00:01
So in summary, the diagnostic investigation
of a patient with a first time seizure
is focused on figuring out the
risk of a second seizure event.
00:09
What is the risk of
a second seizure?
At 3 years in general,
the risk is 40%.
00:15
And we're using our
findings on history,
physical examination,
EEG and MRI
to determine whether that risk is
higher than 40% or lower than 40%.
00:26
Risk of a seizure with early and late
treatment is still around 76 to 77%.
00:31
So regardless of whether we
initiate early treatment or not,
the risk of a second
seizure is about the same.
00:38
And so typically, for a first time
seizure, we would not initiate treatment.
00:42
But there's some characteristics
that raise our concern.
00:46
So I'm going to walk through
a table that can help us to
see and understand
these findings.
00:51
What we're looking at here is
the risk of a second seizure.
00:54
And again, we said the risk of a
second seizure in general is about 40%.
00:59
If we look on history about whether the
patient has a remote history of seizure.
01:03
If there's no history of
seizure, that risk stays at 40%.
01:07
If the patient has a
history of febrile seizures,
or a post traumatic seizure many years
ago, the risk goes up to 60%.
01:14
And we'd be more concerned.
01:16
When we think about
the seizure type,
a generalized seizure,
the risk of second seizure is 40%.
01:21
With a focal onset or partial onset
seizure, that risk is higher at 60%.
01:26
If the EEG is normal, our second
seizure risk goes down to 26%, it's low.
01:31
If abnormal, it's up to 56%.
01:35
And if we think about
the state of the patient
seizures happening out of
awakeness, that risk is low.
01:40
But out of sleep,
the risk of second seizure goes high.
01:43
So again,
we're using these findings
to determine what the risk
of a second seizure is,
and that will be used to calibrate
whether we want to start treatment or not.
01:53
The last thing we think about
when evaluating patients
with the first time
seizure is counselling.
01:58
And really counselling for the event
if a second seizure were to occur.
02:02
We think about
seizure precautions,
what patients should do and not do
given the risk of a potential seizure.
02:08
Seizure, first aid what a caregiver
should do at the time of a second seizure,
and in general
patient education.
02:15
So how dangerous is a seizure?
Seizures actually aren't life
threatening in most situations.
02:21
In terms of the primary
risk of the seizure,
brain injury is unlikely
unless there's very prolonged
tonic-clonic activity or
severe status epilepticus.
02:31
Ictal apnea can occur,
but it's very rare except in neonates
and so patients usually don't
stop breathing during a seizure.
02:39
SUDEP which is sudden unexplained
death and epilepsy is a risk,
and that's the one life
threatening risk in epilepsy.
02:48
We don't know why patients die
in some situations with epilepsy.
02:52
That's why it's sudden
unexplained death in epilepsy.
02:56
This tends to be more common or
more commonly occur in patients
with refractory epilepsy that
occur frequently at night.
03:02
But in general, the risk of dying
during a seizure is very low.
03:07
There are potential
secondary risks.
03:09
When patients are
bathing or swimming,
a seizure could cause them to drown or
patients could drown during their seizure.
03:16
When driving patients could
suffer from an accident.
03:19
And then there are various activities
where we would be concerned
if the patient lost consciousness
that could lead to injury.
03:25
And so when thinking
about seizure precautions,
we counselled them not to take
bus unattended or swim unattended.
03:32
Patients are not allowed to drive and
there's varying rules and regulations
about when patients can go back
to driving after a seizure.
03:38
And various activities where if the
patient were to lose consciousness
or have altered awareness,
we would counsel against those.
03:46
In terms of seizures at home,
we counsel patients on first aid
what to do if a seizure happens.
03:51
Patient should be placed
in a safe position,
typically on their lateral
side, laying on their side.
03:58
Patients and caregivers or caregivers
should clear everything out away
from the patient so they can't
hurt themselves during the event.
04:05
We ask family members not to restrain
movements or restrain patients
and not to stick anything
into a patient's mouth.
04:11
Patients may bite their tongue,
they won't bite their tongue off.
04:14
And with anything in their mouth
that won't prevent the tongue biting
just put them at risk for having an
injury from that being in their mouth.
04:21
And we ask family members to
stay away from the patient,
and about 90 to 95% of seizures will
resolve spontaneously within 1-3 minutes.
04:30
For patients with a first time
seizure who suffer a second seizure,
we would typically ask for the patient
to come in for emergent evaluation.
04:38
To evaluate what may be causing
that and to initiate treatment.
04:42
For patients with refractory
epilepsy that have frequent seizures.
04:45
Many stay at home during
or after a seizure
and can be managed over
the phone or in the clinic
for further evaluation
of their epilepsy.