A Clinical Review of First Seizures in Adult Patients

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A Clinical Review of First Seizures in Adult Paents
Jose de Jesus Vidal Mayo*
Department of Internal Medicine, Naonal Instute of Medical Sciences and Nutrion, Universidad Nacional Autónoma de México (UNAM),
Mexico
*Corresponding author: Jose de Jesus Vidal Mayo, Crical care fellowship, Department of Internal Medicine, Naonal Instute of Medical Sciences
and Nutrion, Universidad Nacional Autónoma de México (UNAM), Mexico, E-mail: interstrok@hotmail.com
Received date: April 17, 2019; Accepted date: May 24, 2019; Published date: May 31, 2019
Citation: de Jesus Vidal Mayo J (2019) A Clinical Review of First Seizures in Adult Patients. Med Clin Rev Vol. 5 No. 2: 3.
Copyright: © 2019 de Jesus Vidal Mayo J. This is an open-access arcle distributed under the terms of the Creave Commons Aribuon License,
which permits unrestricted use, distribuon, and reproducon in any medium, provided the original author and source are credited.
Abstract
First seizures in adult paents are a common problem in
clinical pracce, and their management represents a
challenge for physicians. The aim of this review is to develop
a systemac clinical approach for the classicaon,
diagnosis, and treatment of paents who have experienced
a rst seizure. This could help clinicians to recognize and
treat this condion appropriately. Because these seizures
can arise from several eologies, it is essenal to know if
the event was a provoked (acute symptomac) or
unprovoked seizure. Thus, an adequate classicaon is
important to establish the length of the diagnosis approach,
the necessary treatment, and every individual prognosis.
We found that paents diagnosed with a single unprovoked
seizure require electroencephalography and magnec
resonance imaging. This will allow an assessment of the risk
of recurrence and the idencaon of paents that follow
the diagnosis criteria for epilepsy. We recommend
individualized pharmacological therapy to reduce early
seizure recurrence (≤2 years) even if it can produce some
adverse eects. Finally, we determine that there are sll
certain areas of uncertainty to promote future research in
this topic.
Keywords: First seizure; Epilepsy; Recurrence; Treatment
Introducon
Seizures are a common problem in clinical pracce being
responsible for about 1% of hospital admissions and 3% of
emergency room visits [1]. An epilepc seizure is a transient
event of signs or symptoms due to abnormally excessive or
synchronous neuronal acvity in the brain [2]. In contrast, a
convulsion is the motor manifestaon of this abnormal neuronal
acvity [3]. A rst seizure is dened as one or mulple seizures
with recovery of awareness between them within a period of ≤
24 hours [2].
Epilepsy-according the most recent denion of the
Internaonal League Against Epilepsy (ILAE)-is a disease of the
brain which also includes a single unprovoked seizure with a
high recurrence risk over the next 10 years (at least 60%) [3].
Therefore, it is essenal to perform a correct classicaon of the
paent´s event because it establishes the management and
prognosis. The aim of this review is to develop a systemac
clinical approach for the classicaon, diagnosis, and treatment
of these paents to help clinicians recognize and treat this
condion appropriately.
Epidemiology
Approximately 1 of 10 people throughout their lives will
present an isolated seizure [4]. The lifeme risk for epilepc
seizures is between 8% to 10% and 2%-3% chance of developing
epilepsy [5,6]. About 40% to 50% of the rst seizures correspond
to provoked (acute symptomac) seizures [7,8].
The incidence regarding rst seizures in Europe is around 70
per 100,000 inhabitants per year and is twice as common in the
worldwide poorest countries [9]. In the United States of America
(USA) close to 150,000 people present a rst unprovoked seizure
annually [10]. Some studies have reported a bimodal paern of
presentaon with a higher incidence for children <1 year of age
(252.9 per 100,000 per year) and for adults >75 years (173.2 per
100,000 per year) [11].
There are no epidemiological data in the Mexican populaon
regarding this enty. However, according to the epilepsy priority
program there are about 2 million people with epilepsy in our
country [12].
Classicaon
For this review, we classify the epilepc seizures in two large
groups:
Acute symptomac seizures (also called provoked seizures):
They are in close temporal associaon with an acute damage to
the central nervous system which may be of metabolic, toxic,
structural, infecous, or inammatory origin [13]. They are
presumably the acute manifestaon of the insult [14].
The temporal relaonship in this denion is within the rst
week in stroke, head trauma, or anoxic encephalopathy. The
acve phase of the infecons in the central nervous system
(based on persistent clinical, laboratorial, or imaging ndings) is
not beyond 24 hours for severe metabolic derangement and
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between 7 to 48 hours since the last alcohol intake in alcohol
withdrawal [13].
Unprovoked seizures (also called remote symptomac
seizures): They occur in the absence of a precipitang factor and
may be condioned by a stac or progressive injury [14]. These
ones are the kind of seizures closely related to epilepsy [15].
Seizures can also be classied according to their presumed
clinical and electrographic paerns, as generalized (they arise
and engage neural networks in both cerebral hemispheres), or
focal (they engage neural networks only in one cerebral
hemisphere) [16].
Other experts have suggested a dierent classicaon for this
topic [17], but we prefer to divide rst-me seizures in provoked
and unprovoked seizures to avoid confusion with the
nomenclature.
Eology
Causes of acute symptomac seizures can be categorized as
follows: [15,18,19]
Neurologic insults
Traumac Brain Injury (TBI), brain surgeries are included in
this secon. Some factors associated with seizure occurrence in
this context are: age (more common in children), loss of
awareness, amnesia for >30 minutes, and the presence of
cerebral hemorrhages or subdural hematomas [20].
CNS infecons: about 5% of the paents will have seizures
during the acute phase [21]. The risk factors described are:
encephalis (14 mes more frequently compared to meningis),
the eological agent (most common in herpes simplex
encephalis-up to 40% to 60% of cases), age >42 years and ≤12
in the Glasgow Coma Scale (GCS) score at admission [18,22].
Acute stroke: those paents with cerebral vein thrombosis
present more frequently symptomac seizures (up to 39% of
cases) [23], followed by those ones with subarachnoid
hemorrhage (6% to 18% of paents) [24], up to 16% of cases in
intracerebral haemorrhage [25], and nally paents who have
experienced ischemic stroke (4% to 9%) [26-28].
Metabolic disorders
Metabolic disorders are responsible for 2.9% to 5% of
epilepc seizures in emergency departments [29,30]. In this
group we can include sodium, calcium and magnesium
derangements as well as glucose disorders, and the sengs of
acute liver failure, uremic syndrome, and thyroid emergencies.
If there are electrolyc disturbances, the probability for the
development of seizures depends on the speed and severity of
instauraon [18,19]. In glucose disorders, seizures occur more
frequently in the context of hyperglycemic crises (up to 25%)
parcularly in the hyperglycemic hyperosmolar state, probably
due to the anepilepc eect of ketosis [19]- compared to
hypoglycemia (7% of cases of severe hypoglycemia) [31]. The
associated alteraons and their respecve cut-o points related
to seizures are represented in the Table 1 [13,15,19].
Table 1 Metabolic disorders and their respecve cut-o related
to seizures.
Parameter Cut-off points
Sodium Hyponatremia<115 mmol/L
Calcium Hypocalcemia<5 mg/dL
Magnesium Hypomagnesemia<0.8 mg/dL
Glucose Hypoglycemia<36 mg/dL
Hyperglycemia ≥ 400-450 mg/dL
Medicaons
Around 6% of rst-me seizures are produced by
pharmacological toxicity [32]. There are more than 250 drugs
related to seizures with an adverse eect [33]. This associaon
can occur either in their therapeuc use (very rare, only 0.08%
[34]) and in overdosing [19]. Some drugs with an elevated risk
for seizures are isoniazid, bupropion and venlafaxine [35]. Table
2 lists the most representave drugs [19,35-40].
Table 2 Common medicaons associated with acute
symptomac seizures.
Drug class Representative medications
Antibiotics Beta lactams: penicillins and
cephalosporins
Carbapenems: imipenem-cilastatin,
meropenem and doripenem
Fluoroquinolones
Isoniazid
Antivirals Aciclovir
Metilxantins Theophyline
Antidepressants Tryciclic antidepressants
Selective serotonin reuptake
inhibitors
Bupropion
Venlafaxin
Antipsychotics First generation: chlorpromazine (the
highest risk), molindone, haloperidol,
fluphenazine, pimozide and
trifluoperazine.
Second generation: clozapine
Lithium
Narcotics Meperidine, morphine and
propoxyphene
Antiepileptic drugs Carbamazepine, phenytoin
Anticholinergic drugs Dyphenhydramine
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Sodium channel blockers Lidocaine

Alcohol and toxics
Alcohol abuse is associated from 20% to 40% of paents with
seizures in emergency departments. Although alcohol
absnence is the most common seng, we must consider all the
other possibilies that can produce rst seizures in the paents
[35].
Regarding substances of abuse, the most evident associaons
are absnence from hypnoc-sedave drugs (benzodiazepines
and barbiturates) and intoxicaon by sympathomimecs
(cocaine and amphetamines) [18,35]. Other substances with
uncommon associaon are heroin, mescaline, psilocybin,
psilocin and synthec ergotamine derivaves of diethylamide D-
lysergic acid (LSD) [18].
Others
The seizures associated with Posterior Reversible
Encephalopathy Syndrome (PRES) and eclampsia are considered
within this group [18,19].
About the eology of unprovoked seizures, the most recent
ILAE´s classicaon suggests the following categories: genec,
structural, infecous, metabolic, immune and unknown (Table 3)
[41].
Table 3 Main eologies of unprovoked seizures and epilepsy.
Etiology Representative clinical conditions
Structural Stroke, TBI, tumors, infection.
Genetic Juvenil Myoclonic Epilepsy.
Infectious Neurocysticercosis, tuberculosis, HIV, cerebral toxoplasmosis,
cerebral malaria, postinfectious epilepsy.
Metabolic Porphyria, aminoacidopathies or pyridoxine-dependent seizures.
Immune Autoimmune encephalitis.
Unknown Frontal lobe epilepsy.
It is the most common cause of epilepsy in Mexican adults
[42].
Some common eologies should be considered according to
the age group of the paent [18]:
15-34 years: traumac brain injury, medicaons, alcohol-
toxics and eclampsia.
35-64 years: brain tumors: primary-more frequent in low-
grade tumors-or metastac tumors [43,44]
65 years: cerebrovascular diseases are the main eology
(overall 50%) followed by traumac brain injury and brain
tumors [38,45].
Some large series found as main causes of seizures in
emergency departments the consumpon of alcohol or toxics
(19%), TBI (7.8%-16%), cerebrovascular diseases (16%) and
infecons (15%) [29,46]. The contribuon of epilepsy in one of
these studies was 6.8% and up to 41% of the seizures were
classied as unknown [29]. In approximately 45% of paents
with rst-me seizures in emergency departments no cause is
idened, and they are produced in <10% by toxic-metabolic
eologies [47].
Clinical Features
Spectrum of clinical presentaon depends of the underlying
neuroanatomy, and can range from a focal motor crisis without
altered awareness to generalized tonic-clonic seizures leading to
a convulsive status epilepcus [14,48].
The predominant one is as generalized seizures (86%) [29].
Most of eologies of acute symptomac seizures (especially
toxic-metabolic causes) produce generalized tonic-clonic
seizures [16].
For epidemiological purposes, mulple seizures within 24
hours (seizure clusters) and rst status epilepcus are
considered as a rst epilepc seizure since in themselves these
events do not establish the diagnosis of epilepsy [9,17,49]. A
study found no dierence in the rate of recurrence between
paents who experienced seizure clusters versus paents with a
single seizure, regardless of eology or treatment [50].
Diagnosc Approach
We suggest a systemac approach based on the following
sequence [51,52]:
Dene if the paent's event really corresponds to an epilepc
seizure.
Establish the eology and classify the event: provoked versus
unprovoked seizure.
Idenfy if the event is about the rst seizure or there have
been previous events.
Complementary studies (laboratory, brain imaging, and
electroencephalogram).
Categorize-if possible - the type of epilepc seizure, epilepsy,
and/or epilepc syndrome.
Esmate the risk of seizure recurrence.
Dene the need for treatment with Anepilepc Drugs (AED).
History and physical examinaon
The inial clinical assessment should include a complete
clinical history with emphasis on the family history as well as a
physical examinaon directed towards the evaluaon of vital
signs, look for any neurological decit, and the search of
potenal acute eologies of the episode.
Diagnosis of epilepc seizures and epilepsy are eminently
clinical, thus it is essenal perform an adequate semiology of
the event, so the descripon of the episode by the paent (if
possible) or by a visual witness is of utmost relevance [48,53].
Also, it is recommended an early evaluaon by the neurologist
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when this enty is suspected or if there is doubt about the
diagnosis [9,51,54].
The rst step is to determine if we are facing a rst epilepc
seizure or corresponds to another spell, because an inadequate
diagnosis is made between 16%-42% of the cases [55]. Syncope
and Psychogenic Non-Epilepc Seizures (PNES) are the main
dierenal diagnoses [11,51,54,55]. In the Table 4 are showed
the main dierenal diagnoses of seizures in clinical pracce
[47,54].
Table 4 Most important seizures mimickers in clinical pracce.
Non-neurologic differential
diagnosis
Neurologic differential diagnosis
Syncope
Delirium
Metabolic encephalopathies
Cerebrovascular disorder – Transient
Ischemic Attacks (TIAs)
Episodic movement disorders
Migraine
Sleep disorders: cataplexy,
parasomnia, REM behavior disorder,
periodic limb movements during
sleep.
Psychogenic Non-Epileptic Seizures
(PNES)
Vestibulopathy
Transient global amnesia
Panic attacks
Some clinical features that suggest that the event is an
epilepc seizure are posctal confusion, cyanosis, lateral tongue
bing, preceding déjà vu or jamais vu, conrmed
unresponsiveness, head or gaze turning to one side, and the
presence of limb rhythmic shaking or tonic posturing [9].
Syncope: It is a more frequent situaon in the general
populaon, especially the vasovagal. This diagnosis is supported
by the presence of a situaonal factor and prodromal symptoms
such as blurred vision, sweang, dizziness, nausea, dyspnea or
palpitaons and paleness. There may be associated myoclonic
movements and even generalized tonic-clonic seizures during
the episode due to cerebral hypoxia when the paents cannot
adopt the supine posion [9,48].
Psychogenic Non-Epilepc Seizures (PNES): These spells are
characterized by behaviors closely resembling seizures with a
psychiatric background, but they do not have the clinical and
electrographic ndings present during an epilepc seizure. They
are frequent, accounng for up to 12%-18% of paroxysmal
events with transient loss of awareness and 30% to 50% of
paents admied to electroencephalographic monitoring units
[9,48]. Some features that suggest this enty are prolonged
duraon of apparent loss of awareness with normal colour
and/or oxygen saturaon on room air, uctuang motor acvity,
asynchronous movements with non-anatomical disseminaon,
side-to-side head or body movements, pelvic thrusng, ictal
crying, presence of closed eyes during the event with resistance
to its opening, and a rapid posctal recovery [9,48,54].
About the second point of the approach sequence, we must
rule out a provoked seizure in all paents who have experienced
a rst-me seizure, and only aer that, we can label the seizure
as unprovoked [14,15].
Regarding the third point of the sequence, it is reported that
between 7% to 50% of the paents who present for evaluaon
of a rst seizure have experienced previous seizures, and that
these ones are absences, focal or myoclonic seizures generally
[11,51]. This fact is essenal because it determines if the paent
meets diagnosc criteria for epilepsy, which has a dierent
treatment and prognosis than a single rst seizure.
General laboratory studies (blood cytometry,
glucose, serum electrolytes)
From 0% to 15% of the paents present alteraons in these
studies, but they have clinical signicance rarely (<5%) [55,56].
Thus, they should be requested in an individualized way without
use them rounely [5-57]. However, we suggest assessing serum
glucose as well as serum electrolytes (sodium, calcium and
magnesium) in every paent who has experienced a rst
seizure.
Electroencephalography
Electroencephalogram (EEG) must be performed in all
paents who have experienced a rst unprovoked seizure and
shows signicant abnormalies in 29% of these paents [57]. In
addion, it helps to classify the seizure type (epilepc vs. non-
epilepc, focal vs. generalized), to idenfy the seizure focus
involved, and to characterize the seizure subtype. Therefore,
EEG have implicaon to dene the risk of recurrence and the
treatment which could be employed in each paent
[48,55,57,58].
The sensivity of a single roune record for epilepform
discharges is ≤ 50% in paents with epilepsy [48]. However, the
diagnosc yield can increase by performing 3 or more serial
records (up to 80%-90%), performing records within rst 24
hours aer the epilepc seizure, and with smulaon
maneuvers such as hypervenlaon, photosmulaon and sleep
deprivaon (up to 80%) [9,48,57]. Some paroxysmal discharges
with high epileptogenic potenal (>90%) are the anterior
temporal lobe spikes, vertex spikes, generalized paroxysmal fast
acvity, generalized slow spike and wave and hypsarrhythmia
[48]. Probability of seizure recurrence is esmated around 77%
when there are epilepform discharges [59].
Recent studies of paents who had experienced rst-me
unprovoked seizures in emergency departments found a higher
diagnosc yield if the EEG was performed before their discharge
(24% and 29.4% of them had abnormal records), which was
relevant for starng AED treatment as well as the epilepsy
diagnosis [60,61]. A study 24 hours video-
electroencephalography was performed within the rst 7 days in
paents who had rst unprovoked seizures; epilepform
abnormalies were found in nearly 42% of them and were a risk
factor for seizure recurrence (R.R. 2.25, C.I. 95% 1.30-3.92) [62].
Among its main limitaons are that it does not exclude the
diagnosis of epilepsy, the lack of it availability in emergency
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2019
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departments, its cost and the misinterpretaons of the records
[48,55].
Brain imaging
A neuroimaging study (CT or MRI) must be performed in all
paents with unprovoked rst-me seizures [57].
Cranial Tomography (CT) scan shows signicant alteraons in
approximately 10% of paents with this condion [57]. It is
considered the rst line imaging modality due to its wide
availability in emergency departments and allows a faster
diagnosc evaluaon in paents who present an acute
neurological decit; especially, to exclude vascular eologies or
any situaon that warrants neurosurgical treatment. Hence, CT
scan must perform in every paent who has experienced a rst
seizure [9,47,51,63].
Magnec Resonance Imaging (MRI) is warranted in all
paents with a rst unprovoked seizure; unless, they have
contraindicaons for its realizaon [48,57].
MRI is more sensive than CT scan because allows a greater
idencaon of signicant lesions such as intraparenchymal
hemorrhages, brain tumors, vascular malformaons,
posraumac changes, mesial temporal sclerosis, and
malformaons of corcal development [48].
Studies in this seng have reported that close to 30% of the
paents was found a potenally epileptogenic alteraon
[63,64], and of these paents about 12% had some specic
pathological nding in presence of a normal CT [63]. The
diagnosc yield of MRI is higher in paents with a rst focal or
provoked seizure (around 50%), and performing an epilepsy
protocol-specic brain MRI [65,66].
Lumbar puncture
This procedure should be considered in paents with clinical
suspicion of CNS infecon, subarachnoid hemorrhage as well as
in those with persistent impairment in mental status or are
immunocompromised (even if they are afebrile) [47,67].
Some abnormalies in the cerebrospinal uid of paents who
experienced a rst unprovoked seizure are hyperproteinorrachia
(30%) followed by pleocytosis (10% of the cases, mean of 10.2
cells/mm3). They are probably due to a transient disrupon of
the blood-brain barrier aer the seizure [68].
Other tests
Toxicological prole, prolacn levels, electrocardiogram and
pregnancy test.
Toxicological prole may be performed in selected cases
where there is high clinical suspicion as in paents who have a
toxindrome, known consumpon of substances or altered
mental status on examinaon. Nonetheless, there is not enough
evidence to perform it rounely [56-58].
Prolacn levels have been measured above their normal value
in paents who experienced an epilepc seizure and have been
used to discriminate between seizures with altered awareness
from Psychogenic Non-Epilepc Seizures (PNES). The above is
applicable if there is a baseline determinaon of them (6 hours
prior to the event), and these ones are compared against a new
determinaon performed 10-20 minutes aer the episode,
which is complicated to implement in clinical pracce. Besides,
they cannot disnguish seizures from syncope because in both
situaons they can be elevated [69].
Other studies which should be performed in all paents in this
seng are 12-lead electrocardiogram and pregnancy test in
childbearing age women. The rst one to look for any cardiac
disturbance related to syncope, and the second one due to the
associaon with eclampsia and pregnancy itself with epilepsy
[9,51].
Depending on the context of each paent, it may be
considered to request a test for detecon of Human
Immunodeciency Virus (HIV), Holter study, echocardiogram,
etc. [51,70].
Summary of tests which we must perform in adult paents
who have experienced a rst seizure are shown in the Figure 1.
Figure 1 Emergency tests to perform in all paents who have
experienced a rst seizure. 1. It is preferred by a greater
speed and availability in E.D. 2. Perform epilepsy-protocol
specic MRI if it is available.
Risk of Seizure Recurrence
Acute symptomac seizures
Paents with seizures resulng from acute brain insults
(severe closed injury, acute hemorrhagic and ischemic stroke,
brain surgery and CNS infecons in acve phase) have a lower
recurrence rate (risk of seizure recurrence from 10% to 20%)
compared to those with remote symptomac seizures [14,17].
A study found that the risk of recurrence for a second seizure
in paents who were diagnosed with stroke, TBI and CNS
infecons was signicantly greater only for remote symptomac
seizures when these ones were compared against acute
symptomac seizures in the same seng; demonstrang that,
in general, remote symptomac seizures had a risk of recurrence
greater than 60% [71].
Unprovoked seizures
Global risk of recurrence for a second seizure aer a rst
unprovoked seizure is by 21%-45% within the rst two years
[72], and is parcularly higher in the rst 6 months (60%-70% of
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2019
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recurrences) [51,73]. The likelihood of recurrence aer the
second seizure increases to 57% at 1 year, and 73% at 4 years;
besides, it is associated with a proporonal increase in the
frequency of episodes as well as a concomitant reducon in the
free interval between subsequent seizures [74].
Paents at increased risk for seizure recurrence aer a rst
unprovoked seizure according the American Academy of
Neurology (AAN) Guideline Analysis are the following [72]:
Paents with prior brain lesion or insult (remote
symptomac). This group includes the seizures arising from
stroke, traumac brain injury, CNS infecons, cerebral palsy and
cognive developmental disability (Level A of evidence).
EEG with epilepform abnormalies (Level A of evidence)
Signicant brain-imaging abnormality (Level B of evidence).
Nocturnal seizure (Level B of evidence).
Although there is no precise formula to esmate the risk of
seizure recurrence in each paent, according to the model
paents with history of an abnormal neurological status plus an
abnormal electroencephalogram have a risk of recurrence
greater than 60% at 3 and 5 years [75]. However, this tool have
several limitaons such as it does not consider the brain
imaging, and it has not been validated in other studies
[17,72,75].
Treatment with anepilepc drugs
The evidence regarding pharmacological treatment in this
clinical enty and the ILAE´s denion of epilepsy involves only
unprovoked seizures. Thus, the treatment of provoked seizures
corresponds to the specic of each underlying condion, and
the use of anepilepc drugs is to prevent further acute
symptomac seizures [15,18].
Starng anepilepc drug therapy in paents who have
experienced a rst unprovoked seizure reduces the risk for a
second seizure by about 35% within the subsequent 2 years
[72]; however, it has no impact on long-term recurrence (≥3
years aer the rst episode) and has not demonstrated any
improvement in paents' quality of life [72,76]. In addion,
pharmacological treatment can produce adverse eects
(7%-31% of cases), although these ones are generally mild and
reversible [72].
The evidence about ecacy of AED in the reducon of seizure
recurrence arises from several randomized trials, but the main
ones are: The First Seizure Trial Group study (FIR.ST) [77] and the
European Mulcenter Epilepsy and Single Seizure Study (MESS)
[78]. In both trials it was found that the risk of seizure
recurrence at 2 years was 50% less in the group of paents who
had immediate AED therapy (adjusted relave risk=0.5; CI
95%=0.3-0.6), but there was no impact on long-term remission
rate of these paents [52,77,78].
The only controlled, randomized and double blind trial from a
study found a dierence close to 52% between the group of
paents who were treated with valproic acid aer a rst
unprovoked seizure vs. the untreated group (4.3% in the treated
group vs. 55.7% in the placebo group); nevertheless, it did not
assess the clinical remission [79]. Others two smaller trials found
dierences of seizure recurrence by 34% and 49% between
paents who were treated with AEDs and untreated paents
aer a single unprovoked seizure [80,81]. A meta-analysis of six
studies in this seng showed an absolute risk reducon for
seizure recurrence by 34% (CI 95%=15%-52%) [56].
Some important factors to consider prior to begin AED
therapy are the following [14,15,17]:
Eology and risk of seizure recurrence.
Seizure and epilepsy type.
Paent´s age.
Paent´s comorbidies: pregnancy, kidney or hepac failure,
etc.
Pharmacological properes of AED: pharmacokinec and
pharmacodynamic features, pharmacological interacons,
individual tolerance, side eects, cost, and availability.
Inpaent vs. outpaent treatment. Some indicaons for
hospital admission are shown in the Figure 2.
Figure 2 Indicaons for hospital admission.
Therefore, the decision about starng anepilepc drug
therapy must be individualized and should be always made in
conjuncon with paents [72,82]. We need to consider specic
medical, social and employ features of each paent; although,
the nal decision corresponds to the specialist in this eld
(neurologist, epileptologist) [9,17,55,58,71]. In the Table 5 we
provide a guide about the specic drugs to use according the
seizure type in adults and in older paents (>60 years)
[14,58,83].
Table 5 Preferred anepilepc drugs according to the type of
seizure.
Seizure type First line antiepileptic drugs
Generalized tonic-clonic Carbamazepine
Lamotrigine
Oxcarbazepine
Sodium valproate
Levetiracetam
Topiramate
Focal Carbamazepine
Levetiracetam
Oxcarbazepine
Sodium valproate
Phenytoin
Zonisamide
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Abscenses Euthosuximide
Sodium valproate
Lamotrigine
Myoclonic Levetiracetam
Sodium valproate
Topiramate
Focal seizures in older
patients
Lamotrigine
Gabapentine
Levetiracetam
Length of therapy
Around 70% of paents with new-onset epilepsy enter
prolonged seizure remission during treatment with AED [84-86].
In paents with epilepsy, the factors associated with
successful remission aer starng AED therapy are a seizure free
interval for more than 2 years and a normal neurological
examinaon [87]. On the other hand, risk factors related to
seizure recurrence aer withdrawal are age ≥ 16 years, need for
more than one AED, seizures during AED therapy, history of
generalized tonic-clonic or myoclonic seizures, and an abnormal
EEG in prior year [88].
The largest trial about withdrawal of AEDs in paents with
epilepsy who had been seizure-free for at least 2 years showed
that 59% of them remained seizure-free at 2 years aer weaning
the medicaons. Also, it found that AED disconnuaon doubles
the risk of seizures for up to 2 years aer stopping AED
compared to connued treatment [89].
Consequently, it is recommended consider withdrawal AED
therapy in those paents who have been seizure-free for at least
2 years and without high individual risk of seizure recurrence
[90].
Paents with provoked seizures due to their low risk for
developing epilepsy, the prophylaxis could be limited to 7 days
(e.g. metabolic disorders), and from 1 to 6 months in paents
with an acute brain insult [14].
Follow Up and Prognosis
It is suggested to perform a second evaluaon by a
neurologist within the rst 4 weeks aer the event in paents
who experienced a rst unprovoked seizure and those with
suspected epilepsy, to complete the diagnosc tests
(electroencephalogram and magnec resonance imaging) as
well as to dene the need of AED therapy [91].
The use of specialized clinics in the evaluaon of paents with
rst-me seizures allows a faster implementaon of their study
protocol and a faster diagnosis, with approximately 40% of
paents evaluated in these centres meeng diagnosc criteria
for epilepsy [92].
Some general recommendaons for these paents are avoid
the known precipitants of the seizures (if any) as well as the
consumpon of alcohol and other drugs which reduce the
epilepc threshold, consider driving accompanied because them
have increased risk of trac accidents (up to 40% more), and
avoiding high risk acvies (water sports, heavy machinery use,
etc.,) for at least 3-6 months with even larger periods for
paents who have experienced unprovoked seizures [9,51,93].
Standardized Mortality Rao (SMR) aer a rst unprovoked
seizure is 2.3, which is within the reported SMR by 2 to 4 for
paents with epilepsy [10,94,95]. Mortality of symptomac
seizures is high, ranging from 10% to 40%; however, it is dicult
to disnguish between seizure-related deaths from deaths
aributable to the underlying eology [36].
Discussion
First seizures in adult paents are clinical signicant events
which require a systemac- muldisciplinary approach to
idenfy those paents with a potenal acute eology, and
separate them from those with unprovoked seizures and new
onset epilepsy. The randomized trials and meta-analysis have
found that the anepilepc drugs do not reduce the risk for a
second unprovoked seizure beyond the rst two years since the
rst event; however, a seizure can be a terrifying event with
medical and social consequences. Thus, the decision about
starng pharmacological therapy should be individualized based
in several factors menoned previously.
This review summarizes the most recent scienc evidence in
this eld, and provides a praccal framework for a suitable
classicaon, diagnosis, and treatment of these paents as well
as some elements to consider in the paent counselling aer a
rst seizure.
There are several areas of uncertainty in this topic that are
potenal elds for future research. For example; some experts
have quesoned when a rst unprovoked seizure is epilepsy;
although, most of experts consider with the diagnosis of
epilepsy those paents who have epilepform abnormalies on
EEG or a signicant eology in MRI. A prospecve study by Lawn
et al. reported that aer the rst seizure, a freedom seizure
interval of 12 weeks reduced the inial risk of seizure recurrence
of those paents (all of them had a basal risk of recurrence
greater than 60% at 10 years); in other words, that the risk of
seizure recurrence was me-dependent [96].
Also, the length of therapy in paents who have experienced
a single seizure is uncertain because the available evidence
concerning weaning AEDs arises from paents with epilepsy.
Besides, it is necessary assess the eecveness and the
frequency of side eects of the new anepilepc drugs because
most of trials in this seng used older AEDs. Likewise, the
eects at the epidemiological level regarding the diagnosis of
epilepsy as well as the socioeconomic, legal and emoonal
consequences in paents receiving anepilepc drug therapy
are unknown [55,71].
Finally, it is important to evaluate the performance of the rst
seizure centres in other populaons, and meet the challenges
that they are facing in the management of these paents such
as poor diagnosc accuracy of the referring doctors, under-
detecon of previous seizures, inadequate classicaon of
seizures and low yield of invesgaons [97].
Medical & Clinical Reviews
ISSN 2471-299X Vol.5 No.2:3
2019
© Under License of Creave Commons Aribuon 3.0 License 7

Conclusions
First seizures in adults are common in clinical pracce. A
systemac approach will help clinicians to classify the paents
appropriately between those with provoked seizures and
unprovoked seizures as well as those who meet diagnosc
criteria for new-onset epilepsy, because the management and
prognosis of each condion is very dierent. We must rule out a
provoked seizure in all paents who have experienced a rst
seizure because they have a higher mortality and their
treatment is dened by the underlying eology. Paents who
have experienced unprovoked seizures need to perform an EEG
and a brain MRI to esmate the risk of seizure recurrence.
Anepilepc drug therapy must be individualized, without
forgeng that only impacts in the early seizure recurrence (rst
2 years) and may produce side eects. Every paent needs a
ght follow-up, especially those who have experienced a rst
unprovoked seizure to complete their study protocol and to
dene the need of anepilepc drug therapy.
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Medical & Clinical Reviews
ISSN 2471-299X Vol.5 No.2:3
2019
10 This article is available from: http://medical-clinical-reviews.imedpub.com