Work

Challenges in the Diagnosis of Patients Presenting with the “First Seizure”

Year: 2025

Type: article

Abstract: Epileptic seizures are paroxysmal and episodic phenomena characterised by behavioural, somatosensory, motor, or visual signs and symptoms due to abnormal, excessive, or synchronized neuronal activity in the brain.The clinical situation in which patients present with seizure without a previous history of seizure is considered the first seizure.[1][2][3] The evaluation of a suspected first seizure presents several diagnostic challenges, including determining the underlying etiology, assessing the risk of recurrence, determining the need for diagnostic electroencephalogram (EEG) or neuroimaging, determining whether to initiate anti-seizure medication (ASM), and managing patient and family concerns about social or emotional impact on lifestyle.4 A key concern is whether the event represents a true seizure associated with epileptogenic brain pathology or a "seizure mimic."This distinction is crucial, as it directly affects both seizure recurrence prognosis and the choice of treatment strategies.3,5 A wide spectrum of differential diagnoses must be considered when evaluating a first seizure.These include psychogenic non-epileptic seizures (PNES), syncope, transient ischemic attacks (TIAs), migraine auras, paroxysmal movement disorders, transient global amnesia, sleep disorders, and panic attacks.1,2 Another critical aspect is differentiating between an acute symptomatic seizure and an unprovoked seizure, as their treatment and prognosis differ significantly.It is essential to distinguish between these conditions as early as possible.In addition to obtaining a detailed Abstract Objective: Epileptic seizures are paroxysmal events resulting from abnormal neuronal activity.Diagnosing a first seizure presents a significant clinical challenge, particularly in patients without a previous similar history.This study aims to evaluate the clinical approach to first seizures, which are often posing diagnostic and therapeutic challenges.Methods: This prospective study was conducted in a tertiary care hospital and included patients admitted to the emergency department and neurology outpatient clinic with suspected first seizures from January 2023 to March 2024.Patients were followed for at least one year.Data collected included age, gender, laboratory tests, cranial imaging, and electroencephalogram (EEG) results.Final diagnoses were classified as either "seizure" or "seizure mimics," with seizures further categorized into "unprovoked" and "acute symptomatic."The unprovoked category was divided into "true first seizure" and "recurrent seizure."Results: A total of 210 patients were included in the study, with 152 diagnosed with seizures and 58 with seizure mimics.The mean age was 43.7 years.The male/female ratio was 55.3%/44.7%.In the "seizure" group, 119 patients (56.7%) had unprovoked and 33 (15.8%) had acute symptomatic seizures.In the unprovoked group, 106 patients (50.5%) were classified as having a true first seizure.Detailed history revealed that 13 patients (6.2%) had at least one similar seizure before.Seizure recurrence was observed in 27 patients (25.5%).Conclusion: This study highlights the diagnostic challenges of first seizures.Accurate differentiation between epileptic seizures and mimics is crucial.Comprehensive history and EEG are essential for optimizing treatment, and initiating therapy in true seizure cases effectively reduces the risk of recurrence.

Source: Archives of Epilepsy

DOI: 10.4274/archepilepsy.2025.25184