Imaging Studies

In the past, the timing for CT scan of the head for first-time seizure was controversial. However, because of the availability of CT scanners in the United States, there is almost no reason not to perform the head CT scan on initial presentation.

Head CT scans should also be done for any patient presenting with first-time partial seizure, trauma, immunocompromised state, history of malignancy, anticoagulation, suspicion for AIDS, persistent fever, new pattern or type of seizure, or new focal findings on neurologic exam.

Magnetic resonance imaging (MRI) is the diagnostic imaging test of choice. This is usually not available from the emergency department and done on an outpatient or inpatient basis.

Electroencephalogram (EEG) has a very high yield to predict seizure recurrence and is part of the full neurologic work-up. In the emergency department, it may be needed to ensure that an intubated (and pharmacologically paralyzed or heavily sedated) patient in status epilepticus is not still seizing subclinically.

Management

Treatment and disposition is largely dependent on the history and can be tailored to the individual patient. For all patients, ABC’s are the first step in treatment. Adequate oxygenation should be ensured and supportive care measures taken.

First-Time Seizure

Patients with first-time seizure usually present with a history of recent seizure activity that has resolved by the time they arrive at the emergency department.

Seizures are usually self-limited in this scenario and no further emergency department treatment is needed.

The patient should receive sodium level and glucose level tests, a pregnancy test (as applicable), and a head CT scan.

Patients who present with a generalized seizure with no other worrisome history can be discharged home with close follow-up. Even with a normal EEG and normal CT scan, 1- and 4-year recurrence rates are 14% and 24%, respectively.⁶ However, antiepileptic medications do not affect this recurrence rate, so these agents are not routinely started after the first-time seizure.