The physician should consider the seizure as a symptom of central nervous system (CNS) dysfunction. The first step should be to identify whether the process responsible for the seizure is partial or generalized. A careful history and physical examination are invaluable.

Metabolic disturbances are a common cause of seizures with all types of transplantation, so they should always be sought and corrected.

Infections may occur in afebrile patients. Infections may be systemic or may specifically involve the CNS. A detailed investigation for infections, including cerebrospinal fluid analysis, is imperative even when metabolic abnormalities are present, because both may occur simultaneously. Finding normal cerebrospinal fluid does not exclude infection.

Cranial imaging studies are useful in identifying a structural lesionMRI identifies more abnormalities than CT.56 Although cranial imaging studies may not demonstrate a new or treatable lesion as a cause for the seizures, such studies should be performed when any type of seizure occurs in these patients.8 There are exceptions to this rule, of course, such as when seizures occur as a preterminal or terminal event or after marked hypoxia. Thus, the decision to obtain a cranial imaging study should be individualized.

The electroencephalogram (EEG) is still very useful in assessing patients. It provides information about background rhythms, is a qualitative marker of encephalopathy, and helps characterize epileptiform discharges with regard to focal or generalized distribution, helping to clarify the seizure etiology.

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