What is the recommended workup and treatment for a patient presenting with seizures?

From the Guidelines

The initial workup for a patient presenting with seizures should include a thorough history, physical examination, basic laboratory tests, and an electroencephalogram (EEG), with neuroimaging with MRI preferred over CT to identify structural abnormalities, as recommended by the most recent guidelines 1. When evaluating a patient with seizures, it is crucial to consider the underlying causes, such as electrolyte abnormalities, infection, or toxins, and address them promptly.

• A thorough history and physical examination are essential to identify potential causes and guide further testing.
• Basic laboratory tests, including complete blood count, comprehensive metabolic panel, glucose, calcium, magnesium, and toxicology screen, should be performed to rule out underlying conditions that may be contributing to the seizures.
• An electroencephalogram (EEG) is a critical component of the workup, as it can help identify abnormal brain activity and guide treatment decisions.
• Neuroimaging with MRI is preferred over CT to identify structural abnormalities, such as tumors or stroke, that may be causing the seizures, as recommended by the American College of Emergency Physicians (ACEP) in their 2024 clinical policy 1. For first-line antiseizure medication in adults, levetiracetam (Keppra) is often recommended at a starting dose of 500 mg twice daily, which can be titrated up to 1500 mg twice daily as needed, based on the latest evidence 1.
• Alternatives include lamotrigine (starting at 25 mg daily, gradually increasing to 100-200 mg twice daily over several weeks) or carbamazepine (starting at 200 mg twice daily, increasing to 400-600 mg twice daily).
• Status epilepticus requires emergency treatment with intravenous benzodiazepines (lorazepam 4 mg IV or diazepam 10 mg IV), followed by fosphenytoin or valproate if seizures persist, as outlined in the ACEP clinical policy 1. Medication selection should be tailored to seizure type, patient comorbidities, and potential side effects, and treatment typically continues for at least 2 years after the last seizure before considering discontinuation, as recommended by the ACEP 1.
• Patient education regarding seizure precautions, including driving restrictions, avoiding swimming alone, and medication adherence, is essential to prevent injuries and ensure optimal outcomes.
• Antiseizure medications work by various mechanisms, including sodium channel blockade, enhancement of GABA activity, or calcium channel modulation, to stabilize neuronal membranes and prevent the hypersynchronous neuronal discharges that cause seizures, as described in the literature 1.

From the FDA Drug Label

The recommended dose for topiramate monotherapy in adults and children 10 years of age and older is 400 mg/day in two divided doses The recommended total daily dose of topiramate as adjunctive therapy in adults with partial seizures is 200 to 400 mg/day in two divided doses, and 400 mg/day in two divided doses as adjunctive treatment in adults with primary generalized tonic-clonic seizures. The recommended total daily dose of topiramate as adjunctive therapy for patients with partial seizures, primary generalized tonic-clonic seizures, or seizures associated with Lennox-Gastaut syndrome is approximately 5 to 9 mg/kg/day in two divided doses

The recommended workup and treatment for a patient presenting with seizures is to start with a dose of 25-50 mg/day and titrate up to an effective dose, with a maximum dose of 400 mg/day. The dose should be adjusted based on the patient's response and tolerance. Key considerations include:

• Dose titration: The dose should be increased gradually to minimize side effects.
• Seizure type: The dose and treatment plan may vary depending on the type of seizure.
• Concomitant medications: The patient's other medications, including antiepileptic drugs, should be taken into account when adjusting the dose.
• Renal impairment: The dose should be adjusted in patients with renal impairment.
• Pediatric patients: The dose should be adjusted based on the patient's weight, with a recommended dose of 5-9 mg/kg/day. 2 2

From the Research

Seizure Workup

• The diagnosis and treatment of a first epileptic seizure require an accurate assessment of the seizure, including circumstances of occurrence, clinical manifestations, and postictal symptoms 3.
• Laboratory tests and toxicological screening should be performed only in the presence of circumstances suggesting a metabolic or toxic encephalopathy 3.
• Elevated prolactin levels 10-20 min after the event can help in differentiating generalized tonic-clonic or partial seizures from psychogenic nonepileptic seizures 3.
• An EEG should be performed within 24 h after a seizure, particularly in children, and a sleep EEG is recommended if the EEG is normal during wakefulness 3.
• A CT scan is strictly indicated when a severe structural lesion is suspected or when the etiology is unknown, while MRI may not be indicated in the emergency room but should be preferred to CT as part of the diagnostic assessment 3.

Treatment Options

• Valproate is commonly the first choice for treating myoclonic seizures, alone or in combination with some benzodiazepines or levetiracetam 4.
• Vagus nerve stimulation (VNS) is a neuromodulatory treatment that can be used as an adjunctive therapy for treating people with medically refractory epilepsy 5, 6.
• VNS appears to be an effective and well-tolerated treatment in adult and pediatric patients, with improvements in feelings of well-being, alertness, memory, and thinking skills, as well as mood 5, 6.
• The efficacy of a "standard" seizure workup in the emergency department has been questioned, with routine serum chemistries found to be of extremely low yield, and the clinical examination able to predict accurately the need to obtain these studies 7.

Diagnostic Tools

• EEG is a crucial diagnostic tool in the assessment of seizures, and should be performed within 24 h after a seizure 3.
• Imaging studies, such as CT and MRI, can be useful in selected patients, particularly when a severe structural lesion is suspected or when the etiology is unknown 3.
• Other diagnostic tools, such as neuropsychological tests, ambulatory EEG, functional MRI, SPECT, and PET, may be used on a case-by-case basis, but their added value is as yet unknown 3.