Initial Diagnostic Evaluation of a First Seizure in Adults

A careful history and physical examination, along with routine blood work, can detect many medical problems that may be associated with seizures. Such problems include infection, electrolyte and glucose abnormalities, impaired hepatic or renal function, and cardiopulmonary disease. Most patients with new-onset seizures should have a CBC with platelet count and differential, toxicology screen, thyroid function testing, PT/PTT, determination of serum transaminase, electrolyte, calcium, magnesium, phosphorus, BUN, creatinine, glucose, ABGs, or pulse oximetry. If cardiopulmonary disease is suspected, ECG and chest radiograph should be obtained. Meningitis or encephalitis suspected clinically indicates LP, which is otherwise not necessary. Patients usually recover rapidly after a first seizure, and their clinical progress can be gauged after several hours of observation. Hospitaliza-tion is not usually necessary after a first seizure unless an underlying illness is suspected or there are concerns about the patient's clinical progress, inadequate social support or observation, or patient's ability or motivation to complete outpatient follow-up.

Patients with new-onset seizures should be scheduled for appropriate EEG and neuroimaging studies. MRI and CT are important complements to EEG because of their ability to identify structural abnormalities that may be related to the development of seizures. MRI is preferable to CT because of its superior ability to identify cortical architectural abnormalities, visualize the temporal lobes, detect gliomas, and identify cavernous malformations. CT, however, is appropriate in the emergency setting because it is readily available and can detect hemorrhages acutely. If the patient is seen in the office shortly after a first seizure, neuroimaging does not need to be performed immediately unless the history and physical examination suggest focal brain injury or marked cognitive impairment. In contrast to MRI and CT, positron emission tomography (PET) and single-photon emission CT (SPECT) can provide functional views of the brain. These studies can identify areas of relative hypoperfusion or hypo-metabolism that appear to be structurally normal but might play an important role in the development of partial seizures. Although such studies can be useful, especially for patients with conditions such as localization-related epilepsy, they are not routinely obtained or widely available.

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