First Unprovoked

Seizure in Children

Wael Khreisat, MD
Pediatric Neurology
Royal Medical Services
King Hussein Medical Center
Pediatric Department
Outline
Definitions
Epidemiology
Risks
Seizure type videos
Work-up
Management
To treat or not to treat
Definitions
Seizure: a sudden alteration in motor, sensory, or
cognitive function caused by an electrical
disturbance in the brain.
-Provoked Seizure: Seizure occurring in close
temporal relation to an acute systemic, toxic,
metabolic, or traumatic insult
-Unprovoked Seizure: Seizure occurring in the
absence of one or more precipitating factors

Epilepsy: Recurrent unprovoked seizures

Point-Counterpoint
Seizures should always be treated because
they could cause brain damage and
epilepsy.

Most children with seizures never need

medication. The treatment is often worse
than the disease.
Point-Counterpoint
Point
What does the patient or family want?

Counterpoint
Theyll want what you tell them to want.
Incidence
Each year 25,000 to 40,000 children in the
United States Experience their first nonfebrile
seizure
As many as 5-10% of people will have at
least a single seizure in their lifetimes

AAN Practice parameter: 1st nonfebrile seizure in children, 2000

World Health Organization

 Seizure Recurrence Rates
Prospective study of 407 children with first
unprovoked seizure
29% (118) seizure recurred by 1 year
37% (160) seizure recurred by 2 years
42% (171) seizure recurred by 5 years
Less than 50% up to 8 years post first seizure

Shinnar et al. Pediatrics, 1996

 Predictors of Recurrence
Overall Group
Etiology (cryptogenic vs. remote symptomatic)
Abnormal EEG
Seizure during sleep
Partial seizure
Prior febrile convulsions
Todds paresis
Family History

Shinnar et al. Pediatrics, 1996

 Remote Symptomatic
Defined by either static encephalopathy from
birth and/or a prior neurological insult (stroke,
head trauma)
Still considered unprovoked if seizure occurred
greater than 7 days after insult
(n=65), 44/65 or 68% had recurrences

Shinnar et al. Pediatrics, 1996

 Remote Symptomatic
Predictors of recurrence:
History of prior febrile convulsions
Age younger than 3 years
No increased risk of recurrence:
Status epilepticus
Number of seizures in 24 hours period following
the initial seizure

Shinnar et al. Pediatrics, 1996

 Cryptogenic
Defined by any children of the group who had
unprovoked seizures who did not fit into the
remote symptomatic category
Basically normal children w/o prior insults
(n=342), 127/342 or 37% had recurrences

Shinnar et al. Pediatrics, 1996

 Cryptogenic
Predictors of recurrence
Abnormal EEG (59% vs. 32% by five years)
Seizure during sleep

Todds paresis

Age younger than 3 years

Family history only if accompanied by an

abnormal EEG
(Keep in mind benign focal epilepsy skewing)

Shinnar et al. Pediatrics, 1996

Seizure Types
Single febrile seizure
Single afebrile generalized tonic/clonic
Single afebrile generalized non-convulsive
Single partial seizure (simple vs. complex)
Single generalized tonic/clonic seizure with
h/o myoclonic/atonic seizures
What seizure type?
Absence
Seizure Type?
Atypical Absence
Shuddering Spell
Seizure Type?
Hysparrhythmia
Type of Seizure?
Complex Partial
Type of Seizure?
Psychogenic or Pseudo
Type of Seizure?
Atonic
Type of Seizure?
Type of Seizure?
 Simple Febrile Seizures
Less than 10-15 minutes of generalized
tonic/clonic activity
Resolving spontaneously
Fever
3-6 months to 5-6 years of age
Without focal features or recurrence over 24
hours

Stafstrom, Febrile Seizures, 2002

 Single Febrile Seizures
Risk factors for later epilepsy
Complex febrile convulsions (> 15 minutes or > 1
seizure in 24 hours)
Family history of epilepsy
Abnormal neurological exam
Presence of neurodevelopmental abnormalities
since birth

Berg and Shinnar, 1996 Nelson and Ellenberg, 1976 Annegers et al., 1987
 Single Febrile Seizure Risks
A study of 445 children with single febrile
seizures
Risk of recurrent febrile seizures
25-40%
Risk of unprovoked seizures
3.8% by 1 year
6.2% by 2 years
Risk of epilepsy
3% by 2 years

Berg and Shinnar, 1996

Single Generalized
Tonic/Clonic
Provoked vs. unprovoked
Family history
EEG normal vs. abnormal
Presence or absence of myoclonus
Focal Epilepsy
Benign rolandic (focal) epilepsy
Primarily nocturnal or early AM
Recurrence is variable
Specific EEG pattern
Usually does not require treatment
Benign occipital epilepsy
Evaluation
Immediate Evaluation
Laboratory
LP
EEG
Imaging
Immediate Evaluation
Did a seizure occur?
Seizure, breath-holding, syncope, GE-reflux,
pseudoseizures, other non-epileptic events
Was the seizure provoked?
Hypoglycemia, toxic ingestion, infection, trauma,
tumor, etc.
Take a good history (no kidding)
Physical exam (trauma signs, skin, neuro)
Recommendations for Labs?
Author (year) Recommendations
Rutter et al. (1977) If clinically indicated
Gerber et al. (1981) If clinically indicated
Jaffe et al. (1981) If clinically indicated
Kenney et al. (1992) If clinically indicated
Landfish et al. (1992) If clinically indicated
Nypaver et al. (1992) Routine labs if younger than 3
months
Scarfone et al. (1992) Routine labs if younger than 1
month
 ER study
107 children presented to the ER with suspected unprovoked
seizures (not all were 1st seizure)
54 patients with electrolytes and glucose tested
7/54 with significant abnormalities
5/7 with clinical symptoms of either vomiting, diarrhea, or altered mental status
2/7 asymptomatic
Na 119
Glucose 59

Recommendations:
If clinically indicated
If younger than 2 years
All first unprovoked seizures

Valencia et al. Clinical Pediatrics, 2003

AAN Guidelines
Laboratory tests should be ordered based on
individual clinical circumstances that include
suggestive history or clinical findings such as
vomiting, diarrhea, dehydration, or failure to return
to baseline alertness. (Option)
Toxicology screening should be considered across
the entire pediatric age range if there is any
question of drug exposure or substance abuse.
(Option)

AAN Practice parameter: 1st nonfebrile seizure in children, 2000

 Other Labs
Consider baseline LFTs and CBC as many
anti-epileptic medications could cause
abnormalities
Serum CPK and prolactin levels have NOT
been found to help distinguish seizures from
nonepileptic events

Fein et al. Acad Emerg Med, 1997

 Lumbar Puncture
57 children with CSF after nonfebrile seizure
12.3% with WBC > 5
None had CNS infections
Rider Et al. Pediar Emerg Care, 1995

AAN recommendation:
LP is of limited value and should be used primarily
when there is concern about possible meningitis
or encephalitis. (Option)
 EEG
268 children with a cryptogenic first seizure
103 with an abnormal EEG, 54% had recurrence
165 with a normal EEG, 25% had recurrence

Shinnar et al. Epilepsia, 1994

 EEG
A study of adults and children
EEG within 24 hours: Abnormal in 51%
EEG after 24 hours: Abnormal in 34%
King et al. Lancet, 1998

AAN guidelines concur that an EEG done

within 24 hours of a seizure is most likely to
show abnormalities, but physicians should be
aware that some abnormalities such as
postictal slowing may be transient.
 EEG
EEG is helpful in determining seizure type,
epilepsy syndrome, and risk of recurrence,
and therefore may affect further management
decisions.
The EEG is recommended as part of the
neurodiagnostic evaluation of the child with
an apparent first unprovoked seizure.
(Standard)

AAN Practice parameter: 1st nonfebrile seizure in children, 2000

 Imaging
Study of 613 children with a first unprovoked seizure
388/488 MRI, 197/488 CT, 97/488 Both
62 had an imaging abnormality
14 had normal histories and presentations
4/14 tuberous sclerosis
3/14 brain tumors
3/14 migrational abnormalities
1/14 had a cavernous angioma
3/14 others
13/14 partial seizures
12/14 focal EEG abnormalities
1/14 normal history, presentation, non-focal seizure and EEG

Berg, A et al. Pediatrics, 2000

 Imaging
300 children
No imaging abnormalities were found in children
with EEG confirmed generalized epilepsies or
benign focal epilepsies 138/300

King, MA et al. Lancet, 1998

 Imaging
MRI preferred over CT (Guideline)
Emergent (Option)
Prolonged postictal deficit (Todds paresis)
Slow to return to baseline mental status
Nonurgent (Option)
Static cognitive/motor impairment of unknown etiology
Abnormal neurological exam
Partial seizure with or without generalization
An abnormal EEG pattern that does not fit within a benign
partial epilepsy of childhood or a primary generalized
epilepsy
Children less than a year of age

AAN Practice parameter: 1st nonfebrile seizure in children, 2000

Treatment Considerations
Was it a seizure? (non-epileptic events)
Have they happened before? (febrile seizures,
morning jerking, enuresis, tongue biting, who
spends time with the child, who sleeps in their
room, school/sitter/relative/friend reports)
Risk factors (developmental delay, brain trauma,
family history)
Etiology
Seizure type (history, exam, EEG)
Treatment Considerations
Risks of recurrence
Risks of side effects
Consequences of seizure recurrence
School issues/social issues
Loss of drivers license
Concerns for kindling and brain damage
Concerns for having a recurrence in an unsafe
place
Will AED eliminate seizures?
Recommendations
Two or more seizures-Treat
One seizure
Controversy and Individualized
Summary
History and physical exam important
Labs based on H & P
EEG is helpful
Imaging if focal EEG or Exam, developmental
delay, or children less than a year
Emergent imaging if not recovering
Treatment-Individualized
Thanks