Definition (Neurology 2000;55:616; Pediatr Rev 2007;28:363)
• 1 or more afebrile or otherwise unprovoked seizures (i.e., not 2/2 febrile illness, trauma, or other acute medical condition). Excludes children w/ previous dx of epilepsy
• Provoked seizure: 2/2 acute condition, fever, stress, hypoglycemia, toxic ingestion, intracranial infxn, trauma, alcohol, recreational drug use or w/d, AED abrupt withdrawal related to compliance, & other precipitating factors
• Unprovoked: W/o underlying condition. Idiopathic or 2/2 remote brain insult
• Differentiating between seizures and seizure-like episodes
• Pre-ictal sx include aura, mood, or behavior Δs, vocal sx (cries, gasps, slurred words, garbled speech), motor sx (head or eye turning, eye deviation, posturing, rhythmic jerking, stiffening, automatisms, generalized or focal mvmts), resp sx (Δs breathing pattern, apnea, cyanosis), autonomic sx (pupil dilation, drooling, Δ in RR or HR, incontinence, pallor, vomiting, LOC, inability to understand or speak)
• Ictal sx: Preserved or altered consciousness (simple vs. complex), unilat or bilat (generalized) involvement, ↑ tone (tonic), rhythmic or sporadic jerking (clonic, myoclonic), loss of tone (atonic), or other sx (sensory, autonomic, or psychic)
• Post-ictal symptoms include amnesia for events, confusion, lethargy, sleepiness, HAs and muscle aches, transient focal weakness (Todd paralysis), and N/V
• Seizure-like episodes: Breath-holding, syncope, GERD, pseudoseizure, panic attacks, parasomnias, TIAs, vestibular d/o, paroxysmal choreoathetosis, psychotic hallucinations/delusion, migraine, tics, benign myoclonus of infancy, and other nonepileptic events
Epidemiology (Neurology 2000;55:616)
• 25,000–40,000 children have 1st nonfebrile szr each yr. In US, 1% of children will have an unprovoked seizure by 14 yo. Most common etiology is idiopathic/cryptogenic
Diagnostic Studies (Neurology 2000;55:616)
• EEG: Std of care. Most sensitive within 24 hr of szr but may be scheduled as outpt. Repeat EEG should be obtained if initial EEG is non-diagnostic
• LP: Consider if concern for possible meningitis/encephalitis
• Neuroimaging studies: Emergent if prolonged focal postictal deficit or not back to baseline within few hrs. Strongly consider non-urgent imaging if cognitive or motor impairment of unknown etiology, abnl neuro exam, focal szr, abnl/non-benign EEG, or <1 yo. MRI is preferred over CT if possible
• Consider tox studies if any question of exposure or substance abuse
• Tests ordered on the basis of individual H&P. Routine labs in child >6 mo who returns to baseline and whose hx non-suggestive is generally not necessary
Treatment (Neurology 2003;60:166)
• AEDs generally not indicated after a 1st non-febrile seizure
• No difference in prognosis for long-term szr remission if started after 1st vs. 2nd szr
Complications (Pediatrics 1990;85:1076; Neurology 2005;64:880)
• Majority of children w/ 1st unprovoked afebrile szr have no or few recurrences (24% recurrence in 1 yr, 45% recurrence over 14 yr). Risk ↑ w/ abnl EEG findings & h/o remote brain injury (recurrence risk often >50%)