Dia­gnosis of Epileptic Seizures

Authors: P. Marusič;  H. Krijtová
Authors‘ workplace: Neurologická klinika 2. LF UK a FN Motol, Praha
Published in: Cesk Slov Neurol N 2015; 78/111(3): 253-262
Category: Minimonography
doi: https://doi.org/10.14735/amcsnn2015253


Following a first seizure, it is important to establish whether this was an epileptic or non-epileptic seizure, and to ascertain possible cause of an epileptic seizure. With respect to further management, diagnostic or therapeutic, it is crucial to differentiate non-epileptic from epileptic seizures and to identify provoked epileptic seizures (acute symptomatic). Patient history with a detailed description of the course of a seizure and circumstances under which it happened is instrumental in discriminating between the different types of seizures. Complementary investigations can further support the diagnostic process. Acute symptomatic seizures represent up to 40% of all single epileptic seizures and occur in close chronological proximity to an ongoing central nervous system injury of various origins. The source can easily be identified – most frequently this is an acute cerebrovascular event, craniocerebral injury, inflammatory CNS disorder, while primarily extracerebral effects are also important – toxic and metabolic disorders and drug or alcohol abuse. Unprovoked or reflex single epileptic seizures in patients with persisting predisposition and a high risk (> 60%) of relapse may, according to the new definition, be regarded as epilepsy and long-term antiepileptic treatment may be initiated. MRI under appropriate protocol should always be performed after the first unprovoked seizure. The risk of seizure recurrence can be estimated based on patient history as well as any EEG or physical examination abnormity that suggests an injury of the CNS. Antiepileptic treatment is indicated in patients with a single seizure if there is a high risk of recurrence or an increased likelihood of severe complications of further seizures.

Key words:
seizures – epilepsy – diagnosis

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE “uniform requirements” for biomedical papers.


1. Loiseau J, Loiseau P, Duche B, Guyot M, Dartigues JF, Aublet B. A survey of epileptic disorders in southwest France: seizures in elderly patients. Ann Neurol 1990; 27(3): 232– 237.

2. Annegers JF, Hauser WA, Lee JR, Rocca WA. Incidence of acute symp­tomatic seizures in Rochester, Minnesota, 1935– 1984. Epilepsia 1995; 36(4): 327– 333.

3. Seneviratne U. Management of the first seizure: an evidence-based approach. Postgrad Med J 2009; 85(1010): 667– 673. doi: 10.1136/ pgmj.2009.082883.

4. Beghi E, Carpio A, Forsgren L, Hesdorffer DC, Malmgren K, Sander JW et al. Recommendation for a definition of acute symp­tomatic seizure. Epilepsia 2010; 51(4): 671– 675. doi: 10.1111/ j.1528‑ 1167.2009.02285.x.

5. Fisher RS, Acevedo C, Arzimanoglou A, Bogacz A, Cross JH, Elger CE et al. ILAE official report: a practical clinical definition of epilepsy. Epilepsia 2014; 55(4): 475– 482. doi: 10.1111/ epi.12550.

6. Hauser WA, Annegers JF, Kurland LT. Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota: 1935– 1984. Epilepsia 1993; 34(3): 453– 468.

7. Benbadis S. The differential dia­gnosis of epilepsy: a critical review. Epilepsy Behav 2009; 15(1): 15– 21. doi: 10.1016/ j.yebeh.2009.02.024.

8. Task Force for the Dia­gnosis and Management of Syncope. Guidelines for the dia­gnosis and management of syncope (version 2009). Eur Heart J 2009; 30(21): 2631– 2671. doi: 10.1093/ eurheartj/ ehp298.

9. Lempert T, Bauer M, Schmidt D. Syncope: a videometric analysis of 56 episodes of transient cerebral hypoxia. Ann Neurol 1994; 36(2): 233– 237.

10. Brigo F, Storti M, Lochner P, Tezzon F, Fiaschi A, Bongiovanni LG et al. Tongue biting in epileptic seizures and psychogenic events: an evidence‑based perspective. Epilepsy Behav 2012; 25(2): 251– 255. doi: 10.1016/ j.yebeh.2012.06.020.

11. Hesdorffer DC, Benn EK, Cascino GD, Hauser WA. Is a first acute symp­tomatic seizure epilepsy? Mortality and risk for recurrent seizure. Epilepsia 2009; 50(5): 1102– 1108. doi: 10.1111/ j.1528‑ 1167.2008.01945.x.

12. Shorvon S, Guerrini R. Acute symp­tomatic seizures –  should we retain the term? Epilepsia 2010; 51(4): 722– 723. doi: 10.1111/ j.1528‑ 1167.2010.02501.x.

13. Hauser WA. Seizure disorders: the changes with age. Epilepsia 1992; 33 (Suppl 4): S6– S14.

14. DeLorenzo RJ, Hauser WA, Towne AR, Boggs JG, Pellock JM, Penberthy L et al. A prospective, population‑based epidemiologic study of status epilepticus in Richmond, Virginia. Neurology 1996; 46(4): 1029– 1035.

15. Bladin CF, Alexandrov AV, Bellavance A, Bornstein N, Chambers B, Cote R et al. Seizures after stroke: a prospective multicenter study. Arch Neurol 2000; 57(11): 1617– 1622.

16. Camilo O, Goldstein LB. Seizures and epilepsy after ischemic stroke. Stroke 2004; 35(7): 1769– 1775.

17. Giroud M, Gras P, Fayolle H, Andre N, Soichot P, Dumas R. Early seizures after acute stroke: a study of 1,640 cases. Epilepsia 1994; 35(5): 959– 964.

18. Gupta SR, Naheedy MH, Elias D, Rubino FA. Post-infarction seizures. A clinical study. Stroke 1988; 19(12): 1477– 1481.

19. Kilpatrick CJ, Davis SM, Tress BM, Rossiter SC, Hopper JL, Vandendriesen ML. Epileptic seizures in acute stroke. Arch Neurol 1990; 47(2): 157– 160.

20. Labovitz, DL, Hauser, WA, Sacco RL. Prevalence and predictors of early seizure and status epilepticus after first stroke. Neurology 2001; 57(2): 200– 206.

21. Lamy C, Domigo V, Semah F, Arquizan C, Trystram D, Coste J et al. Early and late seizures after cryptogenic ischemic stroke in young adults. Neurology 2003; 60(3): 400– 404.

22. Vespa PM, Nuwer MR, Nenov V, Ronne‑ Engstrom E, Hovda DA, Bergsneider M et al. Increased incidence and impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring. J Neurosurg 1999; 91(5): 750– 760.

23. Datar S, Singh T, Rabinstein AA, Fugate JE, Hocker S. Long‑term risk of seizures and epilepsy in patients with posterior reversible encephalopathy syndrome. Epilepsia 2015; 56(4): 564– 568. doi: 10.1111/ epi.12933.

24. Annegers JF, Hauser WA, Coan SP, Rocca WA. A population‑based study of seizures after traumatic brain injuries. N Engl J Med 1998; 338(1): 20– 24.

25. Salazar AM, Jabbari B, Vance SC, Grafman J, Amin D, Dillon JD. Epilepsy after penetrating head injury. I. Clinical correlates: a report of the Vietnam Head Injury Study. Neurology 1985; 35(10): 1406– 1414.

26. Jennett B. Epilepsy and acute traumatic intracranial hematoma. J Neurol Neurosurg Psychiatry 1975; 38(4): 378– 381.

27. Misra UK, Tan CT, Kalita J. Viral encephalitis and epilepsy. Epilepsia 2008; 49 (Suppl 6): 13– 18. doi: 10.1111/ j.1528‑ 1167.2008.01751.x.

28. Krýsl D, Elišák M. Autoimunitní encefalitidy. Cesk Slov Neurol N 2015; 78/ 111(1): 7– 23. doi: 10.14735/ amcsnn20157.

29. Tiamkao S, Janon C, Sawanyawisuth K, Pratipanawatr T, Jitpimolmard S. Prediction of seizure control in non‑ketotic hyperglycemic induced seizures. BMC Neurol 2009; 9: 61. doi: 10.1186/ 1471‑ 2377‑ 9‑ 61.

30. Hughes JR. Alcohol withdrawal seizures. Epilepsy Behav 2009; 15(2): 92– 97. doi: 10.1016/ j.yebeh.2009.02.037.

31. Hillbom M, Pieninkeroinen I, Leone M. Seizures in alcohol‑ dependent patients: epidemiology, pathophysiology and management. CNS Drugs 2003; 17(14): 1013– 1030.

32. Thundiyil JG, Kearney TE, Olson KR. Evolving epidemiology of drug‑induced seizures reported to a Poison Control Center System. J Med Toxicol 2007; 3(1): 15– 19.

33. Veran O, Kahane P, Thomas P, Hamelin S, Sabourdy C, Vercueil L. De novo epileptic confusion in the elderly: a 1‑year prospective study. Epilepsia 2010; 51(6): 1030– 1035. doi: 10.1111/ j.1528‑ 1167.2009.02410.x.

34. Harden CL, Huff JS, Schwartz TH, Dubinsky RM, Zim­merman RD, Weinstein S et al. Reassessment: neuroimaging in the emergency patient presenting with seizure (an evidence‑based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2007; 69(18): 1772– 1780.

35. Soubor minimálních dia­gnostických a terapeutických standardů u pa­cientů s epilepsií. EpiStop 2013. [online]. Dostupné z URL: http:/ / www.epistop.cz/ images/ ZOO_DOWN/ EPI_standard_2013_web.pdf.

36. Krumholz A, Wiebe S, Gronseth G, Shinnar S, Levisohn P, Ting T et al. Practice Parameter: evaluating an apparent unprovoked first seizure in adults (an evidence‑based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007; 69(21): 1996– 2007.

37. Sempere AP, Villaverde FJ, Martinez‑ Menéndez B, Cabeza C, Peña P, Tejerina JA. First seizure in adults: a prospective study from the emergency department. Acta Neurol Scand 1992; 86(2): 134– 138.

38. ACEP Clinical Policies Committee, Clinical Policies Subcommittee on Seizures. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med 2004; 43(5): 605– 625.

39. Holtzman DM, Kaku DA, So YT. New‑ onset seizures associated with human immunodeficiency virus infection: causation and clinical features in 100 cases. Am J Med 1989; 87(2): 173– 177.

40. King MA, Newton MR, Jackson GD, Fitt GJ, Mitchell LA,Silvapulle MJ et al. Epileptology of the first‑ seizure presentation: a clinical, electroencephalographic and magnetic resonance imaging study of 300 consecutive patients. Lancet 1998; 352(9133): 1007– 1011.

41. Hauser WA, Rich SS, Annegers JF, Anderson VE. Seizure recurrence after a 1st unprovoked seizure: an extended follow‑up. Neurology 1990; 40(8): 1163– 1170.

42. Wellmer J, Quesada CM, Rothe L, Elger CE, Bien CG, Urbach H. Proposal for a magnetic resonance imaging protocol for the detection of epileptogenic lesions at early outpatient stages. Epilepsia 2013; 54(11): 1977– 1987. doi: 10.1111/ epi.12375.

43. Berg AT. Risk of recurrence after a first unprovoked seizure. Epilepsia 2008; 49 (Suppl 1): 13– 18. doi: 10.1111/ j.1528‑ 1167.2008.01444.x.

44. Kho LK, Lawn ND, Dunne JW, Linto J. First seizure presentation: do multiple seizures within 24 hours predict recurrence? Neurology 2006; 67(6): 1047– 1049.

45. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Guidelines for epidemiologic studies on epilepsy. Epilepsia 1993; 34(4): 592– 596.

46. Pohlmann‑Eden B, Beghi E, Camfield C, Camfield P. The first seizure and its management in adults and children. BMJ 2006; 332(7537): 339– 342.

47. Berg AT, Shinnar S. The risk of seizure recurrence fol­lowing a first unprovoked seizure: a quantitative review. Neurology 1991; 41(7): 965– 972.

48. Kim LG, Johnson TL, Marson AG, Chadwick DW. Prediction of risk of seizure recurrence after a single seizure and early epilepsy: further results from the MESS trial. Lancet Neurol 2006; 5(4): 317– 322.

49. Leone MA, Solari A, Beghi E. Treatment of the first tonic‑ clonic seizure does not affect long‑term remission of epilepsy. Neurology 2006; 67(12): 2227– 2229.

50. Hovorka J. Farmakologická léčba epilepsie. Cesk Slov Neurol N 2010; 73/ 106(4): 351– 373.

51. Krijtová H, Krýsl D, Marusič P. Akutní symp­tomatické záchvaty a akutní symp­tomatický status epilepticus –  definice, příčiny a léčba. Neurol Praxi 2011; 12(4): 203– 208.

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