- Talk to witnesses and the patient. Knowing events surrounding the seizure is key!
- Mime or description of observed physical actions during the seizure.
- Brief, focal symptoms prior to the dramatic event can be easily missed on a cursory history.
- Developmental, family and past medical histories should be covered – inherited seizure disorders, plateaus in development, injuries, hx of meningitis/encephalitis?
SIGNS OF NON-EPILEPTIC SEIZURE:
- occur only when relaxed, not when active
- consistent crying before a “seizure” suggestive of breath-holding spell
- eyes tightly closed during the episode, esp if eye-opening is actively resisted
- generalized motor activity with normal responsiveness, esp if > 5 mins
- return to normal after painful stimulus or shouting of the name
- headaches are infrequent before the episode
- lasting > 5 mins
Abrupt return of consciousness can be seen in frontal lobe seizures, so not a clear sign of non-epileptic seizures.
If headache, N/V with the seizure – think atypical migraine presentation.
- neuro exam and neuroimaging can be completely normal
- ophtho: look for congenital ocular defects, retinal abnormalities suggestive of neurocutaneous and neurodegenerative disorders, signs of earlier infection
- hepatosplenomegaly, suggesting a storage disease
- skin: neurocutaneous disorders
- cyanotic breath-holding spells
- pallid infantile syncope
- vasovagal syncope
- cardiac arrhythmia (think about if pt described as “pale” during episode)
- drug use
- EtOH withdrawal
- EEG awake and while sleeping, as soon as possible after a seizure esp if initial EEG normal
- MRI for structural evaluation – special MRI sequences needed for children < 2 y since immature myelination patterns can be difficult
- CT without contrast of the brain in ED, changes acute mgmt in 3-9%
- EKG if cardiac etiology suggested
- Metabolic investigations if neurometabolic syndrome suggested