seizure undergo a brain imaging study in an effort to detect underlying cerebral lesions (e.g., tumor, abscess, vascular malformation, stroke, traumatic injury). In nonurgent cases, the imaging modality of choice is magnetic resonance imaging (MRI), since it is more sensitive than computed tomography (CT) in identifying these lesions. In patients presenting with a seizure in whom the history or examination suggests new focal deficits, persistent altered mental status, fever, recent trauma, persistent headache, cancer, treatment with anticoagulation or immunocompromised state, emergent neuroimaging is recommended.6 This is usually accomplished with a CT scan, given its widespread availability and speed and its superior ability in the detection of acute hemorrhage, compared with MRI.