What is the appropriate workup for a possible seizure?

From the Guidelines

A comprehensive seizure workup typically involves an initial electroencephalogram (EEG) to assess for abnormal electrical activity, followed by neuroimaging with magnetic resonance imaging (MRI) or computed tomography (CT) scan to rule out structural abnormalities, as recommended by the American College of Radiology 1.

Key Components of Seizure Workup

• EEG: to assess for abnormal electrical activity in the brain
• Neuroimaging:
  • MRI: more sensitive than CT in detecting brain abnormalities, and should be the primary imaging modality in children with newly diagnosed seizures 1
  • CT scan: may be used in emergency situations where MRI is not available
• Laboratory tests:
  • Complete blood count: to rule out infection or inflammation
  • Basic metabolic panel: to evaluate for electrolyte imbalances or other metabolic disorders
  • Serum levels of antiepileptic medications: to monitor medication levels and adjust as needed
• Lumbar puncture: may be considered to evaluate for infectious or inflammatory causes, such as autoimmune encephalitis 1

Additional Considerations

In some cases, a trial of medication such as lorazepam 2mg orally or intravenously for 2-4 weeks may be initiated to assess for response, as part of a comprehensive treatment plan 1. It is essential to note that the specific components of the workup may vary depending on the individual patient's presentation, age, and medical history, as outlined in the American College of Radiology's appropriateness criteria for seizures and epilepsy 1.

From the FDA Drug Label

The treatment of status, however, requires far more than the administration of an anticonvulsant agent It involves observation and management of all parameters critical to maintaining vital function and the capacity to provide support of those functions as required. Ventilatory support must be readily available. The use of benzodiazepines, like lorazepam injection, is ordinarily only one step of a complex and sustained intervention which may require additional interventions (e.g., concomitant intravenous administration of phenytoin). Because status epilepticus may result from a correctable acute cause such as hypoglycemia, hyponatremia, or other metabolic or toxic derangement, such an abnormality must be immediately sought and corrected.

The appropriate workup for a possible seizure includes:

• Observation and management of vital functions
• Ventilatory support
• Identification and correction of potential underlying causes, such as:
  • Hypoglycemia
  • Hyponatremia
  • Other metabolic or toxic derangements
• Consideration of additional interventions, such as concomitant administration of other anticonvulsant agents 2

From the Research

Appropriate Workup for a Possible Seizure

The workup for a possible seizure involves a comprehensive approach to diagnose and manage the condition. The following steps are recommended:

• A focused history and physical examination to identify provoking factors and differentiate seizures from mimics 3
• Laboratory and imaging tests may provide little benefit in definitive diagnosis in the emergency setting, but can help identify underlying causes 3
• For patients with an apparent seizure, resuscitation and management should be prioritized while identifying any provoking factors and treating them accordingly 3
• A comprehensive workup, including routine electroencephalography (EEG), brain computed tomography/magnetic resonance imaging, and specialized consultations, can be launched upon arrival in the emergency department 4
• Prompt neuroimaging to identify structural abnormalities should be obtained, complemented by laboratory findings to assess for underlying systemic causes 5
• The indication for EEG and lumbar puncture should be considered early based on clinical suspicion 5

Diagnostic Tools

The following diagnostic tools can be used to diagnose and manage seizures:

• Electroencephalogram (EEG) to monitor neurologic electrical activity and identify abnormal patterns 4, 6, 5
• Brain computed tomography/magnetic resonance imaging to identify structural abnormalities 4, 5
• Laboratory tests to assess for underlying systemic causes, such as metabolic derangements or infections 3, 5
• Lumbar puncture to assess for central nervous system infections or other conditions 5

Management

The management of seizures involves:

• Immediate antiseizure medication (ASM) therapy, which can improve prognosis and reduce recurrence rates 4
• Identification and treatment of provoking factors, such as metabolic derangements or structural brain lesions 3, 4
• Consideration of eHealth interventions, such as telemedicine, to optimize safety and health of patients with seizures 7