Diagnosis and treatment of the first epileptic seizure: guidelines of the Italian League against Epilepsy

Abstract

The diagnosis and treatment of a first epileptic seizure are made by physicians with different types of expertise. Heterogeneous patterns of care are thus expected, which explain the need for shared patterns of care. These guidelines were developed by a group of experts from the Italian League against Epilepsy (LICE) in accordance with the requirements of evidence-based medicine. An accurate assessment of the seizure is required, with active questioning about circumstances of occurrence, clinical manifestations, and postictal symptoms. For seizures with loss of consciousness, the presence of cyanosis, hypersalivation, tongue biting, and postictal disorientation has a specific diagnostic value. Laboratory tests and toxicological screening should be performed only in the presence of circumstances suggesting a metabolic or toxic encephalopathy. Elevated prolactin levels 10-20 min. after the event help in differentiating generalized tonic-clonic or partial seizures from psychogenic nonepileptic seizures. Except for infants less than six months of age, CSF examination is recommended only when a cerebral infection is suspected. An EEG should be performed within 24 h. after a seizure, particularly in children. If the EEG is normal during wakefulness, a sleep EEG is recommended. A CT scan is strictly indicated when a severe structural lesion is suspected or when the etiology is unknown. MRI may not be indicated in the emergency room, but it should be preferred to CT as part of the diagnostic assessment. The added value of other diagnostic tools (neuropsychological tests, ambulatory EEG, functional MRI, SPECT, and PET) is as yet unknown. These tests may be used on a case-by-case basis. In the presence of an acute symptomatic seizure, treatment of the cause is recommended. Symptomatic therapy is not justified unless the seizure has the characteristics of status epilepticus. Long-term treatment may be considered in patients with abnormal EEG and imaging data and after consideration of the social, emotional, and personal implications of seizure relapse.