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First Adult Seizure


Many diseases can cause paroxysmal clinical events. The correct diagnosis of the paroxysmal event is necessary to provide correct treatment. If the event is an epileptic seizure, the seizure type and associated clinical, electroencephalographic (EEG) (see an example in the image below), and neuroimaging findings assist in determining the risk of seizure recurrence and the possible need to begin anticonvulsant therapy. Yet, the correct diagnosis is often missed.

Scheepers et al reported 49 patients with an incorrect diagnosis and 26 patients with an uncertain diagnosis among 214 patients with a diagnosis of epilepsy.
In addition, about 30% of patients seen at epilepsy centers for refractory seizures turn out to have been misdiagnosed and do not have seizures.

An electroencephalogram (EEG) recording of a tempo

An electroencephalogram (EEG) recording of a temporal lobe seizure. The ictal EEG pattern is shown in the rectangular areas.

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This article focuses on 2 related questions, as follows:

Is the spell an epileptic seizure?

If the event is epileptic, is it likely to recur?

Thus, the stepwise approach should be the following:

Is it a seizure?

Is it epilepsy?

What kind of epilepsy?

What is the cause?

This article describes the common clinical features of patients with a first seizure, risk factors for seizure recurrence, and a general approach to management.


The definitions of the following terms come from the International League Against Epilepsy (ILAE) Guidelines.
In 2017, the ILAE proposed revisions to the terminology, classification, and concepts for seizures and epilepsies, but the ILAE indicates these are guiding principles rather than a presentation of new classification per se.

An epileptic seizure is a clinical event presumed to result from an abnormal and excessive neuronal discharge. The clinical symptoms are paroxysmal and may include impaired consciousness and motor, sensory, autonomic, or psychic events perceived by the subject or an observer.

Epilepsy occurs when 2 or more epileptic seizures occur unprovoked by any immediately identifiable cause. The seizures must occur more than 24 hours apart. In epidemiologic studies, an episode of status epilepticus is considered a single seizure. Febrile seizures and neonatal seizures are excluded from this category.

Idiopathic epilepsy describes epilepsy syndromes with specific age-related onset, specific clinical and electrographic characteristics, and a presumed genetic mechanism.

Epileptic seizures are classified as cryptogenic or symptomatic. A cryptogenic seizure is a seizure of unknown etiology, and it is not associated with a previous central nervous system (CNS) insult known to increase the risk of developing epilepsy. A cryptogenic seizure does not conform to the criteria for the idiopathic or symptomatic categories. Previous studies use the term idiopathic to describe a seizure of unknown etiology. However, the ILAE guidelines discourage use of the term idiopathic to describe a seizure of unknown etiology.

Symptomatic seizure is a seizure caused by a previously known or suspected disorder of the CNS. This type of seizure is associated with a previous CNS insult known to increase the risk of developing epilepsy.

An acute symptomatic seizure is one that occurs following a recent acute disorder such as a metabolic insult, toxic insult, CNS infection, stroke, brain trauma, cerebral hemorrhage, medication toxicity, alcohol withdrawal, or drug withdrawal. An example of an acute symptomatic seizure is a seizure that occurs within 1 week of a stroke or head injury. Studies have reported that 25-30% of first seizures are acute symptomatic seizures.

A remote symptomatic seizure is a seizure that occurs longer than 1 week following a disorder that is known to increase the risk of developing epilepsy. The seizure may occur a long time after the disorder. These disorders may produce static or progressive brain lesions. An example of a remote symptomatic seizure is a seizure that first occurs 6 months following a traumatic brain injury or stroke.

Seizures are also classified as provoked or unprovoked. A provoked seizure is an acute symptomatic seizure. An unprovoked seizure is a cryptogenic or a remote symptomatic seizure.

Compared with an epileptic seizure, a nonepileptic event is a clinical event that can mimic, and be mistaken for, an epileptic seizure. Examples of nonepileptic events that mimic seizures include syncope and psychogenic nonepileptic attacks (PNEAs). Syncope is caused by decreased cerebral perfusion that results mostly from a decrease in the cardiac output, which results in loss of consciousness.

For more information on some of the topics discussed here, see the following:

Benign Childhood Epilepsy

Benign Neonatal Convulsions

EEG in Common Epilepsy Syndromes

Epileptic and Epileptiform Encephalopathies

First Pediatric Seizure

Posttraumatic Epilepsy

Women’s Health and Epilepsy

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