Clinical FAQs: Seizures and Epilepsy

What is the Treatment for a First Seizure?

What is the Differential for a First-Time Seizure in a Child?

• Syncope
• Sleep disorders
• Breath holding spells
• Migraine
• Transient ischemic attack
• Metabolic abnormality (low glucose, calcium)
• Panic attack, pseudoseizure

What Are the Diagnostic Tests for a First Seizure?

• H&P: Following a first seizure, careful history (with witnesses) and physical examination are taken, including birth and developmental history (to look for any type of subtle injury) and family history to look for possible familial syndromes.   
• Infection screen
• Metabolic profile
• Lumbar puncture
• Brain imaging with CT or MRI 
• EEG
• Cardiology evaluation for cardiac causes of alteration of consciousness

How Do You Decide Between a CT and an MRI? 

Often times, after an episode of alteration of consciousness, the patient presents to the Emergency Department, and as part of the infectious workup, a CT is obtained. CT can distinguish traumatic brain injury, hemorrhage, atrophy, or a catastrophic condition that requires immediate treatment. MRI can examine more subtle abnormalities such as cortical migration defect. MRI also provides a good evaluation of the hippocampus (looking for atrophy) and a better view of the brainstem than CT. 

What Are the Characteristics of a Febrile Seizure?

A simple febrile seizure is generally a brief generalized seizure, in association with a fever. Simple febrile seizures are often familial and transmitted in an autosomal dominant fashion. One-third of infants with a simple febrile seizure have a second one with another febrile illnesss. Increased risk for recurrence occurs when the body temperature is less than 40 degress or at an age less than 18 months.

How is a Febrile Seizure Different from a Non-Febrile Seizure?

A seizure with a fever may occur due to several reasons including:

• An infection of the CNS
• An underlying seizure disorder in which a fever (for another reason) triggers a seizure
• A simple febrile seizure

How Do You Treat a First Seizure?

• Identification of any acute process, and treatment of that process (e.g. infection, metabolic abnormality)
• Generally, after a first seizure, we do not initiate antiseizure medications. Following the 2^nd seizure, treatment usually occurs.
• Infants with an abnormal neurological examination or developmental delay are candidates for anticonvulsant therapy.

When Do You Make the Diagnosis of Epilepsy?

Epilepsy is generally defined to be two or more spontaneous, unprovoked seizures.

What Are the Causes of Seizures/Epilepsy?

• Congenital: genetic/metabolic disorders
• Perinatal: hypoxia/ischemia at birth
• Infectious: meningitis, encephalitis
• Trauma/Vascular: subdural, intracranial hemorrhage, cerebral venous thrombosis
• Structural/vascular brain abnormality
• Toxic: Drugs, drug withdrawal
• Metabolic: LOW: glucose, calcium, HIGH: ammonia, lactate
• Idiopathic: most cases are idiopathic

References

• Clinical Pediatric Neurology: Gerald Fenichel 5^th edition
• 100 Questions & Answers About Epilepsy: Anuradha Singh

Audrey Yee, MD , Assistant Professor of Pediatrics, Section of Child Neurology