NEUROLOGY 2005;64:774775 Editorial

The first seizure in childhood

Dont just do something, stand there!
Mary L. Zupanc, MD
The question of which patients to treat after a sei-
zure in childhood remains problematic. In this issue
of Neurology, Shinnar et al.
1
address this often vex-
ing situation in one of a series of articles based on a
cohort of 407 patients who have now been followed
for more than 14 years. This longitudinal, prospec-
tive study focuses on the natural history of an un-
treated cohort and has addressed a childs risk of
seizure recurrence following a first unprovoked sei-
zure, the subsequent risk of developing intractable
epilepsy, and, in the present study, the risk of mor-
tality following a first unprovoked seizure. Such pro-
spective studies are difficult, requiring careful
follow-up and rigorous analysis of the data. The rel-
atively small sample size is a limiting factor.
Follow-up has been predominantly through tele-
phone interviews by nurses for ascertainment of sei-
zure recurrence and current treatment. Such
interviews can be inaccurate unless confirmatory
medical records are obtained. If a patient died, med-
ical records were reviewed; otherwise, the interview
was the sole source of data. The data obtained from
this cohort of patients provide insight into the natu-
ral history of seizures in children, as previous stud-
ies have typically been observational and
retrospective, focusing on the risk of seizure recur-
rence with and without antiepileptic drug (AED)
treatment.
The results are noteworthy. Of the 407 patients
who had a first unprovoked seizure, 45% had recur-
rent seizures. Of those who developed intractable
seizures, many had remote symptomatic CNS pa-
thology (in most cases, cerebral dysgenesis) and pre-
sented with status epilepticus. Even so, none died
prior to initiation of antiepileptic medication. Of the
four whose death could have been a result of their
epilepsy, all had difficult-to-control seizures; three of
the four patients had remote symptomatic epilepsy.
Any parent whose child has had a seizure knows
how frightening it can be. Parents want to protect
and safeguard their children. They grow to feel com-
fortable with most of the responsibilities of parent-
ing, even illnesses. However, when a child has a
seizure, unprovoked and seemingly out of the blue, it
is a jarring experience and most parents suddenly
feel out of control. They are frightened and want a
physician or allied health professional to tell them
that their child will be okay. Most parents also want
to know whether this will ever happen again.
Emergency department physicians and pediatri-
cians usually provide little information to families
regarding prognosis or treatment plan, pending a
visit to the child neurologist. The information pro-
vided by Shinnar et al. deserves wide dissemination
to general physicians and care providers: pediatri-
cians, family practitioners, and nurses. This article
1
and others
2-5
suggest the following:
There should be no haste in starting antiepileptic
medication following a first unprovoked seizure. The
side effects of antiepileptic medication, particularly
subtle cognitive and behavioral side effects, need to
be considered. Physicians are often less familiar with
the newer antiepileptic medications, which may be
better tolerated.
The diagnostic evaluation for a first unprovoked
seizure is only an emergency if it is status epilepti-
cus. Emergency CT scans need not be performed un-
less head trauma is suspected. Otherwise, an
outpatient EEG (awake and sleep) and a non-urgent
brain MRI scan should be obtained.
For a single unprovoked seizure, the risk of recur-
rence is less than 50%. The EEG and brain MRI scan
may contribute additional information with respect
to risk of recurrence and prognosis. Specifically, if
the EEG and brain MRI scan are normal, seizures
will not recur in two-thirds of patients. In addition,
the history, examination, EEG, and brain MRI scan
may identify a specific epilepsy syndrome with a de-
fined prognosis.
The predictors of seizure recurrence include re-
See also page 880
From the Department of Neurology and Pediatrics, Division of Pediatric Neurology, Pediatric Comprehensive Epilepsy Program, Childrens Hospital of
Wisconsin, Medical College of Wisconsin, Milwaukee.
Address correspondence and reprint requests to Dr. Mary L. Zupanc, Professor, Department of Neurology and Pediatrics, Chief, Division of Pediatric
Neurology, Director, Pediatric Comprehensive Epilepsy Program, Childrens Hospital of Wisconsin, Medical College of Wisconsin, 9000 W Wisconsin Ave.,
Milwaukee, WI 53226; e-mail: mzupanc@mcw.edu
774 Copyright 2005 by AAN Enterprises, Inc.
mote CNS injury (such as cerebral dysgenesis), an
abnormal EEG, a seizure occurring while asleep, a
history of prior febrile seizures, and the occurrence of
Todds paresis.
Even in children who have one or two additional
seizures, the mortality, with or without antiepileptic
medication, is extremely low.
The risk of sudden unexplained death in epilepsy
(SUDEP) need not be discussed with families at the
first seizure in children with epilepsy. SUDEP usu-
ally occurs only in children with intractable epilepsy.
There are still unanswered questions, particularly
regarding children with intractable epilepsy. When
can a child be labeled as having intractable epilepsy?
Is the definition similar in children and adults,
6
the
failure of one or two appropriately chosen AEDs pre-
dicting that the childs seizures are going to be diffi-
cult to control? How do children with intractable
epilepsy differ from those with easily controlled epi-
lepsy? What is the long-term outlook for these chil-
drenwith respect to seizure control, cognitive
abilities, school performance, developmental out-
come, and psychosocial outcome? What happens to
their familiesprevalence of divorce, risk of depres-
sion, and sibling outcome? Such answers will be par-
amount in advising parents fully about their childs
prognosis.
References
1. Shinnar S, ODell C, Berg AT. Mortality following a first unprovoked
seizure in children: a prospective study. Neurology 2005;64:880882.
2. Shinnar S, Berg AT, Moshe SL, et al. The risk of seizure recurrence
following a first unprovoked afebrile seizure in childhood: an extended
follow-up. Pediatrics 1996;98:216225.
3. Hirtz D, Berg AT, Bettis D, et al. Practice parameter: treatment of the
child with a first unprovoked seizure. Report of the QSS of the AAN and
the Practice Committee of the CNS. Neurology 2003;60:166175.
4. Shinnar S, Berg AT, ODell C, et al. Predictors of multiple seizures in a
cohort of children prospectively followed from the time of their first
unprovoked seizure. Ann Neurol 2000;48:140147.
5. American Academy of Pediatrics, Committee on Drugs. Behavioral and
cognitive effects of anticonvulsant therapy. Pediatrics 1995;96:538540.
6. Kwan P, Brodie MJ. Early identification of refractory epilepsy. N Engl
J Med 2000;324:314319.
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