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.
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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