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Differentiating seizure-induced reversible MRI abnormalities from MRI changes secondary to underlying cerebral pathologies can be challenging for clinicians in the investigation of seizures. The aim of this study was to delineate the characteristic features of reversible seizure-induced MRI abnormalities. A systematic search of the databases Medline (1946-2020), PubMed (1996-2020), and Embase (1947-2020) was performed in keeping with the Preferred Items Reporting for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All publications in English, including case reports, of single unprovoked seizure patients with seizure-induced MRI abnormalities demonstrating complete resolution, were included. Two authors extracted data using a predefined template and evaluated the quality of the included studies. MRI data were additionally reviewed by a neuroradiologist. All data were synthesised qualitatively. There were 11 publications altogether, yielding a total of 27 cases that were pertinent to our research question. Abnormalities were most commonly observed on T2-weighted sequences. The most commonly observed constellations of MRI features ("composite pattern") included the following: cortical or subcortical signal change with or without leptomeningeal enhancement, signal abnormality in the splenium of the corpus callosum, and hippocampal signal abnormality. Seizure-induced reversible MRI abnormalities were observed as early as six hours from seizure onset and resolved completely as early as five days from seizure onset. A key limitation of this systematic review was the variability and incomplete reporting of clinical data, especially with regards to seizure semiology and MRI sequences performed, which may have limited our ability to make more definitive conclusions. Seizure-induced reversible MRI changes may appear within hours of seizure onset and resolve within a variable time frame, ranging from days to weeks. Bilateral seizure-induced reversible MRI abnormalities tend to be associated with generalised seizures while unilateral seizure-induced reversible MRI abnormalities may be associated with focal seizures, usually ipsilateral to the seizure focus.

The identification of the aetiology of a patient's epilepsy is instrumental in the diagnosis, prognostic counselling and management of the epilepsies. Indeed, the aetiology can be important for determining the recurrence risk of single seizures and so for making a diagnosis of epilepsy. Here, we divide the aetiologies into six categories: structural, genetic, infectious, metabolic, immune (all of which are part of the International League Against Epilepsy [ILAE] classification system) and neurodegenerative (which we have considered separately because of its growing importance in epilepsy). These are not mutually exclusive categories and many aetiologies fall into more than one category. Indeed, genetic factors probably play a role, to varying degrees, in the risk of seizures in all people with epilepsy. In each of the categories, we discuss what we regard as the most important aetiologies; importance being determined not only by prevalence but also by clinical significance. The introduction contains information suitable for level 1 competency (entry level), whilst the subsequent sections contain information aimed at level 2 competency (proficiency level) as part of the new ILAE competency-based curriculum. As we move towards precision medicine and targeted therapies, so aetiologies will play an even greater role in the management of epilepsy.

Highlights • Model predicts risk of seizure recurrence after single fit or epilepsy diagnosis. • Model performs well in independent data. • Future work required to ensure the model is adopted in clinical practice. • Model can improve the lives of people with single seizures and early epilepsy., Purpose Following a single seizure, or recent epilepsy diagnosis, it is difficult to balance risk of medication side effects with the potential to prevent seizure recurrence. A prediction model was developed and validated enabling risk stratification which in turn informs treatment decisions and individualises counselling. Methods Data from a randomised controlled trial was used to develop a prediction model for risk of seizure recurrence following a first seizure or diagnosis of epilepsy. Time-to-event data was modelled via Cox's proportional hazards regression. Model validity was assessed via discrimination and calibration using the original dataset and also using three external datasets – National General Practice Survey of Epilepsy (NGPSE), Western Australian first seizure database (WA) and FIRST (Italian dataset of people with first tonic-clonic seizures). Results People with neurological deficit, focal seizures, abnormal EEG, not indicated for CT/MRI scan, or not immediately treated have a significantly higher risk of seizure recurrence. Discrimination was fair and consistent across the datasets (c-statistics: 0.555 (NGPSE); 0.558 (WA); 0.597 (FIRST)). Calibration plots showed good agreement between observed and predicted probabilities in NGPSE at one and three years. Plots for WA and FIRST showed poorer agreement with the model underpredicting risk in WA, and over-predicting in FIRST. This was resolved following model recalibration. Conclusion The model performs well in independent data especially when recalibrated. It should now be used in clinical practice as it can improve the lives of people with single seizures and early epilepsy by enabling targeted treatment choices and more informed patient counselling.

Suspected epileptic seizures are a frequent cause of emergency hospital care. After single seizures, the emergency management includes safety measures and diagnostic efforts to distinguish epileptic seizures from its manifold mimics and to possibly detect acute causes of epileptic seizures. Convulsive status epilepticus requires rapid anticonvulsant treatment according to established protocols and diagnostics to rule out underlying acute brain diseases. After a first seizure, typical EEG- and MRI findings may indicate an elevated recurrence risk, thereby justifying the ultimate diagnosis of epilepsy and initiation of anticonvulsant therapy. This article reviews the recent definition of epilepsy, summarizes clinical characteristics of epileptic seizures and its mimics and provides an overview of established therapies of single convulsive seizures, convulsive status epilepticus and early care of adults after first unprovoked seizures.

Analyzing and discussing the relationship between brain injury in preterm infants and related risk factors can provide evidence for perinatal prevention and early intervention of brain injury in preterm infants, thereby improving the quality of life of preterm infants. This paper selects term preterm infants diagnosed with preterm infant asphyxia in the NICU of a university’s First Affiliated Hospital from January 2018 to February 2019 as the research object. In addition, healthy term infants born at the same time in the obstetric department of this hospital are selected as the control group. Both groups of premature infants were monitored for brain function within 6 hours after birth. The aEEG results range from background activity (continuous normal voltage, discontinuous normal voltage, burst suppression, continuous low voltage, and plateau) and sleep-wake cycle (no sleep-wake cycle, immature, and mature sleep-wake cycle) to epileptic activity (single seizures, recurrent seizures, and status epilepticus), three aspects to judge. Statistical analysis uses SPSS 17.0 software. Amplitude-integrated EEG is a simplified form of continuous EEG recording. The trace of the trace represents the voltage change signal of the entire EEG background activity, which can reflect the EEG amplitude, frequency, burst-inhibition, and other pieces of information. aEEG can reflect the degree of HIE lesions in premature infants and the long-term prognosis. It is easy to operate and effective in diagnosis and can be continuously monitored. It is worthy of clinical popularization. There is a good correlation between the expression of EEG and biomarkers. Combining multiple methods can diagnose HIE earlier and evaluate the prognosis.

BACKGROUND Cerebrospinal fluid (CSF) lactate concentrations increase after seizure activity in many human patients independent of the underlying disease process. The effect of seizure activity on CSF lactate concentration in dogs is unknown. HYPOTHESIS/OBJECTIVES Cerebrospinal fluid lactate concentration is unaffected by seizure activity in dogs and is more dependent on the underlying disease process causing the seizures. ANIMALS One-hundred eighteen client-owned dogs with seizure disorders. METHODS Case series. Cerebrospinal fluid lactate concentration was determined using a commercially available lactate monitor. Seizure semiology, time from last seizure to CSF collection, number of seizures within the 72 hours preceding CSF collection, and clinical diagnosis were recorded. RESULTS Dogs with focal seizures had higher CSF lactate concentrations than did those with generalized seizures (P = .03). No differences in lactate concentrations were found among dogs with single seizures, cluster seizures or status epilepticus (P = .12), among dogs with CSF collection at different time points after the last seizure activity (P = .39) or among dogs having different numbers of seizures within the 72 hours preceding CSF collection (P = .42). A significant difference (P = .001) was found in CSF lactate concentrations among diagnostic groups, and dogs with inflammatory and neoplastic disease had higher concentrations than did dogs with idiopathic or unknown epilepsy. CONCLUSIONS AND CLINICAL IMPORTANCE Cerebrospinal fluid lactate concentration is minimally affected by seizure activity in dogs and increased concentrations are more likely associated with the underlying disease process.

In electroencephalography books, relative significance is given to “status epilepticus” (SE), maybe because of the idea that it could only be a simple repetition of seizures in a very short time from one another. Actually, at least two factors contribute making the EEG patterns of SE much more complex: the first is the overlapping of the transients related to the seizures with those related to underlying disease, and the second is the EEG modification related to a sustained or prolonged status epilepticus. The EEG of the SE can thus follow its graphic expression which is different from that of single seizures repeated over time, coming up to express critical patterns that are not always easily recognizable. The elements of pathophysiology and clinical electroencephalographic practice show that the SE is a dynamic pathological process that expresses itself in a different manner from patient to patient depending on its etiology, duration, topographic extension, clinical manifestation, and therapeutic interventions that are carried out. The proposed classification of SE in 2015 (Trinka et al., Epilepsia 56(10):1515–23, 2015) establishes the importance of EEG in the diagnosis and management of the SE by including the EEG axial description to define a correct classification of the patient.

We investigated long-term (to 25 years) seizure prognosis and survival in people with newly diagnosed epilepsy in the community. We explored whether prognosis is different in those with epilepsy (>2 unprovoked seizures) and those with a single seizure at presentation. This is a prospective observational cohort study of people with newly diagnosed seizures. We investigated seizure outcome and survival in people presenting with a single seizure and in those presenting with >2 seizures (epilepsy). 695 people (median follow-up 23.6 years) had unprovoked epileptic seizures. For seizure analysis we excluded 38 people with missing data leaving 657 (309 male, and 249 aged

Links between deficits identified on neurological examination, age of seizure onset and the presence of structural forebrain disease have often been postulated in dogs presenting with a history of seizures. The purpose of this study was to assess the influence of such factors on the likelihood of structural or functional brain disease, via a thorough history taking process and interictal neurological examination. Four hundred and four dogs with seizures due to intracranial causes were included. Data including age, sex, neuter status, time until diagnosis, age of seizure onset in years, type of seizure, seizure symmetry, seizure severity, interictal neurological deficits, MRI changes and side effects associated with antiepileptic drugs were extracted from medical files. Two hundred and fifty-eight dogs were diagnosed with epilepsy of unknown origin (EUO), 11 with symmetrical structural lesions and 135 with asymmetrical structural lesions. Multinomial analysis demonstrated that dogs that were older at seizure onset were significantly more likely to have an asymmetrical structural lesion than EUO (OR 95% CI: 1.4–1.8). Dogs that had single seizures rather than cluster seizures were less likely to have asymmetrical structural lesions than dogs with EUO (OR 95% CI: 0.2–0.7). Dogs with abnormal neurological examinations were 16.5 times more likely to have asymmetrical structural lesions (OR 95% CI: 8.5–32.1) and 12.5 times more likely to have symmetrical structural lesions (OR 95% CI: 3.0–52.3) than EUO. These findings support the importance of considering interictal neurological deficits and seizure history in clinical reasoning.

PurposeTo analyze the electroclinical features and evolution of patients diagnosed with convulsions with mild gastroenteritis (CwG) from southwest China.MethodsWe reviewed and analyzed the medical records of 34 patients (13 males) diagnosed with CwG and followed-up for at least 12 months.ResultsThe age of onset was 6–29 months and the female/male ratio 1.62. Seizures were generalized in 32 cases. Single seizures in 15 cases were

In the Multi-Centre Study of Early Epilepsy and Single Seizures (MESS), patients were randomly allocated to immediate or delayed antiepileptic drug treatment. For time to first seizure recurrence, MESS provides strong evidence of an effect for carbamazepine as monotherapy but mixed evidence of an effect for valproate.

We consider the analysis of data from the MRC Multicentre Trial for Early Epilepsy and Single Seizures (MESS), which was undertaken to assess the differences between two policies: immediate, or deferred treatment in patients with single seizures or early epilepsy. In studies of recurrent events, like epileptic seizures, there is typically lots of information about individuals' seizure patterns over a period of time, which is often not fully utilised in analysis. We develop methodology that allows pre-randomisation seizure counts and multiple post-randomisation survival times to be jointly modelled, assuming that both these outcomes are predicted by (unobserved) seizure rates. The joint model was found to be superior to standard survival methods, although interesting characteristics within the data, not present in the model were also highlighted. We consider modifications to the joint model to accommodate these properties.

Summary: Neuron-specific enolase (NSE) is a marker of brain injury after acute neurologic insults. We report changes in serum NSE (s-NSE) in 25 patients (15 with epilepsy and 10 patients with nonepileptic events) during continuous inpatient video/EEG monitoring. s-NSE was significantly increased as compared with baseline and normal controls after the first ictal event in the epileptic group, especially in patients with secondarily generalized tonic-clonic seizures (p = 0.01), but s-NSE was not increased in patients with nonepileptic events. These preliminary data indicate that s-NSE may be increased after complex partial seizures-and generalized tonic-clonic seizures (GTCS).

In this paper, we consider the analysis of recurrent event data that examines the differences between two treatments. The outcomes that are considered in the analysis are the pre-randomisation event count and post-randomisation times to first and second events with associated cure fractions. We develop methods that allow pre-randomisation counts and two post-randomisation survival times to be jointly modelled under a Poisson process framework, assuming that outcomes are predicted by (unobserved) event rates. We apply these methods to data that examine the difference between immediate and deferred treatment policies in patients presenting with single seizures or early epilepsy. We find evidence to suggest that post-randomisation seizure rates change at randomisation and following a first seizure after randomisation. We also find that there are cure rates associated with the post-randomisation times to first and second seizures. The increase in power over standard survival techniques, offered by the joint models that we propose, resulted in more precise estimates of the treatment effect and the ability to detect interactions with covariate effects.

The relationships between the effects of seizures on hormones and the influences of hormones on seizures crosses anatomic boundaries and medical specialties. This article focuses on these interrelationships in men and women with epilepsy. Anatomic and physiologic connections between limbic structures and the hypothalamus are reviewed, as are the neuroendocrine aspects of single seizures and reproductive endocrine disorders.

Publisher Summary This chapter focuses primarily on data from epidemiological studies and randomized controlled trials that have addressed prognosis and outcome for patients with single seizures and early epilepsy. For patients with a single seizure or early epilepsy, when compared to deferred treatment, immediate treatment with one of the current firstline antiepileptic drugs reduces the risk of seizure recurrence, but has no impact on the longer-term seizure outcome in epilepsy. Consensus holds that antiepileptic drug treatment should be initiated for the majority of patients who have had two or more seizures, as the risk of recurrence is high, although the aim of treatment is to control seizures rather than influence the natural history of epilepsy. For patients with a single seizure, the recurrence risk is generally low, and there is a trade-off between preventing seizures and adverse effects of antiepileptic drugs such that neither policy is associated with overall quality-of-life gains. Patients can be identified at a low, medium, and high risk of seizure recurrence to aid patients and clinicians in discussions regarding the pros and cons of starting antiepileptic drug treatment following a single seizure.

Decisions about when to start or to stop antiepileptic drug (AED) treatment must be informed by reliable information of the natural history of epilepsy, the effect of treatment, and the social context of the individual. Ultimately the patient will be the decision maker, the clinician or health-care professional, the provider and interpreter of information. While observational studies will provide information on natural history, the most reliable information on the effect of intervention will come from randomised controlled trials in relevant populations of patients. However, these need to be large enough to allow interpretation not just of the average effect across the recruited patients, but also some estimate of the effects for an individual based on the prognostic effects that most effect outcomes. When trials are of sufficient size they can allow the development of predictive models that assist decision making. The Medical Research Council studies of AED withdrawal and early epilepsy and single seizures provide examples of such trials.

As in Clark and Prout's classic work, we identify three phases of generalised convulsive status epilepticus, which we call impending, established, and subtle. We review physiological and subcellular changes that might play a part in the transition from single seizures to status epilepticus and in the development of time-dependent pharmacoresistance. We review the principles underlying the treatment of status epilepticus and suggest that prehospital treatment is beneficial, that therapeutic drugs should be used in rapid sequence according to a defined protocol, and that refractory status epilepticus should be treated with general anaesthesia. We comment on our preference for drugs with a short elimination half-life and discuss some therapeutic choices.

Commentary on: LJ Bonnett, C Tudur-Smith, PR Williamson, et al.. Risk of recurrence after a first seizure and implications for driving: further analysis of the Multicentre study of early Epilepsy and Single Seizures. BMJ2010;341:c6477.

This study considered the management of first seizures in adults in Stirling Royal Infirmary over a six month period. Thirty-four patients presented of whom 19 were admitted to medical wards. Alcohol was implicated in 35% of cases. Blood tests were done in many but provided little useful information. CT Scan was performed in 53% and was abnormal in 15% (five patients). EEG was requested for 21% and failed to influence management in any. Six patients (18%) were started on anticonvulsant therapy. It was recorded in only three cases that advice on driving had been given. The literature concerning single seizures is complex, especially with regards to recurrence risk and treatment benefits. We await with interest the publication of the SIGN (Scottish Intercollegiate Guidelines Network) guidelines for seizure investigation and treatment in Scotland.

Among 55 patients undergoing temporal lobectomy for refractory epilepsy, patients with seizures in the week following surgery had a poor long-term, seizure-free outcome compared with patients without seizures. Outcome for patients with single seizures or seizures restricted to the first postoperative day seemed favorable compared with patients with multiple or later seizures. Seizure type and similarity to preoperative events did not predict outcome.

Source Citation Marson A, Jacoby A, Johnson A, et al. Immediate versus deferred antiepileptic drug treatment for early epilepsy and single seizures: a randomised controlled trial. Lancet. 2005;365:...

EDITOR,—Ronald A Schoenenberger and Sabine M Heim suggest that cerebral imaging after a single seizure may be unnecessary if a score of >/= 3 is elicited with the CAGE questionnaire (a screening questionnaire on alcohol misuse).1 Their study raises several related issues that merit further comment. Focal cerebral lesions thought …

Summary In the last decade community and hospital-based studies of epilepsy from the onset of the disorder have revealed a much more favorable prognosis for seizure control than previously reported. Approximately three-quarters of newly diagnosed patients can enter a prolonged remission on currently available medication. The natural history of untreated epilepsy is unknown but there is some evidence of an escalating process in the early stages in patients with tonic-clonic seizures. The first two years of treatment seem to be important in determining the subsequent course of epilepsy. The longer seizures continue, the less likely they are to b: controlled. Early effective treatment may be important in preventing the evolution of chronic epilepsy. These observations have implications for the management of patients with single seizures.

Of 53 patients with drug-induced seizures seen in the last decade, 45% had single seizures, 40% had multiple convulsions, and 15% had status epilepticus. Generalized seizures with focal features were common, but simple partial (motor) seizures occurred in only two patients. Isoniazid, insulin, lidocaine, and psychotropic medications were the most common drugs that caused seizures. Forty-nine patients recovered without ill effects, but 4 patients died of cardiovascular complications. The combined cardiovascular toxicity of the convulsants, antidotes, and anticonvulsants was more important than the number or duration of seizures in determining outcome.

The serum concentration of prolactin is frequently increased after single epileptic seizures and has therefore been used as a method to differentiate between hysterical attacks and epileptic seizures. We determined plasma prolactin concentrations in fifteen patients with status epilepticus. Seven patients had absence status, five complex partial and three generalised tonic-clonic status epilepticus. Prolactin levels were normal in all patients which indicates that, in contrast to single seizures, status epilepticus is not associated with an increase in serum prolactin.

A total of 122 patients with a history of non-febrile epileptic seizures were identified in a survey of 6000 persons from a single general practice. The lifetime prevalence was 20.3/1000 including single seizures and 17.0/1000 excluding single seizures; 5.3/1000 had active epilepsy. Diagnosis and classification of seizures in such a survey were difficult. Most patients were seen by a hospital specialist at some point, but hospital follow up was sporadic. Overall patient assessment and monitoring was poor. There is a place for specialised epilepsy clinics that could be organised along the lines of the clinics for diabetes. These provide facilities for initial diagnosis and assessment, for planning long term management, for the selected follow up of difficult cases, and for referral for specific problems. Such a system would improve the long term care of patients with epilepsy.

• To determine the usefulness of cranial computed tomography (CCT) in adults with a single seizure, we prospectively examined 62 such patients who were initially seen within 24 hours of the event. Age range was 16 to 86 years. Seizure was partial in ten patients and generalized in 52. Neurologic examination results were abnormal in 28 and normal in 34. Laboratory studies, including EEG and CCT, were completed within the subsequent 24 hours. In 29 patients, CCT was abnormal. Only nine of them had normal neurologic examination results, and only four also had a normal EEG. In these, generalized atrophy was the only CCT abnormality. None of the nine occurred in patients aged 16 to 30 years. We concluded that CCT is not essential for patients aged 16 to 30 years who have normal examination results. In patients aged 31 years or older with normal examination results and normal EEG, CCT may be abnormal but is unlikely to provide essential information. Irrespective of age or seizure type, CCT is useful and essential in patients with abnormal neurologic examination results.