Neuro report pearls! evaluating a (suspected) first seizure

Massive thanks to Arturo Montano for demystifying the human brain for us today in neuro report. He spoke with us about approach to a (suspected) first life-time seizure
When managing a first life-time seizure, the primary goal is to distinguish a seizure from a non-epileptic seizure. If it is a seizure, it is then crucial to identify any reversible or life threatening systemic causes.
Further categorization of suspected seizures below:
    Screen Shot 2016-07-20 at 7.36.14 PM.png
(i believe in giving attribution for images. I made this one with some articles and things I learned during report =)
Use your history to identify factors that are more likely to put people into one of the 4 above categories. Use the physical exam to identify focal neurologic deficits. We will talk about the management of first time seizures another day.
Some random epilepsy pearls 
  • All people have a seizure threshold. Provoked seizures do not mean someone will have lifetime epilepsy. People with epilepsy have a lower seizure threshold
  • Various things that are more suggestive of seizure
    • 70% of people with severe TBI have post-traumatic epilepsy
    • Tongue laceration is insensitive but very specific for epilepsy. ~96% specific in a metaanalysis.
    • Bowel and bladder incontinence are much less specific.
  • Many, many medications cause seizures. UpToDate has the most exhaustive list I can find. If you are wondering whether your patient’s seizure is med-induced, pull up their too-massive-for-the-blog table here.
Bonus pearl -Pokemon and seizures (for the Pokemon Go crazed)
Photic epilepsy (seizures brought on by flashing lights) is a rare but real type of epilepsy.
  • In 1997, a Pokemon cartoon watched by 7 million Japanese viewers triggered seizures in ~600 children.
  • There are now consensus guidelines in Japan, Great Britain, and the US about limiting the nature and type of flashing lights in TV shows.
Sources:
Brigo F, Nardone R, Dongiovanni LG. Value of tongue biting in the differential diagnosis between epileptic seizures and syncope. Seizure. 2012 Oct;21(8):568-72. Epub 2012 Jul 6.
Takada H, Aso K, Watanabe K, Okumura A, Negoro T, Ishikawa T. Epileptic seizures induced by animated cartoon, “Pocket Monster”. Epilepsia. 1999;40(7):997.
Angus-Leppan H1. First seizure in adults.BMJ. 2014 Apr 15;348:g2470.
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