From the Guidelines
A comprehensive seizure workup is essential to determine the cause and guide treatment, and should include a detailed medical history, physical and neurological examination, laboratory tests, electroencephalogram (EEG), and brain imaging with MRI, as recommended by the most recent guidelines 1.
Key Components of a Seizure Workup
- A detailed medical history, including seizure description, timing, triggers, and family history
- Physical and neurological examination to identify any abnormalities
- Laboratory tests, such as complete blood count, comprehensive metabolic panel, glucose, calcium, magnesium, and drug screens
- Electroencephalogram (EEG) to detect abnormal brain electrical activity, with both routine and sleep-deprived EEGs recommended for higher sensitivity
- Brain imaging with MRI, preferred over CT, to identify structural abnormalities like tumors, strokes, or malformations
Additional Tests and Considerations
- Lumbar puncture may be necessary to rule out infection or inflammation
- Toxicology screening, genetic testing, or video EEG monitoring may be considered for difficult-to-diagnose cases
- The choice of imaging modality depends on the clinical scenario, with MRI usually appropriate for most scenarios, except in emergent situations where a noncontrast CT of the head may be preferred 1
Treatment and Management
- Antiepileptic medications, such as levetiracetam, may be prescribed to control seizures
- Lifestyle modifications and addressing reversible causes are also crucial in managing seizures
- Early and thorough evaluation improves outcomes by enabling targeted treatment and potentially preventing future seizures, as emphasized by the American College of Emergency Physicians (ACEP) clinical policy 1
From the Research
Seizure Workup
The workup for seizures typically involves a combination of diagnostic tests, including:
- Electroencephalography (EEG) to record electrical activity in the brain 2
- Magnetic Resonance Imaging (MRI) to identify potentially epileptogenic lesions 2, 3, 4
- Computed Tomography (CT) scans in some cases, especially in emergency situations 5
- Other adjunctive tests such as ambulatory EEG, video/EEG, positron emission tomography, single photon emission computed tomography, and serum evaluation may be used in specific circumstances 2
Diagnostic Testing
Diagnostic testing for seizures is guided by the patient's history and physical examination 4, 6. The choice of tests depends on the suspected cause of the seizure and the presence of any underlying medical conditions.
- EEG is a necessary extension of the neurologic examination and can help characterize the type of seizure disorder 2
- MRI is useful for identifying structural lesions that may be causing the seizures, such as tumors or malformations 2, 3, 4
- CT scans may be used in emergency situations, such as when a patient presents with status epilepticus 5
Imaging Modalities
Imaging modalities play a crucial role in the diagnosis and localization of status epilepticus 5.
- MRI has a higher spatial resolution than EEG and can provide information about brain activity over a longer period of time 3
- MRI can aid in the differential diagnosis of generalized nonconvulsive status epilepticus and can help identify the ictal nature of lateralized periodic discharges (LPDs) 3
- CT scans and other imaging modalities, such as perfusion and radionucleotide imaging, may also be used to localize the seizure onset zone and understand the pathophysiology of status epilepticus 5