An evidence‐based approach to the first seizure

Abstract

SUMMARYEvidence-based care (EBC) is an explicit approach to applying the best evidence to the care of individual patients. We outline the basic principles of EBC and apply them to various clinical questions pertaining to a patient presenting with a first seizure, providing a summary of the best available evidence for each question. Depending on the question at hand, the evidence derives from retrospective, prospective, and randomized controlled studies in children and adults. There is solid evidence that early seizure recurrence is reduced by early initiation of AEDs. A meta-analysis of six randomized trials revealed an average absolute risk reduction of 34% (95% CI 15-52) with AED therapy. However, the prognosis for the development of epilepsy is not altered by early intervention. EEG epileptiform abnormalities, family history of epilepsy, imaging lesions, and remote symptomatic seizures increase the risk of recurrence, and impact the risk-benefit ratio of treatment after a single event. In the end, clinicians must evaluate patients with a first unprovoked seizure on a case-by-case basis to determine the appropriateness of treatment with a given AED. KEY WORDS: Single seizure, Single unprovoked seizure, Epilepsy, Treatment, Diagnosis. OVERVIEW OF THE EVIDENCE-BASED CARE PROCESSThe clinical encounter with a patient with a first, unprovoked seizure generates numerous important questions. For example, what is the differential diagnosis? What is the diagnostic and prognostic usefulness of EEG, and imaging? What is the yield of routine blood work? What is the prognosis for recurrence? Should one recommend antiepileptic drug (AED) treatment? What are the implications for work and driving? Clinicians answering these questions must draw on the best available evidence, interpret it in the context of their clinical experience and the problem at hand, and apply it according to the patient's preferences and values. Evidence-based care (EBC) is an explicit approach to conscientiously and judiciously apply the best external evidence to the management of individual patients. Briefly, EBC entails the following steps: (1) stating the clinical problem at hand in the form of a defined, answerable question; (2) efficiently searching the literature for the best evidence; (3) critically appraising the evidence for its Address correspondence to Dr. Samuel Wiebe, Division of Neurology, Foothills Medical Centre, 1403 -29 St. N.W., Calgary, Alberta, Canada T2N 2T9. E-mail: swiebe@ucalgary.ca Blackwell Publishing, Inc. C International League Against Epilepsy validity and usefulness; and (4) applying the evidence in the context of the patients' circumstances and values. Here we outline the basic principles of EBC and apply them to various clinical questions pertaining to a patient presenting with a first seizure, providing a summary of the best available evidence for each question. Our aim is to illustrate for clinicians how evidence-based medicine principles can be applied to a common clinical scenario. Asking focused questionsA critical...

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