Seizures and Epilepsy (Questions 8-10)
8. What Evaluation is Needed for a First Seizure?
- History taking: To determine that it actually was a seizure and find causes or risk factors
- Physical examination: To find neurological abnormalities that increase the risk for further seizures
- EEG: If abnormal increase the risk for further seizure
- MRI of the brain: To find causes for seizures, such as a brain tumor, stroke, or other defects that may be treatable.
If a child had a single definite seizure and all of the above evaluations are normal the risk for further seizures will be about 25%. This doesn’t justify treatment unless the seizure was life threatening.
If the EEG is abnormal, the risk increases to a minimum of 65-70% for further seizures in the next 4 years. This does justify treatment. Each of the other evaluations done above have similar contributions to the risk. Treatment must be considered based on the risk of leaving a child untreated.
9. What Other Conditions May Look Like Seizures?
Since seizures are sudden conditions that usually occur “out of the blue” without any warning signs, any other condition that is sudden and is associated with a change in the level of consciousness or control over function may mimic seizures.
In the pediatric (children) age group, these conditions may be divided to the age of the child:
The neonatal age
- Jitteriness associated with shaking
- Drug withdrawal
- Apnea (cessation of respiration) may be caused by gastro-esophageal reflux of anemia.
- Unusual normal movements
- Myoclonus (spontaneous jerking of muscles) may occur during sleep
- Opistotonus (stretching of the neck backwards and arching of the body) may be caused by gastro-esophageal reflux
- Hypoglycemia or hypocalcemia may cause jitteriness or seizures
Children younger than 2 years
- Breath holding spells: Breath holding spells are very important to recognize and properly diagnose since that may resemble seizures of several types. These events usually start after 1 year of age and are associated with a trigger (unlike seizures). The trigger however may be minimal and at times forgotten to the scary event that follows.The more common are the blue and cyanotic breath holding spells. These usually follow a crying spell. The child becomes blue, faints, becomes limp and unresponsive for about 1 minute then returns to his normal self after resuming his crying. The more confusing spells are the white or pallid breath holding spells. These occur usually due to a minimal trigger, such as a mild head trauma. The child doesn’t necessarily turn blue, but does become pale, then follows the above-described loss of consciousness and recovery. In some instances these kids may have some jerky movements as they lose their consciousness, and may have a prolonged drowsiness following the event. I’ve seen kids with breath holding spells become drowsy for 4 to 10 hours following a spell, and others who had up to 10 short spells per day. These spells are considered “benign” and are left untreated once are recognized not to be convulsive (seizures).
There is, however, a simple treatment. In several studies, kids were shown to respond to iron supplementation even when no clear anemia was demonstrated. This simple treatment should be considered I children who have frequent breath holding spells.
- Dystonia: Transient paroxysmal dystonia of childhood, a rare disorder associated in uncontrolled extremity movement.
- Migraines and migraine variants: Migraines may cause a visual change followed by severe headaches and drowsiness. Migraine variants include benign paroxysmal vertigo, sudden severe dizziness followed by drowsiness, cyclic vomiting, and paroxysmal torticollis.
This age group may still experience late onset breath holding spells and migraine variants as above.
Other conditions include the following:
- Syncope: Fainting events, most commonly caused by a vaso-vagal reaction. This is the typical fainting event that may occur when someone is emotionally overcome (from seeing blood or being scared). This may also occur when getting up from a sitting position exacerbated by fatigue, dehydration, hot temperature or illness. The mechanism is stimulation of the vagus nerve that in return causes a rapid dilation of the blood vessels. This causes a sudden drop in blood pressure and fainting.
- Staring spells: Children who seem “spaced out” due to an attempt deficit problem may be confused as having convulsive (epileptic) staring spells.
- Anxiety: Anxiety may cause hyperventilation followed by fainting. This may be associated with a tingling sensation of the extremities, and a feeling of being shocked. These are panic attacks. Anxiety may also cause a conversion reaction. This is a strong belief that a sudden neurological impairment has occurred such as a sudden weakness of numbness. In most cases involving the left side of the body.
- Night terrors: These kids sit up in the middle of the night, start screaming and crying very violently and inconsolably for a few minutes, then go back to sleep as if nothing occurred and have no recollection of the event the next day. Unlike nightmares that may be remembered.
- Narcolepsy catalepsy: In narcolepsy, patients fall asleep without any apparent reason, then wake up refreshed. This may occur multiple times per day. Catalepsy is part of this disorder and consists of sudden loss of muscle tone, triggered by laughter or emotional stress and may be confused with convulsive drop attacks.
- Paroxysmal dyskinesia: This rare genetic disorder may be exertion induced. Parxysmal kinesogenic dyskinesia and paroxysmal nonkinesogenic dyskinesia are sudden developments of some unusual uncontrolled movements that may last for a few minutes at the time and may be very frequent. Even though non-convulsive, these may respond to treatment with anti-seizure medications.
- Startle disease: Also known as hyperreteplexia, another rare genetic disorder associated with extreme startle response associated with stiffening and even falling to the ground.
10. Who Requires Treatment for Seizures?
The decision to treat children for seizures has to be a responsible serious decision based on the statistical risk for further seizures. Treatment is generally continued for two (2) years after the last seizure.
In those who’ve had one (1) seizure event, have normal development, a normal neurological examination, and a normal EEG and MRI, the risk for further seizures is about 25% for the next four (4) years. In this situation, no treatment will be initiated. If any of the above turn out to show an abnormality indicating an increased seizure risk or if a second seizure has occurred, treatment with anticonvulsant medications will be started for two (2) years.
During treatment blood tests for liver functions, blood counts must be obtained on regular intervals.