Approach to the Child with a Seizure

Background

Seizures are the clinical manifestation of aberrant, abnormal electrical activity in the cortical neurons. Thus they can be regarded as a symptom of cerebral pathology and are not in themselves a disease. The term epilepsy is not synonymous with seizures. Epilepsy, which comes from the Greek epilepsia meaning “taking hold of”, is a chronic disorder characterized by the tendency for spontaneous, recurrent seizures and requires at least two unprovoked seizures to be considered as a diagnosis.

Seizures occur in 3% to 5% of all children, making it the most common neurological disorder of the pediatric population. Febrile seizures occur in 2% to 4% of the pediatric population whereas epilepsy occurs in approximately 1%.

Questions to ask

It is important to get a detailed account of the event or spell from a witness in order to answer the three questions above (Was the spell in question a seizure? What type of seizure? Cause of seizure?).

Start with asking the witness to describe the spell from beginning to end. Then ask focused questions to ascertain details. Questions regarding the possible seizure can be divided into pre-ictal, ictal, and post-ictal categories.

Pre-ictal

Was there any warning before the spell? If so, what was the warning?
Did the child complain of abdominal discomfort, fear or any other unpleasant sensations before the spell?
What was the child doing before the spell?
Was the child asleep or awake prior to the event?
Was the child sleep deprived prior to the spell?
Were there any triggers for the spell?
Was the child well before the spell or was there a fever or illness?

Ictal

Was the child responding during the spell or was consciousness impaired?
Did the child remember anything that occurred during the spell?
Were there any repetitive behaviors during the episode, such as lip smacking, pulling at clothing, and constant rubbing of objects.
Did any body movements occur?
Was there any perioral cyanosis?
What was the child’s skin colour during the event?
Did the patient lose continence during the spell?
How long did the spell last?
How many episodes has the child experienced?
How often do the spells occur?

Post-ictal

How did the patient feel after the spell?
Did the child seem confused and tired after the spell?
How long did it take for the child to get back to baseline condition?
Did the child suffer from a headache after the spell?

Other questions to ask:

Has the child ever had any seizures before? Febrile seizures?
Ask about past medical history, developmental history and current medications to rule out a symptomatic seizure.
Is there any family history of seizures?

Diagnosis

Clinical categories

The categorization of seizures is important for determining treatment and prognosis

In order to describe the seizure you need to answer two main questions:

Is the seizure simple or complex?

simple seizure – consciousness is completely intact
complex seizure – consciousness is impaired

Is the seizure partial or generalized?

Partial seizure – involves a focal area of the brain and therefore affects a specific portion of the body. The clinical presentation of the partial seizure at onset indicates the location of the epileptic focus in the brain.

Generalized seizure – affects the whole body and involves the entire cerebral cortex.

Below follows a description of the different clinical seizure categories:

Partial Seizures	Simple Partial	Focal in onsetNo impairment of consciousnessUsually short lived, rarely longer than 10 to 20 secondsAssociated with either motor, somatosensory/special sensory, autonomic or psychic (dysphasic, dysmnesic, cognitive, affective, illusions, structured hallucinations) symptoms. Characteristic EEG demonstrates unilateral spikes or sharp waves in anterior temporal region, but discharges may be bilateral or multifocal on occasion.
	Complex Partial	Focal in onsetImpairment of consciousness either from onset or simple partial developing into complex partial seizure.Average duration of seizure is 1 to 2 minutes, which is significantly longer than simple partial or absence seizures.Aura common, signals seizure onset in 30% children, who typically complain of epigastric discomfort, fear, or an unpleasant feeling. Auras occur before impairment of consciousness. Automatisms (stereotypical, repetitive behaviors) characteristic of complex partial seizures and present in 50% to 75% of cases. Automatisms occur after impairment of consciousness and include: lip smacking, picking or pulling at clothing, constant rubbing of objects, and walking. EEG usually shows sharp waves or spike discharges in the anterior temporal or frontal lobe, but may on occasion reveal multifocal spikes.
	Partial with secondary generalization	Focal in onset but then spreads throughout cortex causing a generalized seizure.
Generalized Seizures (all complex)	Absence seizures OrPetit mal(Fr.: small bad)	Seizures typically start around age 5 to 6 years.Characterized by short (5 to 20 second) lapses in consciousness, speech or motor activity.No auraNo postictal drowsiness Automatisms may be present during the seizure and usually involve eye blinking or lip smacking. Often provoked by hyperventilation for 3 to 4 minutes. EEG demonstrates 3 cycles per second generalized spike and wave activity. Atypical absence seizures may involve myoclonic movements of the face or body and may result in loss of body tone causing the patient to fall. Furthermore, the onset and cessation of the seizure may not be abrupt as in typical absence seizure. EEG in atypical absence seizures often reveals either 2 to 2.5 or 3.5 to 4.5 cycles per second generalize spike and wave activity.
	Tonic-clonic seizures OrGrand mal(Fr.: big bad)	Characterized by sudden loss of consciousness and tonic-clonic, tonic or clonic contractions.Tonic contraction is an intense, generalized muscle contraction.Clonic contractions are rhythmic, often symmetric muscle contractions.Tonic-clonic contractions start with a tonic contraction and then produce clonic contractions. Perioral cyanosis may be present. Loss of bladder may occur. Seizure is often followed by 30 to 60 minute deep sleep and postictal headache.
	Tonic seizures	Involve intense muscle contraction only.
	Clonic seizure	Involve rhythmic, often symmetric muscle contractions only.
	Myoclonic seizure	Myoclonus refers to the spasm of a muscle or a group of musclesThese seizures occur either in isolation or in connection with other seizure types.Clinically characterized by brief, repetitive, symmetric muscle contractions.
	Atonic seizures	Sudden loss of postural tone causes child to fall.May be difficult to differentiate from other seizure types

Etiology

Seizures are either symptomatic or idiopathic.

Symptomatic seizures are caused by:

CNS Infection
Meningitis
Encephalitis
Abscess
CNS Trauma
Acute trauma
Previous trauma may lead to scar tissue formation
Cerebrovascular
Infarction
Hemorrhage
Arteriovenous malformation
Venous thrombosis
Hypoxic
Hypoxic ischemic encephalopathy
Metabolic
Hypoglycemia
Electrolyte disturbances
Inborn errors of metabolism
Neurologic effects of systemic disease
Toxic
Drugs
Drug withdrawal
Alcohol
Alcohol withdrawal
Lead poisoning
Tumour
Congenital CNS malformations
Cortical dysplasia
Lissencephaly
Neurocutaneous syndromes (e.g. tuberous sclerosis)
Fever – febrile seizures are discussed elsewhere

Idiopathic seizures

Idiopathic seizures occur in the absence of any underlying CNS pathology. Patients with idiopathic seizures are thought to have an increased susceptibility for seizures yet have normal brain function. Approximately 50% of seizure disorders in children can be placed in a seizure syndrome with unknown etiology.

The details of all the seizure syndromes are beyond the scope of this paper. See Table I in appendix for a brief reference to five seizure syndromes found in children

Differential Diagnosis

Differential diagnosis for seizure includes:

Syncope
Breath holding spell
Aspiration
GERD
Panic attack
Daydreaming
Conversion or pseudoseizures
Benign sleep myoclonus
Benign paroxysmal vertigo
Complicated migraine
Motor tics
Complex behaviors
Decorticate posturing

Physical Examination

All children who present with a possible seizure should have a complete pediatric exam.

Pay particular attention to the following elements of the physical exam:

Vitals, including temperature
Height, weight and head circumference – plot on a growth chart to determine percentiles
Developmental stage of child in gross motor, fine motor, language and social domains. A delay indicates a cerebral insult. The insult may be remote (e.g. cerebral palsy), chronic ongoing (e.g. brain tumour), or may be secondary to another disease. Furthermore, developmental delay may occur in infantile spasms, an idiopathic epilepsy syndrome (See Table I).
Signs of trauma. Direct trauma to the brain can be a cause or consequence of seizures.
Signs of increased intracranial pressure
Skin lesions – may suggest a neurocutaneous diseases underlying seizure activity. See the Table II in appendix for neurocutaneous disorders that can cause seizures in infancy.

Special tests:

Fundoscopy – look for papilledema – suggests an increase in intracranial pressure (link to Signs of inc_ICP.doc).
Neurologic exam – looking for focal deficits – indicates symptomatic seizure.

Include components:

Mental status
Cranial nerves
Motor
Reflexes
Sensory
Coordination and gait
Brudzinski’s test and a Kernig’s test positive test suggest meningitis

Investigations

The particular investigations for each patient depend on the differential generated after the history and physical examination.

Blood tests

In general, all patients should have acute symptomatic causes of seizures ruled out. Therefore all children should have the following tests perforemed:
CBC and differential
Electrolytes
Calcium, phosphorus, magnesium
Blood glucose level

Additional tests need to be considered when investigating the possibility of the following specific conditions:

Hemorrhagic basis – INR, PTT
Toxic basis – blood levels of suspected drugs and metabolites
Genetic disease – possible karyotype and other tests specific to illness

Metabolic disease – tests specific to disease, may include:

Ammonia
Lactate
Pyruvate
Amino acids
Urine organic acids

Lumbar puncture

Lumbar puncture is indicated in:
Infants <12months with a first time febrile seizure to rule out meningitis
Infants 12 to 18 months with a simple febrile seizure
Any child with meningeal signs

Imaging

CT scan – indicated if head trauma is present/suspected
MRI – indicated if the child has new or focal neurological deficits, recurrent seizures and/or papilledema
EEG – children with their first seizure in the absence of fever (as recommended by the American Academy of Neurology). *** Note that many neurologists feel that this is unnecessary as EEG findings rarely impact treatment recommendations. Most offer EEGs more selectively when the seizure is focal, in a child < 1 year and associated with neurological abnormalities.
Appendix

Table I: Summary of Five Seizure Syndromes found in Children (1)

Table II: Neurocutaneous Disorders Causing Seizures in Infancy (2)

References

Haslam, Robert H. A. Nonfebrile seizures. Pediatrics in review. 1997 Feb; 18(2): 40.

Fenichel, Gerald M. Clinical Pediatric Neurology, 3rd ed. Philadelphia: W.B. Saunders, 1997

Goetz, Christopher G. Textbook of Clinical Neurology, 2nd ed. Philadelphia : W.B. Saunders, 2003.

Hill, Alan. Neonatal Seizures. Pediatrics in Review. 2000 Apr; 21(4): 117-121.

Lindsay, Kenneth W. and Ian Bone. Neurology and Neurosurgery Illustrated, 4th ed. Philadelphia: Churchill Livingstone, 2004.

Polin, Richard A. and Mark F. Ditmar. Pediatric Secrets, 3rd ed. Philadelphia: Hanley and Belfus, 2001.

www.emedicine.com/neuro/topic527.htm (October 18, 2004) First Seizure: Pediatric Perspective. Author: Kenneth J. Mack, MD, PhD, Senior Associate Consultant, Department of Child and Adolescent Neurology, Mayo Clinic.

www.emedicine,com/neuro/topic415.htm (October 18, 2004) Seizures and Epilepsy: Overview and Classification. Author: Jose E. Cavazos, MD, PhD, Assistant Professor, Departments of Medicine, Pharmacology, University of Texas Health Science Center at San Antonio.

Acknowledgements

Written by: Sharan Mann

Edited by: Elmine Statham