Evaluation of a first seizure

Seizure is a common presentation in the emergency care setting, and new-onset epilepsy is the most common cause of unprovoked seizures. The patient history and physical examination should direct the type and timing of laboratory and imaging studies. No single sign, symptom, or test dearly differentiates a seizure from a nonseizure event (e.g., syncope, pseudoseizure). Electroencephalography is recommended for patients presenting with a first seizure, and neuroimaging is recommended for adults. Neuroimaging also should be performed in children with risk factors such as head trauma, focal neurologic deficits, or a history of malignancy. Magnetic resonance imaging is preferred over computed tomography except when acute intracranial bleeding is suspected. The most common laboratory findings associated with a seizure are abnormal sodium and glucose levels. Patients with a normal neurologic examination, normal test results, and no structural brain disease do not require hospitalization or antiepileptic medications. Treatment with antiepileptic medications reduces the one- to two-year risk of recurrent seizures but does not reduce the long-term risk of recurrence and does not affect remission rates. Regardless of etiology, a seizure diagnosis severely limits a patient's driving privileges, although laws vary by state.