00:01
So how do we evaluate
the first time seizure?
Starts with a history and we
need a good seizure semiology
to understand the
type of seizure,
we look at the patient's prior
history and family history.
00:13
Following a history and
physical examination
will conduct laboratory evaluation
just like any other patient.
00:18
Neuroimaging is key,
and nearly all patients who were
evaluating for seizures will undergo
an EEG or
electroencephalography.
00:27
The goal of evaluating
a first time seizure
is to figure out the
risk of a second seizure.
00:33
So William Gowers,
one of the famous neurologist said,
seizures beget seizures,
and he's right,
the more seizure
a patient suffer,
the more likely they are to
suffer long term seizures.
00:43
So we want to reduce the
risk of a second seizure.
00:47
And the tests we do on physical
examination in history,
as well as the diagnostic
investigations with imaging and EG
are really to differentiate the patient's
risk of developing a second seizure.
00:58
In general,
the risk of recurrent seizure
after a first unprovoked
seizure is 40%.
01:04
40% of patients will have a
second seizure, which is low,
and this is why we don't
treat all first time seizures.
01:11
The risk of a recurrent seizure
after a second unprovoked seizure
is upwards of 75%.
01:18
If you've had two seizures,
the likelihood of having a third is 75%.
01:22
If you've had three,
that number is more than 80 or 90%.
01:25
And so we treat after
the second seizure.
01:28
The goal of evaluation is to
stratify the risk of recurrence.
01:32
Is this patient with a first time seizure
likely to suffer a second time seizure.
01:37
If that risk is greater than
50%, we may treat.
01:40
If it's less than 50%, as with the
standard, healthy adult, we would not.
01:45
And the goal of treatment is to
prevent and manage recurrent events,
prevent the risk
of future seizures.
01:53
So let's talk through the
history and examination
and understand what we do to
evaluate the first time seizure.
01:58
On history,
we're looking at the aura,
the pre-ictal process,
vocal motor,
respiratory and autonomic signs
that may point us to
the seizure semiology,
we look for precipitants,
particularly if they're treatable
electrolyte abnormalities,
fever and infectious
symptoms or new medications.
02:16
We ask about and look
for ictal automatisms,
common automatisms these
are automatic behaviors
that occur during the
seizure and can tip us off
to whether other seizures
may have occurred
are chewing, swallowing,
eating, gestures, ambulation and
mimicry all of those we can see.
02:33
There are also some automatisms that
are associated with absence seizures
and may include scratching
or fumbling with clothes
or lingual movements and other
complex motor activities.
02:45
On examination, we're looking for
neurologic deficits or focal abnormalities
that indicate the
location of the seizure,
the lateralization
of the seizure
or potential co-occurring phenomenon,
a stroke in addition to seizure.
02:58
When we ask about and
look at ictal symptoms,
we're trying to figure out,
what is the lateralization?
What's the side of the
brain that's affected,
that helps us to
approach imaging
and for patients
that fail medications
and we're considering surgery will
point us to the side to consider.
03:13
We're also looking for things
that will help us to localize.
03:16
This is more advanced
in lateralization,
not just which side of the brain
is the seizure coming from,
but what's the precise focus?
Can we get it into a
specific lobe of the brain?
Can we hone in even
further on a specific area
or cortex area of
cortex of the brain?
And some of the clinical descriptions
can help hone us in on those.
03:37
Head turning which is
called head version
can be a helpful lateralizing
and localizing sign.
03:43
Early non-forced head version
is typically seen from an
ipsilateral temporal origin,
forced early head version from
ipsilateral frontal origin,
late forced head versions so
that's a head moving to one side,
late in the seizure is seen with
contralateral frontal or temporal origin.
04:00
And you can see a number
of other findings,
ocular version that's moving
of the eyes to one side,
focal clonic activity
or dystonic limb,
unilateral tonic limb,
a M2e to sign which
is a fencing posture
can be seen with frontal,
contralateral frontal seizure origin,
a figure 4 shape of the hands
can be seen again with contralateral
hemisphere seizure onset.
04:24
Ictal paresis is seen in the
contralateral motor cortex.
04:29
Todd's paralysis is common after focal
onset seizures involving the motor cortex
and points us in the direction of
the contralateral motor cortex.
04:37
Unilateral blinking,
unilateral limb automatisms
from the ipsilateral hemisphere.
04:43
Postictal nose rubbing
is a localizing finding,
localizing to the
ipsilateral temporal lobe
postictal cough,
bipedal abnormalities,
hypermotor activity,
ictal spitting can be
lateralizing to the right side,
as well as the automatism
with reserved responsiveness
in the right temporal lobe.
05:04
So we use these features to
figure out which side of the brain
and which location in the brain
the seizures may be coming from,
which can help us in orienteering
evaluation and subsequently treatment.
05:15
And I've included here some other
localizing collateralizing sign,
gelastic seizures with laugh can be
seen in hypothalamic areas of onset.
05:25
And you can see here it
does urge and speech arrest
and post ictal aphasia.
05:31
So if that's how
the seizure begins,
we also want to interrogate
what happens during the event,
the semiology of the event,
and we think about other signs
that can help us to understand
where the seizure may be
coming from during the event.
05:43
Ictal vomiting and the insular cortex
paraesthesia from the sensory cortex,
clonic or tonic clonic activity
involving the motor cortex.
05:51
Dystonic posturing points
to a frontal lobe seizure,
60% of auras involve
sensory symptoms,
the parietal cortex
is commonly affected.
06:00
89% of patients with frontal lobe
epilepsy will have dystonic posturing,
sometimes with retained
awareness out of sleep
which can be quite jarring to
patients and or other caregivers.
06:12
And then early head
version we said localizes
and late of the head
version lateralized.
06:18
A fencing posturing can
be seen from seizures
originated in the
supplementary motor area.
06:23
Again, early head version
is ipsilateral origin,
late head version is from
a contralateral origin.
06:29
And pain can be seen from a
contralateral sensory cortex seizure.
06:35
Olfactory symptoms or
automatisms, or olfactory smells
can be seen with seizures originating
from the orbital frontal cortex.
06:42
Ictal spit, piloerection
localized to the temporal lobe,
lateral temporal lobe, we can see Deja
vu early in the seizure as the aura
and with medial temporal lobe,
abdominal fear a rising sense
of nausea patients can describe.