Seizures and epilepsy in the acute medical setting: presentation and management

Article Figures & Data

Table 1.

The Sheldon questionnaire. The patient has seizures if point score ≥1, and syncope if score is <1. The same questions can be asked of a witness

Questions shown to distinguish seizures from syncope	Points (if yes)

At times do you wake with a cut tongue after your spells?	2
At times do you have a sense of déjà vu or jamais vu before your spells?	1
At times is emotional stress associated with losing consciousness?	1
Has anyone noted your head turning during a spell?	1
Has anyone ever noted that you are unresponsive, have unusual posturing or have jerking limbs during your spells or have no memory of your spells afterwards? (Score as yes for any positive response)	1
Has anyone ever noted that you are confused after a spell?	1
Have you ever had lightheaded spells?	-2
At times do you sweat before your spells?	-2
Is prolonged sitting or standing associated with your spells?	-2

Table 2.

Parameters for acute symptomatic seizures proposed by the International League against Epilepsy

Provoking insult	Time-frame
Stroke/hypoxia	<1 week
Traumatic brain injury without subdural haematoma	<1 week
Traumatic brain injury with subdural haematoma	Up to 1 month
Intracranial surgery	<1 week
Arteriovenous malformation at time of haemorrhage	<1 week
CNS infection	Until laboratory and clinical signs of infection have resolved
Multiple sclerosis	<1 week (of relapse)
Alcohol withdrawal	7–48 hours from last alcoholic drink
Serum glucose (within 24 hours)	<36 mg/dL (2 mM) or >450 mg/dL (25 mM) and ketoacidosis
Serum sodium (within 24 hours)	<115 mg/dL (<5 mM)
Serum calcium (within 24 hours)	<5 mg/dL (<1.2 mM)
Serum magnesium (within 24 hours)	<0.8 mg/dL (<0.3 mM)
Urea nitrogen (within 24 hours)	>100 mg/dL (>35.7 mM)
Creatinine (within 24 hours)	>10 mg/dL (>884 uM)

Adapted with permission from Beghi et al, 2010.¹⁴ CNS = central nervous system

Box 1.

Indications for urgent brain imaging and/or hospital admission

Indications for urgent brain imaging ^a and/or hospital admission

Acute head trauma

New onset focal neurologic deficit

Altered mental status persists (behaviour or cognition)

Recurrent events

Persistent headache

Anticoagulation

A history of immunodeficiency or malignancy

Fever

Focal seizure (partial seizure)

New neurological symptoms prior to the seizure

Patients in whom follow-up cannot be ensured

^aUrgent imaging is not required for syncope, non-epileptic seizures, or patients with well-characterised epilepsy or recurrent admissions with drug/alcohol-provoked seizures in the absence of any additional reason to suspect new intracranial pathology