1) High risk factors for seizure recurrence after a first unprovoked seizure include epileptiform abnormalities on EEG, a remote symptomatic cause identified on clinical history or neuroimaging, and an abnormal neurologic examination with focal findings or mental retardation. 2) AED treatment may be considered for patients with one or more of these high risk factors. While immediate AED treatment can reduce short-term seizure recurrence rates by 30-50%, it has little impact on long-term outcome and individual patient preferences regarding adverse effects should be taken into account. 3) Other potential risk factors with uncertain significance include a history of febrile seizures, family history of epilepsy, and seizures occurring during sleep. Status epilepticus

1. DR Y. SASIKUMAR

2.  An epileptic seizure - A clinical event
presumed to result from an abnormal and
excessive neuronal discharge. The clinical
symptoms are paroxysmal and may include
impaired consciousness and
motor, sensory, autonomic, or psychic events
perceived by the subject or an observer.

3.  Epilepsy - when 2 or more epileptic seizures
occur unprovoked by any immediately
identifiable cause.
The seizures must occur more than 24 hours
apart.
 Symptomatic seizure -A seizure caused by a
previously known or suspected disorder of
the CNS.

4.  An acute symptomatic seizure - Occurs
following a recent acute disorder such as a
metabolic insult, toxic insult, CNS
infection, stroke, brain trauma, cerebral
hemorrhage, medication toxicity, alcohol
withdrawal, or drug withdrawal.
That occurs within 1 week of a insult
 A remote symptomatic seizure -A seizure
that occurs longer than 1 week following a
disorder that is known to increase the risk of
developing epilepsy.
example - traumatic brain injury or stroke.

5.  Provoked or unprovoked seizure .

6. 1. Fever or signs suggestive of infection.
2. Prolonged seizure for more than 5 minutes.
3. Recurrent seizure .. Eg - 2 graand mal
seizure in 24 hrs.
4. Incomplete recovery after a seizure.. Eg-
drowsiness for >2 hrs.
5. Persistent post-ictall focal neurological
deficit.

7. Detailed history-
1. Regarding seizure event.
2. Past medical history- severe head injury.
3. Growth and developmental history -
cerebral palsy or mental retardation.
4. Family history.
5. Social history - exposure to lead or drugs of
abuse, as well to the practical impact on
employment and lifestyle.
6. Review of systems may find other
non-neurological signs or risk factors
associated with seizures

8. The physical examination –
Include both a general exam and a detailed
age-appropriate neurological exam.
 The general exam should focus on
identifying systemic signs that may be
associated with seizures ,such as the
dysmorphic facial features of a
chromosomal disorder or the skin lesions of
tuberous sclerosis.
 The neurological exam should look for any
abnormalities that would help identify an
underlying neurological disease

9.  Reactive or systemic causes
1. Reactive seizures triggered by sleep
deprivation, fever, drug withdrawal or
toxycity
2. Systemic disease–
infection,hypoglycemia,hypoxia,hypocalcem
ia
 CNS insult
1. Direct CNS insult– head
injury, stroke,encephalitis, brain neoplasm
2. May be the manifestation of idiopathic
epilepsy

10.  MRI or CT brain
 Metabolic screening– S/E, blood glucose, liver
function,toxicology studies
(alcohol,paracitomol,cocaine).
 EEG
 CSF analysis only if there is suspicion of intra
cranial infection.

11.  In adolescents and young adults
1. Syncope
2. Psychological disorders
3. Sleep disorders
4. Paroxysmal movement disorders
5. Migraine
6. Miscellaneous neurologic events
 In the elderly
1. Transient ischemic attack
2. Transient global amnesia

12.  The risks versus benefits of giving antiepileptic
drugs (AEDs) after a first seizure are
controversial for patients of any age.
 Several factors must be weighed in making a
decision about prescribing medication:
 Is the diagnosis correct?
 Are seizures likely to recur?
 Is treatment likely to be successful?
 Does the risk of more seizures outweigh the
negative aspects of treatment?

13.  Antiepileptic drug (AED) therapy is generally
reserved for patients who are at increased
risk for recurrent seizures.

14. FINDINGS:
 Number of seizures of all types at
presentation, presence of a neurological
disorder, and an abnormal EEG were
significant factors in indicating future
seizures.
 Individuals with two or three seizures, a
neurological disorder, or an abnormal EEG
were identified as the medium-risk group

15.  Those with two of these features or more than
three seizures as the high-risk group.
 Those with a single seizure only as the low-risk
group
 INTERPRETATION: The model shows that there is
little benefit to immediate treatment in patients
at low risk of seizure recurrence, but potentially
worthwhile benefits are seen in those at medium
and high risk.
Lancet Neurol. 2006;5(4):317

16.  Pediatric Study: Prospective study of 407 children, with
mean follow-up of 6.3 years (Shinnar et al. 1990, 1996).
 Overall recurrence risk = 42% at 5 years.
 5 risk factors for recurrence were identified:
1. Etiology: remote symptomatic (66%) vs. idiopathic
(37%).
2. EEG: abnormal EEG (59%) vs normal EEG (32%).
3. Sleep state: seizure in sleep (53%) vs awake (36%).
4. Hx of febrile seizure: positive history (54%) vs
negative (39%).
5. Status epilepticus did not increase recurrence risk,
Multiple seizures within 24 hours did not increase
recurrence risk.

17.  Minnesota Study: 208 primarily adult patients with
mean follow-up of 4 years (Hauser et al. 1982)
Overall recurrence risk =34% at 4 years.
 Risk factors:
 Etiology: remote symptomatic (48%) vs idiopathic
(29%).
 Among idiopathic cases, increased recurrence was
associated with positive FHx of epilepsy (46% vs 27%)
 Abnormal EEG (58% vs 26%).
 Hx of febrile/acute symptomatic seizure (39% vs
27%).

18.  Other Studies (Annegers et al.
1986, Camfield et al. 1985, Hart et al. 1990)
have found partial seizures and an abnormal
neurological
examination to have increased recurrence
risk.

19. high risk features for seizure recurrence after a
first unprovoked seizure
1. Epileptiform abnormalities on EEG.
2. Remote symptomatic cause, as identified by
clinical history or neuroimaging (eg, brain
tumor, brain malformation).
3. Abnormal neurologic examination, including
focal findings and mental retardation.
 AED treatment after a first seizure may be
considered in any of these higher risk subgroups.

20. Other potential risk factors for seizure
 Patients who have a first presentation with
status epilepticus or with multiple seizures
within a single day.
However, limited data suggest that these
features, in the absence of other risk
factors, do not increase the risk of seizure
recurrence.

21.  Whether a history of prior febrile seizures is
associated with an increased risk of seizure
recurrence after a first unprovoked seizure
is uncertain.
 Study results have conflicted as to whether
a family history of epilepsy impacts
recurrence risk.
 Some observations suggest that a first
seizure that occurs during sleep is
associated with a greater risk of recurrence

22. Benefit of early versus deferred treatment
 Immediate AED treatment reduces the
incidence of seizure recurrence in the short-
term(30%-50%), studies suggest that it has
little impact on long-term outcome.
 However, the questionnaires demonstrated
significant trade-offs between the adverse
effects of seizures versus adverse effects of
taking AEDs, suggesting that individual
patient preferences should be considered.

24.  THANKYOU