Seizures are a relatively common neurological disorder and may be seen in a wide range of clinical settings. Clinicians in multiple subspecialties should be competent in the identification, evaluation, and management of a first seizure episode as well as the recognition of seizure mimics. Decisions ranging from determining whether the seizure was provoked or unprovoked, investigating the etiology of unprovoked seizures, and initiating antiepileptic medications need to be approached in a logical, stepwise fashion. Unlike a first seizure episode, status epilepticus represents a true neurologic emergency. Prompt recognition and treatment are essential for ensuring optimal outcomes.
FIRST-TIME SEIZURE EPISODE
A 72-year-old man with a history of a prior stroke and mild residual left-sided weakness is brought to the emergency department (ED) following a period of unresponsiveness. The patient's granddaughter, who witnessed the event, describes the spell as starting with 2 or 3 seconds of a blank stare. This was followed by a slow turn of the head and eyes to the left. The arms began to bend and then “jerked” several times in quick succession. He lost control of his bladder, slumped over in his chair, and began snoring loudly. The patient’s granddaughter is unsure of how long the spell lasted, although it “seemed like forever.” She called 911, and the patient arrived at the hospital approximately 1 hour after the initial event. While he is now arousable to loud voice, he remains somnolent and confused. There is no history of seizure in the patient or the family.
Comment: The history described above is typical of a first seizure episode. What is a seizure? Why might the patient have seized? What should you tell the family, and how do you evaluate such an event? These questions will be addressed in the subsequent chapter in which we will provide an approach to a first seizure episode.
Each year, there are more than one million visits to the ED across the country for evaluation of suspected seizure and about 10% of the general population will suffer a seizure at some point in their life.1 Many of these patients and their families present to the hospital seeking help for a condition that is not only frightening to observe, but also associated with significant morbidity and mortality, social stigma, and substantial societal costs. It is estimated that the annual cost of epilepsy tops $12.5 billion, with misdiagnosis and poor treatment only adding to the overall expense.2
The term “spell” is often used initially to describe a constellation of symptoms concerning for seizure until the history, physical examination, or other ancillary testing supports the diagnosis of seizure. There are several conditions that may mimic a seizure.
A seizure is a constellation of symptoms and signs that result from abnormal electrical discharges in the brain.