New-Onset Seizure Evaluation in Children – Matelich

HISTORY

  • 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.

EXAM

  • 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

DIFFERENTIAL DIAGNOSIS

  • cyanotic breath-holding spells
  • pallid infantile syncope
  • ADHD
  • vasovagal syncope
  • cardiac arrhythmia (think about if pt described as “pale” during episode)
  • drug use
  • EtOH withdrawal

EVALUATION:

  • 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

 

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