I wanted to ask a question about using the EEG to decide whether or not to start someone on an antiseizure medication following a first unprovoked seizure with normal imaging. My understanding is that if the EEG shows occasional or frequent epileptiform discharges, it is reasonable to start an AED. However, if you see a single or rare epeileptiform discharges (e.g, 2-3 spkes or sharp waves during a routine EEG), it is reasonable to hold of on starting treatment as the EEG is only borderline abnormal. I would like to know how other Neurologists approach this issue.
Thanks,
Yeah, always a gray area, probably the best to jump in and offer their opinion would be an individual that did clinical neurophys training with emphasis on EEG, but I will give my two cents as a lowly general neurologist that see a bazillion headaches per year.
Yeah, "spikes" can be non-specific, but you have to take into the account the entire clinical picture. Okay, probably not the answer you are looking for but the number one tenant of EEG reading is not to overcall. I have a colleague in town that over calls many of these "spikes" and trust me, its really aggravating when I know that clincally the patient is psychogenic.
My rules are very simple, when in doubt, repeat and do serial EEGs, which most patients do not enjoy, so the other option is prolonged 96 hour ambulatory study done by my the local epilepsy center and reviewed by an epilepsy trained neurologist. I usually let them be the "tie breaker". Trust me I have seen a number of psychogenic cases where these little spikes were over called by a neurologist and the epilepsy center does these long studies on video and eventually says, "this is crap!".
Now, in your case, not psychogenic, "real" first time provoked seizure. Again, account for the entire clinical picture. I saw a patient recently who claims that his seizures were due to overuse of energy drinks. I have seen a few cases this year alone of individuals who took over the counter supplements, and whenever you research the ingredients, you find that these supplements have components that are metabolically converted to sympathamimetics, I have even seen one test positive for amphetamines. So, hey, perhaps a claim of overuse of energy drinks is valid? But he had three events? How many people day in day out overuse over the counter stimulants and do not have seizures? You'd have to wonder in this case why this individual's seizure threshold was so sensitive?
I'd refer to local epilepsy center, let them repeat the studies or offer a prolonged EEG with activating procedures and make the final call.
