The first epileptic seizure in adults

The first epileptic seizure does not always mean the debut of epilepsy, as a disease. According to some researchers, 5-9% of people in the general population suffer at least one non-febrile seizure at any period of their life. Nevertheless, the first seizure in adults should give rise to the search for organic, toxic or metabolic brain diseases or extracerebral disorders that can cause seizures. Epilepsy in its etiopathogenesis refers to multifactorial states. Therefore, a patient with epilepsy must undergo mandatory electroencephalographic and neuroimaging, and sometimes obscheomatic examination.

When the first attack occurs in adulthood, the list of the diseases listed below should be considered very seriously, which implies repeated examinations of the patient if the first series of examinations were uninformative.

Previously, of course, it is necessary to clarify whether the seizures are really epileptic in nature.

Syndromic differential diagnosis is performed with syncope, hyperventilation attacks, cardiovascular disorders, some parasomnias, paroxysmal dyskinesias, hyperrexia, facial hemispasm, paroxysmal dizziness, transient global amnesia, psychogenic seizures, less often with such conditions as trigeminal neuralgia, migraine, and some psychotic disorders.

Unfortunately, very often there are no witnesses to the attack, or their description is not informative. Such valuable symptoms as bite of the tongue or lip, urinary loss or increased serum creatine kinase are often absent, and sometimes only non-specific changes are recorded on the EEG. A very big help in recognizing the nature of a seizure can be the video recording of an attack (including at home). If the epileptic nature of the first seizure is not in doubt, then consider the following range of major diseases (epileptic seizures can be caused by almost all diseases and brain damage).

The main causes of the first epileptic fit in adults:

1. The withdrawal syndrome (alcohol or medication).
2. Brain tumor.
3. Abscess of the brain and other voluminous formations.
4. Craniocerebral injury.
5. Viral encephalitis.
6. Arteriovenous malformation and malformations of the brain.
7. Thrombosis of cerebral sinuses.
8. A cerebral infarction.
9. Carcinomatous meningitis.
10. Metabolic encephalopathy.
11. Multiple sclerosis.
12. Extracerebral diseases: cardiac pathology, hypoglycemia.
13. Idiopathic (primary) forms of epilepsy.

The withdrawal syndrome (alcohol or medication)

While the most common causes of the first epileptic fit in adults are the abuse of alcohol or tranquilizers (as well as a brain tumor or abscess).

Alcohol-related ("toxic") seizures appear, as a rule, during the cancellation period, which indicates the regular intake of large doses of alcohol or drugs for a sufficiently long period of time.

A valuable symptom of withdrawal is a small tremor of elongated fingers and hands. Many patients note an increase in the amplitude (not frequency) of tremor in the mornings after a night break in taking another dose and decrease during the day under the influence of alcohol or medication. (Family or "essential" tremor also decreases under the influence of alcohol, but it usually looks coarser, and often hereditary, EEG is usually normal.) Neuroimaging often reveals a global decrease in the volume of the hemispheres and also a cerebral "atrophy". The decrease in volume indicates dystrophy rather than atrophy, and is reversible in some patients, provided that they refuse to continue drinking alcohol.

Attacks with withdrawal can be a harbinger of psychosis, which will develop within 1-3 days. This condition is potentially dangerous, intensive medical care must be provided early enough. The drug cancellation syndrome is more difficult to recognize both in the history and in the medical examination, and in addition, treatment here takes longer and requires intensive care in its entirety.

Brain tumor

The next state, which should be considered in the first epileptic fit, is a brain tumor. Since basically there are histologically benign, slowly growing gliomas (or vascular malformations), the anamnesis in many cases is not very informative, as is the usual neurological examination. Neurovisualization with contrasting is the method of choice among the auxiliary methods, and this examination should be repeated if the first results are normal and there are no other reasons for the occurrence of seizures.

Abscess of the brain and other voluminous formations (subdural hematoma)

Abscess of the brain (as well as subdural hematoma) will never be missed if a neurovisual examination is performed. The necessary laboratory tests may not indicate the presence of an inflammatory disease. EEG, as a rule, reveals focal disturbances in a very slow delta range, plus generalized disorders. In this case, at least, an examination of the ear, a throat, a nose and a roentgenography of a thorax is required. A study of blood and liquor here can also be useful.

Craniocerebral injury

Epilepsy due to craniocerebral trauma (TBI) can occur after a long period of interruption, so the patient often forgets to tell the doctor about this event. Therefore, the collection of anamnesis in these cases is particularly important. However, it is useful to remember that the occurrence of epileptic seizures after CCT does not yet mean that it is the trauma that is the cause of epilepsy, this connection must be proved in doubtful cases.

In favor of a traumatic genesis of epilepsy is evidenced by:

1. heavy head injury; the risk of epilepsy increases if the duration of loss of consciousness and amnesia exceeds 24 hours, there are depressed cranial fractures, intracranial hematoma, focal neurological symptoms;
2. presence of early seizures (occurred within the first week after injury);
3. the partial nature of seizures, including secondary generalization.

In addition, the period from the moment of injury to the onset of seizures is important (50% of posttraumatic seizures occur within the first year, and if seizures appear after 5 years, their traumatic genesis is unlikely). Finally, not every paroxysmal activity on the EEG can be called epileptic. EEG data should always be correlated with the clinical picture.

Viral encephalitis

Any viral encephalitis can begin with epileptic seizures. The most characteristic is a triad of epileptic seizures, generalized deceleration and irregular EEG, disorientation or apparently psychotic behavior. Cerebrospinal fluid may contain an increased number of lymphocytes, although the level of protein and lactate is normal or slightly elevated (the level of lactate increases when bacteria "lower" glucose). A rare, but very dangerous condition is encephalitis, caused by the herpes simplex virus (herpetic encephalitis). It usually begins with a series of epileptic seizures that follow darkening of consciousness, hemiplegia and aphasia, if the temporal lobe is affected. The patient's condition quickly deteriorates to coma and decerebral rigidity due to massive edema of the temporal lobes, which put pressure on the brain stem. In neuroimaging imaging, a decrease in density in the limbic region of the temporal and later frontal lobe is determined, which is involved in the process after the first week of the disease. During the first few days, nonspecific abnormalities are recorded on the EEG. The occurrence of periodic high-voltage slow complexes in both temporal leads is very characteristic. When examining the cerebrospinal fluid, pronounced lymphocytic pleocytosis and an increase in the protein level are detected. It is justified to search for herpes simplex virus in CSF.

Arteriovenous malformation and malformations of the brain

The presence of arteriovenous malformation can be suspected when a neuroimaging study with contrasting reveals a round, inhomogeneous region of reduced density on the convective surface of the hemisphere without edema of surrounding tissues. The diagnosis is confirmed by angiography.

The developmental defects of the brain are also easily detected by methods of neuroimaging.

Thrombosis of the cerebral sinus (s)

Thrombosis of cerebral sinuses may be the cause of epileptic seizures, because in the hemisphere, where venous outflow is blocked, hypoxia and diapedemic hemorrhages develop. Consciousness is usually disturbed until the appearance of focal symptoms, which to some extent facilitates the recognition of thrombosis. The prevalence of generalized slow activity is observed on the EEG.

The cerebral infarction, as the cause of the first epileptic fit, occurs in about 6-7% of cases and is easily recognized by the concomitant clinical picture. However, single and multiple (repeated) "mute" infarcts are possible with discirculatory encephalopathy, which sometimes lead to epileptic seizures ("late epilepsy").

Carcinomatous meningitis

With an unexplained headache and mild rigidity of the neck, a lumbar puncture should be performed. If there is a small increase in the number of atypical cells in the CSF analysis (which can be detected by a cytological test), a significant increase in the protein level and a decrease in glucose level (glucose is metabolized by tumor cells), then carcinomatous meningitis should be suspected.

Metabolic encephalopathy

The diagnosis of metabolic encephalopathy (often uremia or hyponatremia) is usually based on a characteristic pattern of laboratory data that can not be given here in detail. It is important to suspect and conduct a screening of metabolic disorders.

Multiple sclerosis

It should be remembered that in very rare cases, multiple sclerosis can debut with epileptic attacks, both generalized and partial, and, with the exclusion of other possible causes of epileptic seizures, carry out specifying diagnostic procedures (MRI, evoked potentials, and immunological studies of CSF).

Extracerebral diseases: cardiac pathology, hypoglycaemia

The cause of epileptic seizures may be transient abnormalities in supplying the brain with oxygen due to cardiac pathology. Recurring asystole, as with Adams-Stoke disease, is a well-known example, but there are other conditions, so it is useful to conduct a thorough cardiological examination, especially in elderly patients. Hypoglycemia (including hyperinsulinism) may also be a factor provoking epileptic seizures.

Idiopathic (primary) forms of epilepsy usually develop not in adults, but in infancy, childhood or adolescence.

Epileptic syndromes with some degenerative diseases of the nervous system (for example, progressive myoclonus-epilepsies) usually develop against a background of progressive neurological deficits and are not discussed here.

Diagnosis of the first epileptic seizure

General and biochemical blood analysis, urine analysis, screening for metabolic disorders, toxic agent identification, cerebrospinal analysis, MRI of the brain, EEG with functional loads (hyperventilation, sleep deprivation, use of sleep electrophoresis), ECG, evoked potentials of different modalities.