What is the role of workup for new-onset seizures in older adults (over 60)?

• A. Rule out stroke, tumor, metabolic issues; obtain MRI brain (often without contrast) and pertinent labs; consider neuro consult.
• B. EEG alone is sufficient
• C. No imaging is needed
• D. Lumbar puncture is always required

Answer: (A)

When an older adult has a new seizure, the most important aim is to quickly identify any urgent, reversible brain problems and metabolic disturbances that could be triggering the event. That’s why the recommended workup centers on imaging to look for structural causes and labs to check for metabolic issues, with a specialist involved as needed.

Obtaining an MRI of the brain is the key imaging step because it is more sensitive than other modalities for detecting acute stroke, tumors, hemorrhage, infections, and other subtle lesions that can provoke seizures. Doing this brain imaging early helps guide treatment decisions, such as whether there is a need for stroke-directed therapy, tumor workup, or other interventions. Often this MRI is done without contrast initially, with contrast added if a lesion is suspected or if further characterization is needed. Alongside imaging, pertinent laboratory tests assess metabolic contributors to seizures—glucose, electrolytes (sodium, calcium, magnesium), kidney and liver function, and infection markers as indicated—to correct reversible causes promptly.

Neuro consultation is helpful to tailor management, determine the need for admission, and plan further workup or treatment based on imaging and labs. While EEG is a useful tool for characterizing seizure type and assessing risk of recurrence after the acute issue is addressed, it should complement—not replace—initial imaging and labs. Lumbar puncture isn’t automatically required; it’s reserved for cases where infection or inflammatory CNS disease is suspected.