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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 3  |  Page : 125-128

Management of first seizure: An inductive reading to the local clinical parameters among libyan doctors


1 Department of Medicine, Benghazi Medical Center, Benghazi, Libya
2 Department of Medicine, Neurology Unit, University Hospital, Benghazi, Libya

Date of Submission15-Apr-2020
Date of Acceptance28-Jun-2020
Date of Web Publication21-Sep-2020

Correspondence Address:
Ashraf M Rajab
Department of Medicine, Neurology Unit, University Hospital, Benghazi
Libya
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/LJMS.LJMS_27_20

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  Abstract 


Background: Epilepsy is a common neurological disorder with the first onset of seizure represents a common cause of emergency department visit. Objectives: The objective of this study is to provide the data as well as to assess our local clinical practice parameters regarding the management of patients with first-onset seizure. Patients and Methods: A retrospective study was carried out using the medical records at 7th October hospital, included all patients admitted to the hospital with first seizure during the time period from “January 2013 to January 2014.” Results: Out of 145 patients presented with seizures, 52 (36%) patients presented with first seizure and admitted to the general medical ward and were managed by internist. The mean age of the study population was 45 ± 24 years, 26 (50%) patients were male. Thirteen (25%) patients had unprovoked seizure and 39 had provoked seizure with stroke being the most common cause. Brain scan and electroencephalogram were ordered in 28 (54%) and 16 (31%), respectively. Anti-epileptic drugs were prescribed to 32/52 (62%) patients, including all poststroke seizure patients and seven patients with unprovoked first seizure. Conclusion: We provided data regarding patients presenting with first seizure and insight into local practice regarding care of this group of patients. To our knowledge, such data were not reported before from our area. The findings were partly in agreement with evidence-based practice, though justification was still needed. The larger and more constructed study is warranted as “First Fit Presentation” is one of the common presentations in the emergency department.

Keywords: Antiepileptic drugs, brain imaging, first-onset seizure


How to cite this article:
Rajab AM, Bennour AM, Lawgaly SA. Management of first seizure: An inductive reading to the local clinical parameters among libyan doctors. Libyan J Med Sci 2020;4:125-8

How to cite this URL:
Rajab AM, Bennour AM, Lawgaly SA. Management of first seizure: An inductive reading to the local clinical parameters among libyan doctors. Libyan J Med Sci [serial online] 2020 [cited 2020 Oct 24];4:125-8. Available from: https://www.ljmsonline.com/text.asp?2020/4/3/125/295609




  Introduction Top


Epilepsy is a common chronic neurologic disorder, characterized by recurrent unprovoked seizure and affects 1%–3% of the population.[1] It is one of the most common neurological disorders in Benghazi, Libya, with a prevalence approaching 190\100,000.[2]

In general, around 10% of the population will have at least one seizure at some point in their lifetime.[3],[4] In the U. S. 150,000 adults present with first-onset seizures annually, and after a follow up only 40% of them tend to develop recurrent seizures, i.e., develop epilepsy.[5]

Accurate diagnosis of epilepsy from its first presentation is a crucial clinical step, as it is usually surrounded by great stigmata and wrong cultural believes. Furthermore, first-onset seizure is usually a worrisome event with serious social and medical consequences; therefore, careful evidence-based evaluation is essential to predict the recurrence of seizure. These include the presence of epileptiform activities in electroencephalogram (EEG), remote symptomatic seizures, abnormal brain imaging, nocturnal seizures, family history, and the presence of focal neurological deficit.[6]

The decision to treat a patient with a solitary unprovoked seizure is complex and requires a thorough consideration of various factors such as patient age, sex, comorbidities, and side effects of the treatment, in addition to the factors that predict recurrence. There is evidence that early initiation of antiepileptic drugs (AEDs) can significantly reduce the early recurrence and is preferable over deferring treatment.[7]

Because patients with first seizure are usually seen by physicians including emergency department doctors, and not necessarily neurologists, this study is intended to shed lights on attitude of physicians toward patients with first seizure.

Objectives

The objectives of this study are to provide data regarding patients with first-onset seizure, as well as to assess our local clinical pathway in managing this group of patients.


  Patients and Methods Top


A retrospective study was carried out using the medical records at 7th October hospital, included all patients admitted to the hospital with first seizure during the time period from “January 2013 to January 2014.” The study period was before the Libyan war when 7th October hospital was one of the four hospitals in Benghazi capable of looking after approximately 4000–5000 annual admissions. The local hospital protocol for the management of patients with first seizure includes admission of the patient to the general medical ward, first-line management by internist, and call to neurologist for decision-making regarding initiation of AEDs.

Statistical analyses were performed using the Statistical Package for the Social Sciences (Windows version 17; SPSS Inc., Chicago, IL, USA). Differences between the groups were tested using the unpaired t-test. Any result was considered statistically significant when the P value was 0.05 or less.


  Results Top


During the study period, a total of 4000 patients were admitted to the hospital, out of them 145 patients presented with seizures. Fifty-two out of 145 (36%) patients were admitted to general medical ward with first-onset seizure and were managed by internist. The mean age of the study population is 45 ± 24 years, 26 (50%) patients were male. Although female patients being slightly older than males (44 ± 23 vs. 46 ± 25), it was not statistically significant [Table 1]. However, patients with symptomatic seizures were significantly older than those with undetermined cause (mean age of 54 ± 23 vs. 25 ± 9 years, P = 0.001).
Table 1: Clinical characteristics of the study population

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The mean duration of hospitalization was 5.3 ± 3.5 days. There was no significant statistical difference between males and females, or between those with idiopathic or symptomatic seizure.

Study population according to type of seizure

Generalized tonic–clonic seizure constitute the majority of the patients (45; 86.5%), whereas seven (13.5%) patients had focal seizure [Table 1].

Study population according to cause of seizure

There were 13 (25%) patients had unprovoked seizure. The remaining patients have their seizure provoked by stroke (17; 33%), posttraumatic (4; 8%), drug addiction (9; 17%), central nervous system (CNS) infection (2; 4%), arrhythmia (1; 1.9%) and metabolic/electrolyte imbalance in 6 (11.5%) patients; hypoglycemia in two and hyponatremia in four patients [Table 1]. Among patients with cerebrovascular disease, 6/17 (35%) patients experienced early onset-seizures, in whom the time elapsed from stroke to seizure onset ranges from four to 8 days, whereas 11 (65%) patients had late onset poststroke seizure.

Study population according to diagnostic approach

Brain scan was ordered in 28/52 (54%) patients. EEG was ordered in 16 (31%) patients. Among patients with unprovoked seizure (n = 13), there were nine and eight patients underwent brain scan and EEG, respectively. Cerebrospinal fluid analysis was carried out in two patients (those with CNS infection).

Initiation of antiepileptic drugs

AEDs were prescribed to 32/52 (62%) patients. This included all patients with poststroke seizure, six of the drug-induced seizure, two postinfection, and seven of patients with unprovoked seizure. The other twenty patients in whom AEDs were not prescribed were referred to neurology out-patient clinic for decision-making regarding AEDs initiation. None of the metabolic derangement subgroup or of the posttraumatic seizures were prescribed AEDs.

Among AEDs, phenytoin, and carbamazepine were prescribed for patients with symptomatic seizure whereas sodium valproate was prescribed for patients with unprovoked seizure. During the time of the study, these three AEDs were constantly available and feasible to the patient.


  Discussion Top


Epilepsy is the fourth most common neurologic disorder, affecting 70 million people globally,[8] and unsurprisingly, it comes on the top of common neurologic diseases in Libya.[2] Furthermore, first seizure is the most terrifying life event a person can experience, and it is a common cause of hospital admissions.

This study evaluated the daily practice management of physician toward patients with first seizure. The study population represents patients with first seizure as nearly one-third of patients with established diagnosis of epilepsy. This figure is a little higher than that in Wyman et al. study.[9] We found equal proportions of men and women with an average age similar to other cohort[10],[11] which showed an average age of 40 years among patients with first unprovoked seizure. However, patients with symptomatic seizure were significantly older than those with undetermined cause. This can be explained by the fact that the majority of symptomatic seizures are poststroke seizures both early and late onset. In general terms, strokes represent up to 50% of epilepsy etiologies in elderly patients.[12] In addition, with an increasingly aging population, the magnitude of strokes and their complications including seizures and epilepsy are increasing.

As expected the main type of seizure in our patients is the generalized type. On the other hand, proportion of patients with unprovoked seizure was less than expected[13],[14] and is found to be more in females than males. However, in other larger reports, the incidence and prevalence of unprovoked seizure are found to be higher in men than women.[15]

When evaluating the diagnostic approach, we found that more than half of the study population underwent brain imaging and one third performed EEG. Magnetic resonance imaging (MRI) is the best method for structural imaging.[16] However, because the radiology center is located at a distance from the admitting hospital and the working hours are not available around the clock, our practice parameter is justified to do MRI in patients with first seizure whenever available and possible. Despite the fact that the yield of EEG reaches up to 70% in the first 24–48 h,[17] only one third of the study population performed EEG. This is attributed to the in-availability of routine EEG laboratory in the hospital, and therefore, referral of the patient to another center. This practice leads to delay in performing EEG and hence lowering the yield. The clinical practice in this regard needs further justification.

Giving the diagnosis of epilepsy does not represent only a considerable impact on the patient's social and psychological lives, but it extends beyond this to affect their health status by introducing a long term, if not, life-long AEDs. Initiation of AED to patient having first episode of seizure is more complex than that for patients experiencing two or more unprovoked seizures, as the decision must weigh the risk of seizure recurrence against the risks of side effects from chronic drug therapy. Furthermore, prescription of AEDs to patients with first unprovoked seizure remains debated as seizure recurrence can be stratified on the basis of clinical factors.[5] In our study, more than half of the studied patients were subjected to AEDs. Regarding patients with unprovoked seizures, AEDs were immediately instituted considering the fact that risk of seizure recurrence is likely to be reduced, and hence the psychological and social impact of seizure recurrence. Our clinical parameter in this issue is supported by Bao et al. results which determine preferable immediate AEDs in adult first seizure.[7] In contrast, AEDs were initiated in all patients with poststroke seizure. This is because all of patients with poststroke seizure in our study exhibit focal structural brain deficit which carries the high risk of seizure recurrence. In this regard, we should emphasize that our study is a retrospective study, and no follow-up data concerning seizure recurrence or use of AEDs can be withdrawn. One study highlighted that early poststroke seizures (defined as fits within 2 weeks of stroke onset) tend not to recur and hence AEDs can be awaited.[12],[18] Although up to 20% of all people with stroke develop poststroke seizures at some stage, only a sub set of this group will develop epilepsy.[18] Accordingly, careful assessment on an individual basis should be carried out to poststroke seizure patients.[6],[8] On the other hand, patients with metabolic/electrolyte disturbances were not subjected to treatment with AEDs as they have minor risk of subsequent epilepsy. In patients with posttraumatic head injury, AEDs were not initiated based on their clinical history of recent head trauma in three patients, while one patient had remote history of subdural hematoma. These patients were advised to follow-up neurology clinic for decision-making regarding AEDs. In patients whose seizures are attributed to drugs, the reason to start AEDs was not clear as four of them had normal computed tomography brain. In this regard, the application of evidence-based guidelines is of paramount importance, and hence, dissemination of the currently existing guidelines would sharpen the decision of whether or not to start AEDs and will lend more confidence to doctors reassuring their patients.


  Conclusion Top


We provided the data regarding the management of patients with first seizure, and the results were partly in agreement with evidence-based practice, though more justifications still needed. The results cannot be generalized because the study is a single centered and contains a small sample size. Larger and more constructed study is warranted as first seizure is a common and important neurologic issue.

Acknowledgment

We thank the department of archiving and file system at October 7 hospital for their cooperation to get an access in reviewing the medical records.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shneker BF, Fountain NB. Epilepsy. Dis Mon 2003;49:426-78.  Back to cited text no. 1
    
2.
Benamer HT. Neurological disorders in Libya: An overview. Neuroepidemiology 2007;29:143-9.  Back to cited text no. 2
    
3.
Ngugi AK, Kariuki SM, Bottomley C, Kleinschmidt I, Sander JW, Newton CR. Incidence of epilepsy: A systematic review and meta-analysis. Neurology 2011;77:1005-12.  Back to cited text no. 3
    
4.
Hauser WA, Beghi E. First seizure definitions and worldwide incidence and mortality. Epilepsia 2008;49 Suppl 1:8-12.  Back to cited text no. 4
    
5.
Krumholz A, Wiebe S, Gronseth G, Shinnar S, Levisohn P, Ting T, et al. Practice parameter: Evaluating an apparent unprovoked first seizure in adults (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007;69:1996-2007.  Back to cited text no. 5
    
6.
Krumholz A, Wiebe S, Gronseth GS, Gloss DS, Sanchez AM, Kabir AA, et al. Report of the Guideline Development Subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2015;84:1705-13.  Back to cited text no. 6
    
7.
Bao EL, Chao LY, Ni P, Moura LM, Cole AJ, Cash SS, et al. Antiepileptic drug treatment after an unprovoked first seizure: A decision analysis. Neurology 2018;91:e1429-39.  Back to cited text no. 7
    
8.
Zack MM, Kobau R. National and State Estimates of the Numbers of Adults and Children with Active Epilepsy-United States, 2015. MMWR Morb Mortal Wkly Rep 2017;66:821-5.  Back to cited text no. 8
    
9.
Wyman AJ, Mayes BN, Hernandez-Nino J, Rozario N, Beverly SK, Asimos AW. The First-Time Seizure Emergency Department Electroencephalogram Study. Ann Emerg Med 2017;69:184-910.  Back to cited text no. 9
    
10.
Hopkins A, Garman A, Clarke C. The first seizure in adult life. Value of clinical features, electroencephalography, and computerised tomographic scanning in prediction of seizure recurrence. Lancet 1988;1:721-6.  Back to cited text no. 10
    
11.
van Donselaar CA, Schimsheimer RJ, Geerts AT, Declerck AC. Value of the encephalogram in adult patients with untreatedidiopathic first seizure. Arch Neurol 1992;49:231-7.  Back to cited text no. 11
    
12.
Silverman IE, Restrepo L, Mathews GC. Poststroke seizures. Arch Neurol 2002;59:195-201.  Back to cited text no. 12
    
13.
Hart YM, Sander JW, Johnson AL, Shorvon SD. National General Practice Study of epilepsy: Recurrence after a seizure. Lancet 1990;336:1271-4.  Back to cited text no. 13
    
14.
Annegers JF, Hauser WA, Lee JR, Rocca WA. Incidence of acute symptomatic seizures in Rochester, Minnesota, 1935-1984. Epilepsia 1995;36:327-33.  Back to cited text no. 14
    
15.
Kotsopoulos IA, van Merode T, Kessels FG, de Krom MC, Knottnerus JA. Systematic review and meta-analysis of incidence studies of epilepsy and unprovoked seizures. Epilepsia 2002;43:1402-9.  Back to cited text no. 15
    
16.
American College of Emergency Physician, American Academy of Neurology, American Association of Neurological Surgeons, American Society of Neuroradiology. Practice Parameters: Neuroimaging in the emergency patient presenting with seizure (summary statement). Ann Emerg Med 1996;28:114-8.  Back to cited text no. 16
    
17.
Schreiner A, Pohlmann-Eden B. Value of the early electroencephalogram after a first unprovoked seizure. Clin Electroencephalogr 2003;34:140-4.  Back to cited text no. 17
    
18.
Camilo O, Goldstein LB. Seizure and epilepsy after ischemic stroke. Stroke 2004,35:1769-1775.  Back to cited text no. 18
    



 
 
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