Professor of Pediatrics, Kalawati Saran Children Hospital, New Delhi
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|When the clinician in confronted with the problem of a child who has experienced a single episode that seems to be of epileptic origin, some questions have to be considered. Was the event really epileptic? If so, what is the risk of more seizures occurring? Should anticonvulsant treatment be offered and with what goal? What is the longterm outcome with or without treatment? The answers to these questions are discussed in this talk. Only generalized tonic-clonic seizure or partial onset seizures (simple partial or complex partial seizures with or without secondary generalization) present as single seizures. Myoclonic/atonic seizures and Absences are never seen as a single event and are not included.
Only generalized tonic-clonic seizure or partial onset seizures (simple partial or complex partial seizures with or without secondary generalization) present as single seizures.
|Was it an epileptic event?|
|It is critical to obtain a detailed history as possible at the time of presentation. The determination that a seizure has occurred is typically based on a detailed history provided by a reliable observer. A careful history and neurologic examination may allow a correct diagnosis without need for further evaluation. Non-epileptic events like breath-holding spells, syncope, gastroesophageal reflux, and pseudoseizures (psychogenic) seizures are diagnostic consideration. In patients who have recurrent seizures the chances of getting a reliable history are much better than in an isolated event which may not have been witnessed by family members or may occur during sleep or in school. However no effort should be spared to get history from the witnesses. Presence of tongue bite or drooling may provide a clue to a seizure.
Presence of tongue bite or drooling may provide a clue to a seizure.
|Is it an acute symptomatic seizure?|
|When a seizure occurs with in a week of acute CNS insult or at the time of systemic or neurologic insult it is called as acute symptomatic seizure. The acute symptomatic seizure requires specific management of the underlying cause and thus should be identified as distinct from the unprovoked seizures. These generally occur in an infant who has symptoms and signs of CNS insult or other systemic/metabolic problem besides seizures. Normally if the child is well looking and alert, has no evidence of systemic or CNS disorder is unlikely to have an underlying pathology. However in infants <1 year the signs are not reliable hence need to be observed more closely and investigated for underlying cause.
If the acute symptomatic seizure has been excluded, other diagnoses in a child with a first afebrile seizure includes isolated seizure, first episode of primary epilepsy and a ill-defined recognized condition termed as non-febrile illness seizures. There are several case reports of non-febrile illness seizures occurring with mild gastroenteritis where medically significant electrolyte abnormalities and dehydration were absent. These non-febrile illness seizures share characteristics with both unprovoked and febrile seizures, and are associated with a history of diarrhea.
These non-febrile illness seizures share characteristics with both unprovoked and febrile seizures, and are associated with a history of diarrhea.
|Does the child needs hospitalization?|
|Seizure episode is accompanied with a great deal of parental anxiety and this question has to answered by the physician after careful observation. All children with seizures need evaluation by a pediatrician. Children less than 1 year of age and suspicion of underlying CNS or systemic cause of seizure or a recurrent seizure need to be hospitalized for observation and further investigation (Table 1). Children who look well and alert and have none of these criteria can be evaluated in an outpatient basis.
Children less than 1 year of age and suspicion of underlying CNS or systemic cause of seizure or a recurrent seizure need to be hospitalized for observation and further investigation.
|What investigations should be done?|
|All children presenting with afebrile seizure should have their blood pressure measured at the time of presentation. A finger prick blood glucose should be performed if a child is still convulsing or not fully alert. In India, hypocalcemia is a common cause of seizures in infants hence Serum Calcium should be checked. It is not necessary routinely to check a full blood count, urea and electrolytes, following a first afebrile seizure unless history or examination features suggest otherwise. |
|Should an EEG be done after first afebrile seizure? |
|An EEG helps in determination of seizure type, epilepsy syndrome, and risk for recurrence, and therefore may affect further management decisions. Experts commonly recommend that an EEG be performed after all first non-febrile seizures. The optimal timing for obtaining an EEG after the seizure is not clear. Transient post-ictal slowing is seen after a seizure and is a non-specific finding though in patients where the diagnosis of epileptic event was doubtful it may support the diagnosis of epileptic seizure. Since the EEG is useful for classifying the seizure and epileptic syndrome, getting an EEG after about 10 days is a better option. The EEG is also useful in predicting the prognosis for recurrences and thus has implication for therapy.
Getting an EEG after about 10 days is a better option. The EEG is also useful in predicting the prognosis for recurrences and thus has implication for therapy.
|Should Neuroimaging be done?|
|Report from developed countries show that abnormalities on neuroimaging are seen in up to one third of children with a first seizure. However most of these abnormalities do not influence management decisions. The main reason for doing a neuroimaging is to exclude an acute underlying CNS insult e.g. infarction. Emergent neuroimaging should be performed in a child of any age who exhibits a postictal focal deficit (Todd's paresis) not quickly resolving, or who has not returned to baseline within several hours after the seizure. The other reason for doing neuroimaging is to look for a cause for unprovoked seizure e.g., malformation. Non-urgent imaging studies with MRI preferably or CT should be seriously considered in any child with a significant cognitive or motor impairment of unknown etiology, unexplained abnormalities on neurologic examination, a seizure of partial onset with or without secondary generalization, an EEG that does not represent a benign partial epilepsy of childhood or prima ry generalized epilepsy, or in children under 1 year of age. In countries endemic for NCC, neuroimaging has a higher yield and is justified. |
|Should the patient be treated with AED?|
|A decade back most physicians used to start AEDs after a single seizure. The rationale for this practice was based on the belief that all seizures were likely to recur and that seizures could be dangerous and cause brain damage. Furthermore, it was thought that if any recurrence were to take place, this would lead to progressively more seizures. This question can be looked into by estimating the risk resulting from having a second seizure if the child is left without treatment. The potential risks can be injury or death due to second seizure and increased risk of recurrence of seizures. |
|Mortality after 1st seizure|
|One reason why treatment is given is concern about the risk of physical injury or death from a subsequent seizure. Serious injury from a seizure in a child is a rare event, though it can occur if there is a fall with loss of consciousness in an hazardous environment e.g., near fireplace. When death occurs in children with epilepsy, it is nearly always related to an underlying neurologic handicap rather than the epilepsy. A prospective cohort of patients included after any kind of first afebrile epileptic seizure were followed up for 1 year and causes of death noted. Seizure-related death were seen in 6%. Early mortality clearly differed according to the etiology of the firs seizure. No death was seen in idiopathic seizures. The highest mortality was associated with provoked seizures and with seizures caused by progressive central nervous system disorders. Patients died far more often from underlying or unrelated conditions than from seizures. |
|Risk of recurrence |
|What are the chances of having a 2nd seizure?: The probability of having a second seizure has been explored in several observational studies with long-term follow-up. The cumulative risk of recurrence increases over time; and the majority of the recurrences occur early (within the first 1 to 2 years). A prospective study evaluated the risk of recurrence over a period of 8 years. The cumulative risk of seizure recurrence was 29%, 37%, 42% and 44% at 1, 2, 5, and 8 years, respectively. The study concluded that majority of children with a firs unprovoked seizure will not have recurrences. Children with first seizures and a normal EEG whose initial seizure occurred while awake had a particularly favorable prognosis, with a 5-year recurrence risk of only 21%. The risk of recurrence after a first unprovoked seizure in children from a developing country is similar to that found in developed countries.
The cumulative risk of recurrence increases over time; and the majority of the recurrences occur early (within the first 1 to 2 years).
|What are the clinical predictors of recurrence?|
|Of the several factors which predict the recurrence risk after a first unprovoked seizure, the etiology of the seizures is perhaps the most important. An abnormal EEG is consistently quoted as a risk factor. The recurrence rate is higher in patients with remote symptomatic epilepsy than in those with idiopathic epilepsy. |
|What if the first afebrile seizure was status epilepticus? Is the outcome any different?|
|There is very little information on this aspect. The overall recurrence risk of having a second seizure is same if the first seizure was status or a brief seizure. However, if the first seizure was prolonged the recurrence is also more likely to be prolonged.
The overall recurrence risk of having a second seizure is same if the first seizure was status or a brief seizure.
|Does the treatment with AEDs prevent recurrences?|
|Yes. Treatment with AED after a first seizure reduces the risk of seizure recurrence. This has been shown in a number of randomized clinical trials. However, this benefit has to be weighed against the side effects of AEDs. |
|Does treatment with AED after a first seizure improve the longterm prognosis for seizure remission?|
|Although treatment after a first unprovoked seizure may reduce the risk of a second seizure, it does not necessarily mean that it affects the long term outcome. Two randomized, prospective first-seizure studies which addressed this issue, found on evidence of a difference when treatment is started after the first seizure versus after a second seizure in achieving a 1 or 2 year seizure remission.
|What is the harm in starting AEDs?|
|All established AEDs which are given as first line drugs are associated with systemic side effects which may be dose-related, neurotoxic and sometimes may have severe reactions such as hepatic toxicity, bone marrow toxicity and Steven Johnson syndrome. Behavioral and cognitive effects are also of concern in childhood. An overall 24% of patients with newly diagnosed epilepsy report to have side effects of common AEDs and it can be inferred the same proportion of children with first afebrile seizure would have adverse effects if treated. The psychosocial effects of taking a medication on daily basis itself should be kept in mind. A child who is taking chronic medication is perceived to have a chronic illness by the child, and his family, and can result in social limitations. |
|To treat or not to treat?|
|The majority of children who present with first unprovoked seizure will have few or no recurrence. Treatment with AEDs after first seizure does not improve the long term outcome although it reduces the risk of recurrence.
The decision as whether to treat or not to treat with AED following first unprovoked seizure in a child must be based on weighing the risk of having another seizure versus the risk of chronic AED therapy. If the clinical predictors of recurrence are present and chances of recurrence are high only then should the treatment be considered. The decision should be individualized and take in account the medical history and the social background of the family and its access to medical facility. Treatment with AED is considered only in case the benefit to reducing the second seizure outweigh the risk of side effects of AEDs.
In all cases, the patient and the family has to be counseled regarding first aid/home management of seizures, and avoiding hazardous activities and when to report back to health facility.
|Table 1. Admission Criteria following an Afebrile seizure |
- Age Less than 1 year
- Altered sensorium
- Neurological signs
- Suspected Raised intracranial pressure
- Suspicion of systemic illness
- Prolonged (> 15 minutes), focal, recurrent seizure
- Signs of aspiration or Respiratory distress
- High parental anxiety
|Table 2. Indications of Neuroimaging|
- Age < 1 year
- Area endemic for NCC
- Focal seizures
- Cognitive impairment
- EEG suggestive of focal epilepsy (not idiopathic)
- Abnormal neurological examination
- Post-ictal deficit
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