Fits/seizures

Epileptic Seizures

Generalized Tonic-Clonic Seizures: Characterized by loss of consciousness, tonic (stiffening) phase, followed by clonic (jerking) movements. Postictal confusion is common.
Absence Seizures: Brief lapses in awareness, often seen in children, with no postictal confusion.
Myoclonic Seizures: Sudden, brief, shock-like muscle jerks, often occurring shortly after waking.
Focal Seizures: Seizures originating from one hemisphere of the brain, with symptoms depending on the area affected (e.g., motor, sensory, or autonomic).
Complex Partial Seizures: Impaired consciousness with automatisms (e.g., lip-smacking), often with postictal confusion.
Status Epilepticus: A medical emergency where seizure activity persists for more than 5 minutes, or multiple seizures occur without recovery in between.

Non-Epileptic Seizures

Psychogenic Non-Epileptic Seizures (PNES): Episodes resembling epileptic seizures but without electrical discharges; often associated with psychological factors.
Syncope: Transient loss of consciousness due to reduced cerebral perfusion, often preceded by a prodrome (e.g., lightheadedness, sweating), with rapid recovery.
Cardiac Arrhythmias: Can cause syncope or sudden collapse, sometimes mistaken for seizures; consider if there is a history of palpitations or structural heart disease.
Migraine with Aura: May present with neurological symptoms that mimic seizures, such as visual disturbances or sensory changes.
Transient Ischemic Attack (TIA): Focal neurological deficits that resolve within 24 hours; may be mistaken for a focal seizure, particularly in elderly patients.
Hypoglycemia: Can cause confusion, abnormal behavior, or loss of consciousness, potentially mimicking a seizure.
Metabolic Disturbances: Electrolyte imbalances, such as hyponatremia, can precipitate seizures or seizure-like activity.
Alcohol Withdrawal: Seizures can occur in the context of alcohol withdrawal, typically 6-48 hours after the last drink.

Other Causes

Febrile Seizures: Seizures occurring in young children associated with a rapid rise in body temperature, usually benign with a good prognosis.
Intracranial Pathology: Brain tumors, hemorrhage, or infections (e.g., meningitis, encephalitis) can present with seizures.
Electrolyte Imbalances: Conditions like hyponatremia, hypocalcemia, or hyperglycemia can lower the seizure threshold.
Drug Toxicity: Overdose or side effects of medications, such as antidepressants or antipsychotics, can induce seizures.
Trauma: Head injuries can lead to post-traumatic seizures, which may occur immediately or be delayed.
Cerebral Hypoxia: Prolonged hypoxia, due to causes like cardiac arrest, can result in seizures.

Precipitating Factors

Triggers: Ask about potential seizure triggers such as sleep deprivation, stress, alcohol consumption, or flickering lights.
Recent Illness: Fever or recent infection may point towards febrile seizures, especially in children.
Medication Changes: Recent changes in medication, including withdrawal from anticonvulsants, can precipitate seizures.
Substance Use: Alcohol or recreational drug use, as well as withdrawal, can be relevant precipitating factors.
Head Trauma: History of recent or remote head trauma is important, as this can be a cause of seizures.

Seizure Description

Aura: Ask if the patient experienced any warning signs, such as a strange smell, déjà vu, or a rising sensation in the stomach, which could suggest a focal onset.
Witness Accounts: Obtain a detailed description from any witnesses, including the duration, type of movements, and whether the patient lost consciousness.
Postictal State: Clarify the length and nature of postictal confusion or fatigue, which is often prolonged in generalized seizures.
Incontinence and Tongue Biting: These are commonly associated with generalized tonic-clonic seizures.
Frequency and Pattern: Determine whether this is the patient’s first seizure or part of a recurrent pattern, and if so, how often seizures occur.

Background

Past Medical History: Note any history of epilepsy, febrile seizures in childhood, or neurological conditions.
Drug History: Review current and past medications, particularly anticonvulsants, and assess for compliance.
Family History: Ask about any family history of epilepsy or other neurological conditions.
Social History: Include alcohol use, drug use, and occupational risks, as well as any driving or operating machinery responsibilities.
Developmental History: In children, inquire about developmental milestones, as delays may be associated with underlying neurological disorders.
Recent Changes: Consider recent stressors or life changes that could contribute to seizure risk, particularly in the context of PNES.

Blood Tests

Full Blood Count (FBC): To assess for infection or hematological causes that might lower the seizure threshold.
Urea and Electrolytes (U&E): To check for electrolyte disturbances such as hyponatremia or hypocalcemia, which can precipitate seizures.
Glucose: To rule out hypoglycemia as a cause of the seizure.
Liver Function Tests (LFTs): To assess for hepatic encephalopathy, particularly in patients with known liver disease.
Toxicology Screen: Consider in cases of suspected drug or alcohol-related seizures.
Anticonvulsant Levels: If the patient is on anticonvulsants, check drug levels to assess compliance and therapeutic levels.
Calcium, Magnesium, and Phosphate Levels: To evaluate for metabolic causes of seizures.
Infection Markers: Consider blood cultures, CRP, and other markers if infection (e.g., meningitis, encephalitis) is suspected.
Autoimmune Screen: In cases of new-onset seizures, consider testing for autoimmune encephalitis, particularly if other systemic features are present.

Imaging

CT Head: Typically first-line imaging to rule out acute intracranial pathology such as hemorrhage, stroke, or mass lesion.
MRI Brain: More sensitive than CT for identifying structural abnormalities, particularly in cases of focal seizures or if the CT is normal but suspicion remains.
EEG (Electroencephalogram): To assess for epileptiform activity and help classify the type of seizure; may be normal in between seizures.
Lumbar Puncture: Indicated if there is suspicion of meningitis or encephalitis, or if the patient presents with a first seizure and a fever.
Video EEG Monitoring: Consider in patients with recurrent episodes where diagnosis remains unclear, particularly in differentiating between epileptic and non-epileptic seizures.
PET/SPECT Scan: Sometimes used in pre-surgical evaluation to localize seizure foci in patients with refractory epilepsy.

Special Tests

Cardiac Monitoring: Consider if syncope or arrhythmia is suspected; includes ECG and potentially Holter monitoring.
Tilt Table Test: To evaluate for vasovagal syncope in patients with suspected non-epileptic seizures.
Neuropsychological Testing: Useful in patients with psychogenic non-epileptic seizures (PNES) or cognitive decline associated with epilepsy.
Genetic Testing: Consider in cases of childhood-onset epilepsy or if there is a family history suggesting a genetic disorder.
Metabolic Screening: For inborn errors of metabolism, particularly in young children or if there is a history of developmental delay.

Neurosciences