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AAN Special Article
November 19, 2007

Practice Parameter: Evaluating an apparent unprovoked first seizure in adults (an evidence-based review): [RETIRED]
Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society

November 20, 2007 issue
69 (21) 1996-2007

Abstract

Objective: The Quality Standards Subcommittee of the American Academy of Neurology develops practice parameters as strategies for patient care based on analysis of evidence. For this practice parameter the authors reviewed available evidence relevant to evaluating adults presenting with an apparent unprovoked first seizure.
Methods: Relevant questions were defined and addressed by multiple searches of medical literature. Each article was then reviewed, abstracted, and classified using an established evidence scoring system. Conclusions and recommendations were based on a standard three-tiered scheme of evidence classification.
Results: For adults presenting with a first seizure, a routine EEG revealed epileptiform abnormalities in approximately 23% of patients, and these were predictive of seizure recurrence. A brain imaging study (CT or MRI) was significantly abnormal in 10% of patients, indicating a possible seizure etiology. Laboratory tests such as blood counts, blood glucose, and electrolyte panels were abnormal in up to 15% of individuals, but abnormalities were minor and did not cause the seizure. Overt clinical signs of infection such as fever typically predicted significant CSF abnormalities on lumbar puncture. Toxicology screening studies were limited, but report some positive tests.
Recommendations: EEG should be considered as part of the routine neurodiagnostic evaluation of adults presenting with an apparent unprovoked first seizure (Level B). Brain imaging with CT or MRI should be considered as part of the routine neurodiagnostic evaluation of adults presenting with an apparent unprovoked first seizure (Level B). Laboratory tests, such as blood counts, blood glucose, and electrolyte panels (particularly sodium), lumbar puncture, and toxicology screening may be helpful as determined by the specific clinical circumstances based on the history, physical, and neurologic examination, but there are insufficient data to support or refute recommending any of these tests for the routine evaluation of adults presenting with an apparent first unprovoked seizure (Level U).

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Published In

Neurology®
Volume 69Number 21November 20, 2007
Pages: 1996-2007
PubMed: 18025394

Publication History

Published online: November 19, 2007
Published in print: November 20, 2007

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Authors

Affiliations & Disclosures

A. Krumholz, MD
From the University of Maryland School of Medicine (A.K., T.T., J.H.), Baltimore; University of Calgary Foothills Medical Centre (S.W.), Calgary, Alberta, Canada; University of Kansas Medical Center (G.G.), Kansas City, KS; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Children's Hospital (P.L.), Denver, CO; Beth Israel Deaconess Medical Center (P.S.), Boston, MA; Fletcher Allen Health Care/University of Vermont College of Medicine (H.M.), Burlington; Peachtree Neurological Clinic (L.S.), Atlanta, GA; Henry Ford Medical Hospital (G.B.), Detroit, MI; and Department of Neurology (J.F.), New York University School of Medicine, New York.
S. Wiebe, MD
From the University of Maryland School of Medicine (A.K., T.T., J.H.), Baltimore; University of Calgary Foothills Medical Centre (S.W.), Calgary, Alberta, Canada; University of Kansas Medical Center (G.G.), Kansas City, KS; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Children's Hospital (P.L.), Denver, CO; Beth Israel Deaconess Medical Center (P.S.), Boston, MA; Fletcher Allen Health Care/University of Vermont College of Medicine (H.M.), Burlington; Peachtree Neurological Clinic (L.S.), Atlanta, GA; Henry Ford Medical Hospital (G.B.), Detroit, MI; and Department of Neurology (J.F.), New York University School of Medicine, New York.
G. Gronseth, MD
From the University of Maryland School of Medicine (A.K., T.T., J.H.), Baltimore; University of Calgary Foothills Medical Centre (S.W.), Calgary, Alberta, Canada; University of Kansas Medical Center (G.G.), Kansas City, KS; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Children's Hospital (P.L.), Denver, CO; Beth Israel Deaconess Medical Center (P.S.), Boston, MA; Fletcher Allen Health Care/University of Vermont College of Medicine (H.M.), Burlington; Peachtree Neurological Clinic (L.S.), Atlanta, GA; Henry Ford Medical Hospital (G.B.), Detroit, MI; and Department of Neurology (J.F.), New York University School of Medicine, New York.
S. Shinnar, MD, PhD
From the University of Maryland School of Medicine (A.K., T.T., J.H.), Baltimore; University of Calgary Foothills Medical Centre (S.W.), Calgary, Alberta, Canada; University of Kansas Medical Center (G.G.), Kansas City, KS; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Children's Hospital (P.L.), Denver, CO; Beth Israel Deaconess Medical Center (P.S.), Boston, MA; Fletcher Allen Health Care/University of Vermont College of Medicine (H.M.), Burlington; Peachtree Neurological Clinic (L.S.), Atlanta, GA; Henry Ford Medical Hospital (G.B.), Detroit, MI; and Department of Neurology (J.F.), New York University School of Medicine, New York.
P. Levisohn, MD
From the University of Maryland School of Medicine (A.K., T.T., J.H.), Baltimore; University of Calgary Foothills Medical Centre (S.W.), Calgary, Alberta, Canada; University of Kansas Medical Center (G.G.), Kansas City, KS; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Children's Hospital (P.L.), Denver, CO; Beth Israel Deaconess Medical Center (P.S.), Boston, MA; Fletcher Allen Health Care/University of Vermont College of Medicine (H.M.), Burlington; Peachtree Neurological Clinic (L.S.), Atlanta, GA; Henry Ford Medical Hospital (G.B.), Detroit, MI; and Department of Neurology (J.F.), New York University School of Medicine, New York.
T. Ting, MD
From the University of Maryland School of Medicine (A.K., T.T., J.H.), Baltimore; University of Calgary Foothills Medical Centre (S.W.), Calgary, Alberta, Canada; University of Kansas Medical Center (G.G.), Kansas City, KS; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Children's Hospital (P.L.), Denver, CO; Beth Israel Deaconess Medical Center (P.S.), Boston, MA; Fletcher Allen Health Care/University of Vermont College of Medicine (H.M.), Burlington; Peachtree Neurological Clinic (L.S.), Atlanta, GA; Henry Ford Medical Hospital (G.B.), Detroit, MI; and Department of Neurology (J.F.), New York University School of Medicine, New York.
J. Hopp, MD
From the University of Maryland School of Medicine (A.K., T.T., J.H.), Baltimore; University of Calgary Foothills Medical Centre (S.W.), Calgary, Alberta, Canada; University of Kansas Medical Center (G.G.), Kansas City, KS; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Children's Hospital (P.L.), Denver, CO; Beth Israel Deaconess Medical Center (P.S.), Boston, MA; Fletcher Allen Health Care/University of Vermont College of Medicine (H.M.), Burlington; Peachtree Neurological Clinic (L.S.), Atlanta, GA; Henry Ford Medical Hospital (G.B.), Detroit, MI; and Department of Neurology (J.F.), New York University School of Medicine, New York.
P. Shafer, RN
From the University of Maryland School of Medicine (A.K., T.T., J.H.), Baltimore; University of Calgary Foothills Medical Centre (S.W.), Calgary, Alberta, Canada; University of Kansas Medical Center (G.G.), Kansas City, KS; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Children's Hospital (P.L.), Denver, CO; Beth Israel Deaconess Medical Center (P.S.), Boston, MA; Fletcher Allen Health Care/University of Vermont College of Medicine (H.M.), Burlington; Peachtree Neurological Clinic (L.S.), Atlanta, GA; Henry Ford Medical Hospital (G.B.), Detroit, MI; and Department of Neurology (J.F.), New York University School of Medicine, New York.
H. Morris, MD
From the University of Maryland School of Medicine (A.K., T.T., J.H.), Baltimore; University of Calgary Foothills Medical Centre (S.W.), Calgary, Alberta, Canada; University of Kansas Medical Center (G.G.), Kansas City, KS; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Children's Hospital (P.L.), Denver, CO; Beth Israel Deaconess Medical Center (P.S.), Boston, MA; Fletcher Allen Health Care/University of Vermont College of Medicine (H.M.), Burlington; Peachtree Neurological Clinic (L.S.), Atlanta, GA; Henry Ford Medical Hospital (G.B.), Detroit, MI; and Department of Neurology (J.F.), New York University School of Medicine, New York.
L. Seiden, MD
From the University of Maryland School of Medicine (A.K., T.T., J.H.), Baltimore; University of Calgary Foothills Medical Centre (S.W.), Calgary, Alberta, Canada; University of Kansas Medical Center (G.G.), Kansas City, KS; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Children's Hospital (P.L.), Denver, CO; Beth Israel Deaconess Medical Center (P.S.), Boston, MA; Fletcher Allen Health Care/University of Vermont College of Medicine (H.M.), Burlington; Peachtree Neurological Clinic (L.S.), Atlanta, GA; Henry Ford Medical Hospital (G.B.), Detroit, MI; and Department of Neurology (J.F.), New York University School of Medicine, New York.
G. Barkley, MD
From the University of Maryland School of Medicine (A.K., T.T., J.H.), Baltimore; University of Calgary Foothills Medical Centre (S.W.), Calgary, Alberta, Canada; University of Kansas Medical Center (G.G.), Kansas City, KS; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Children's Hospital (P.L.), Denver, CO; Beth Israel Deaconess Medical Center (P.S.), Boston, MA; Fletcher Allen Health Care/University of Vermont College of Medicine (H.M.), Burlington; Peachtree Neurological Clinic (L.S.), Atlanta, GA; Henry Ford Medical Hospital (G.B.), Detroit, MI; and Department of Neurology (J.F.), New York University School of Medicine, New York.
J. French, MD
From the University of Maryland School of Medicine (A.K., T.T., J.H.), Baltimore; University of Calgary Foothills Medical Centre (S.W.), Calgary, Alberta, Canada; University of Kansas Medical Center (G.G.), Kansas City, KS; Departments of Neurology and Pediatrics (S.S.), Comprehensive Epilepsy Management Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY; Children's Hospital (P.L.), Denver, CO; Beth Israel Deaconess Medical Center (P.S.), Boston, MA; Fletcher Allen Health Care/University of Vermont College of Medicine (H.M.), Burlington; Peachtree Neurological Clinic (L.S.), Atlanta, GA; Henry Ford Medical Hospital (G.B.), Detroit, MI; and Department of Neurology (J.F.), New York University School of Medicine, New York.

Notes

Address correspondence and reprint requests to the American Academy of Neurology, 1080 Montreal Avenue, St. Paul, MN 55116 [email protected]

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  1. Brivaracetam to Treat Partial Onset Seizures in Adults, Health Psychology Research, 10, 5, (2023).https://doi.org/10.52965/001c.56782
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  5. First seizure management: I can see clearly now?, Neurology Clinical Practice, 5, 5, (368-369), (2023)./doi/10.1212/01.CPJ.0000472924.45066.59
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  6. Computer-assisted analysis of routine electroencephalogram to identify hidden biomarkers of epilepsy: protocol for a systematic review, BMJ Open, 13, 1, (e066932), (2023).https://doi.org/10.1136/bmjopen-2022-066932
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  7. Added value of advanced workup after the first seizure: A 7‐year cohort study, Epilepsia, 64, 12, (3246-3256), (2023).https://doi.org/10.1111/epi.17771
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  8. First unprovoked seizures among soldiers recruited to the Israeli Defense Forces during 10 consecutive years: A population‐based study, Epilepsia, (2023).https://doi.org/10.1111/epi.17750
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  9. Trends in the neurological emergency room, focusing on persons with seizures, European Journal of Neurology, 30, 10, (3008-3015), (2023).https://doi.org/10.1111/ene.15976
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