Unprovoked first seizure: to treat or not to treat?
Nitin K.Sethi, Assistant Professor of Neurology
Published May 01, 2015
I read with interest the evidence based guidelines on management of an unprovoked first seizure in adults issued by the guideline development subcommittee of the American Academy of Neurology and the American Epilepsy Society. [1] The decision to initiate antiepileptic drug (AED) therapy in an adult after an unprovoked first seizure has to be individualized to the patient. There are a few situations where I disagree with the recommended guidelines. An adult with a history of static encephalopathy--usually mild--who has an unprovoked first seizure may warrant AED treatment even if MRI shows no structural epileptogenic lesions and EEG is free of epileptiform features. In some patients presenting after an unprovoked first seizure, EEG may show no epileptiform discharges but the background is slow. Focal or even diffuse slowing in the clinical context of an unprovoked seizure may be significant. The quality of the MRI scan, the duration of the EEG study (20 minutes study versus an extended 24 to 48 hours), and how soon EEG was initiated after the index event are factors that need to be addressed before choosing AED therapy in favor of a wait-and-watch approach.
1. Krumholz A, Wiebe S, Gronseth GS, et al. Evidence-based guideline: Management of an unprovoked first seizure in adults: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2015; 84:1705-1713.
For disclosures, please contact the editorial office at journal@neurology.org.
I read with interest the evidence based guidelines on management of an unprovoked first seizure in adults issued by the guideline development subcommittee of the American Academy of Neurology and the American Epilepsy Society. [1] The decision to initiate antiepileptic drug (AED) therapy in an adult after an unprovoked first seizure has to be individualized to the patient. There are a few situations where I disagree with the recommended guidelines. An adult with a history of static encephalopathy--usually mild--who has an unprovoked first seizure may warrant AED treatment even if MRI shows no structural epileptogenic lesions and EEG is free of epileptiform features. In some patients presenting after an unprovoked first seizure, EEG may show no epileptiform discharges but the background is slow. Focal or even diffuse slowing in the clinical context of an unprovoked seizure may be significant. The quality of the MRI scan, the duration of the EEG study (20 minutes study versus an extended 24 to 48 hours), and how soon EEG was initiated after the index event are factors that need to be addressed before choosing AED therapy in favor of a wait-and-watch approach.
1. Krumholz A, Wiebe S, Gronseth GS, et al. Evidence-based guideline: Management of an unprovoked first seizure in adults: Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2015; 84:1705-1713.
For disclosures, please contact the editorial office at journal@neurology.org.