Epileptic seizures are one of the three commonest neurological emergencies (1). A first seizure is a life changing experience for many patients, especially when it is an initial presentation of epilepsy (i.e. a chronic disorder characterised by an increased risk of unprovoked seizures). However, it could also be a provoked seizure caused by transient factors acting on an otherwise normal brain, an acute symptomatic seizure (occurring at the time of a systemic insult or shortly after such an insult) or a remote symptomatic seizure (related to a pre-existing brain injury or abnormality). In all of these scenarios a first seizure is not only worrying in itself but also raises immediate concerns about the underlying cause, which may require urgent treatment.
The first seizure presentation therefore raises a host of questions. The present “in focus” issue of Seizure edited by Bernhard Pohlmann-Eden and Jorge Burneo addresses many of these. For example, my Editor’s Choice by Syed Rizvi et al. focuses on the important question how to identify patients at increased risk of further seizures (2). Their narrative review based on 82 scientific publications states that, overall, the risk of recurrence after a first seizure is about 30% by five years. However, the recurrence risk varies greatly between different groups of patients. For instance a history of a previous brain injury increases the recurrence risk by a factor of 2.5. Focal or nocturnal seizures, epileptiform discharges on EEG and neuroimaging abnormalities also increase the risk of seizure recurrence. Rizvi et al. recommend rapid access to first seizure clinics as the ideal place to coordinate appropriate investigations and provide advice.
While particularly highlighting this paper as my Editor’s Choice, I would also like to recommend the other papers about the first seizure presentation in the current ‘in-focus’ issue of Seizure which explore the important topics of history taking and examination in patients with a first seizure (3), counselling (4), EEG (5), neuroimaging (6), psychiatric abnormalities (7) and cognitive problems (8). Last but not least two contributions argue for and against the use of antiepileptic drugs after a first seizure (9-10).
(1) Dickson, J.M.; Taylor, L.H.; Shewan, J.; Baldwin, T.; Gruenewald, R.A.; Reuber, M. A Cross-Sectional Study of the Pre-hospital Management of Patients With a Suspected Seizure (EPIC1). BMJ Open. 2016;6(e010573),1-10
(2) Rizvi, S.; Ladino D.; Hernandez-Ronquillo, L.; Tellez-Zenteno, J. Epidemiology of Early Stages of Epilepsy: Risk of seizure recurrence after a first seizure. Seizure 2017; 49: 46-53
(3) Nowacki, T.A.; Jirsch, J.D. Evaluation of the First Seizure Patient: Key Points in the History and Physical Examination. Seizure 2017; 49: 54-63
(4) Legg, K.T.; Newton, M. Counselling adults who experience a first seizure. Seizure 2017; 49: 64-68
(5) Debicki, D.B. Electroencephalography after a single unprovoked seizure. Seizure 2017; 49: 69-73
(6) Crocker, C.E.; Pohlmann-Eden, B.; Schmidt, M.H. Role of Neuroimaging in First Seizure Diagnosis. Seizure 2017; 49: 74-78
(7) Kanner, A.M. Psychiatric Comorbidities in New Onset Epilepsy: Should they be always investigated?. Seizure 2017; 49: 79-82
(8) Helmstaedter, C.; Witt, JA. Epilepsy and cognition - a bidirectional relationship?. Seizure 2017; 49: 83-89
(9) Olmes, D.G.; Hamer, H.M. The debate: Treatment after the first seizure - the PRO. Seizure 2017; 49: 90-91
(10) Steinhoff, B.J. The debate: Treatment after the first seizure - the CONTRA. Seizure 2017; 49: 92-94