Management of New-Onset Seizure in a 60-Year-Old Male with Normal MRI
This patient requires outpatient neurology follow-up with EEG, consideration of antiepileptic drug initiation (preferably levetiracetam or lamotrigine), and evaluation for underlying etiologies, with hospital admission generally not required if he has returned to neurologic baseline.
Immediate Laboratory Evaluation
- Obtain serum glucose and sodium levels as these are the most clinically relevant metabolic abnormalities that can cause seizures and may not be predicted by history alone 1
- Check pregnancy test if applicable (though not relevant for this male patient) 1
- Consider additional metabolic panel including calcium and magnesium, as these abnormalities occasionally present without obvious clinical predictors 1
Neuroimaging Interpretation
- A normal MRI is reassuring but does not eliminate the need for further workup, as the underlying etiology still needs identification 2
- MRI is superior to CT for detecting epileptogenic lesions (55% sensitivity vs 18-30% for CT), so this normal result carries significant weight 2
- At age 60, stroke and tumor are important considerations (23% of new-onset seizures in one series), but the normal MRI makes acute structural lesions less likely 1
Admission Decision
- Hospital admission is generally not required if the patient has returned to neurologic baseline, has no concerning features, and reliable outpatient follow-up can be arranged 1
- The seizure recurrence rate within 24 hours is approximately 19% overall, but drops to 9-12% when excluding alcohol-related events and focal CT lesions 1
- Admission should be considered if: immunocompromised status (requiring lumbar puncture after imaging), persistent altered mental status, concern for status epilepticus, or unreliable follow-up 1
Antiepileptic Drug Initiation
Levetiracetam is the preferred first-line agent for this elderly patient due to superior tolerability, lack of drug interactions, and favorable pharmacokinetic profile 3, 4
Specific Medication Recommendations:
Levetiracetam: Start 500-1000 mg daily, titrate to 1000-2000 mg daily in divided doses
Lamotrigine: Alternative option with similar retention rates (55.6% at 1 year) and good tolerability 3, 4
- Requires slow titration (weeks) which may be disadvantageous
Avoid phenytoin, carbamazepine, and phenobarbital in elderly patients due to enzyme induction, nonlinear pharmacokinetics, cognitive effects, and high drug interaction potential 6, 4
Essential Outpatient Follow-up
- EEG should be obtained to characterize seizure type and identify epileptiform abnormalities that guide prognosis and treatment 1
- Neurology consultation within 1-2 weeks to determine long-term management strategy
- If antiepileptic drug is started, monitor for efficacy and adverse effects, particularly cognitive and gait disturbances which are more common in elderly patients 4
Etiologic Investigation
At age 60, the most common causes of new-onset seizures include:
- Cerebrovascular disease (stroke/TIA) - most common in this age group 1, 5
- Cryptogenic/unknown etiology - 24% in one series 1
- Consider additional workup for occult malignancy if clinically indicated
- Evaluate for alcohol use or withdrawal 1
Critical Pitfalls to Avoid
- Do not assume normal MRI excludes all structural pathology - some lesions may only be visible on dedicated epilepsy protocol MRI with thin cuts through hippocampus 2
- Do not use older-generation antiepileptic drugs (phenytoin, carbamazepine, phenobarbital) as first-line in elderly patients due to poor tolerability and drug interactions 3, 6, 4
- Do not delay EEG - it provides critical information about seizure type and epileptiform activity that CT/MRI cannot 2
- Ensure reliable follow-up is arranged before discharge, as this is essential for safe outpatient management 1