A Practical Approach to

The Diagnosis and

Evaluation of Seizures

Dr JD Kabamba
Three basic questions

■ 1. Is it a seizure?
– If so, what kind?
■ 2. What caused it?
■ 3. What should be done?
Further questions

■ 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?
Seizure

A seizure is a set of clinical symptoms

associated with abnormal electrical activity
in neurons in the cortex of the brain.
The clinical characteristics of a seizure are the
result of the area of the brain that is
abnormally stimulated.
Epilepsy is a clinical condition in which there
are multiple seizures that are unprovoked.
Types of seizures

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.
 Generalized seizure - affects the whole body
and involves the entire cerebral cortex.
Types of seizures

■ Partial seizures ( Focal)

- Simple
- Complex
- Partial with secondly generalised

■ Generalized seizures
- Absence seizure (Petit Mal)
- Tonic clonic seizure (Grand Mal)
- Tonic
Partial seizures (focal)

■ Arise from one area of the cortex and may

spread to involve adjacent areas or distant
areas
■ Examples:
– Simple partial seizures
■ Symptoms are referable to the area of the brain
involved, no alteration of consciousness
– Complex partial seizures
■ Partial seizures with alteration of consciousness
– Partial seizures with secondary generalization
■ Partial seizure at onset (aura) followed by generalized
convulsive activity
Generalized seizures

– Generalized seizures arise from both sides

of the brain simultaneously. Motor activity
is symmetrical and alteration of
consciousness occurs.
– Ex. Primary generalized seizures (grand mal)
■ Absence seizures (petit mal)
■ Myoclonic seizures, atonic seizures
Seizure-like episodes

■ Syncope
– Syncopal seizures may have tonic stiffening,
clonic jerking and/or post-ictal confusion
■ Parasomnias
– Sleepwalking, night terrors
■ Hyperventilation
■ Stereotypies/Tics
■ Staring spells
 Diagnosis

Diagnosis is largely based on the history of the

event.
■Precipitating factors
– Position, activity, intercurrent illness, medications
■Description of the episode
– Eye movements, body movements, one sided or both
sides, loss of consciousness or alteration of
consciousness, incontinence, duration, aftereffects
■Predisposing factors
– Past medical history, recent illness or neurological
symptoms, family history
Etiology of Seizure

1. Acute/subacute
– Metabolic causes
■ Hypoglycemia, hypo or hypernatremia,
hypocalemia
■ Intoxications/ toxins (lead)
– Infectious/Inflammatory
■ Meningitis, encephalitis, sepsis
■ Post-infectious or autoimmune causes
– Fever
– Trauma
– Vascular accidents
Etiology of Seizure (cont.)

2. Chronic/ Progressive
– Remote insults
■ Perinatal asphyxia or vascular insult
■ Past head injury
– Developmental brain abnormalities
■ Agenesis of the corpus callosum,
schizencephaly, cortical dysplasia
– Inborn errors of metabolism
■ Storage disorders, amino acid disorders,
organic acid disorders
– Neurocutaneous disorders
– Cerebral degenerative diseases
Idiopathic seizures

■ The cause of the seizure can not be

determined by conventional testing or
■ Seizures of genetic origin in which
seizures are the only manifestation.
■ This category may comprise as much
as 60% of all childhood seizure
disorders.
Determining the cause of
a child’s seizure(s)
■ History
– Associated symptoms, intercurrent illness, recent
medications, exposures (drugs, toxins, pets), past medical
history ( birth history, developmental history, family
history)
■ Examination
– Fever or other abnormal vital signs
– Head size, skin abnormalities (hypo/hyperpigmented
areas) ,menigismus, asymmetry of the face or the
extremities, enlarged organs, dysmorphic features
– Alteration of mental status, cranial nerve abnormalities,
motor tone or strength or reflex changes, gait
abnormalities, ataxia, sensory abnormalities.
Diagnostic workout
■ Blood :electrolytes, Ca, glucose
■ Urine :toxicology, amino acid and organic acid
measurement*
■ EEG
– Useful for evaluating interictal abnormalities
– Occasionally useful for determining nature of a
clinical symptom (absence seizures, tics or other
frequent movements)
– Helpful in predicting recurrence of seizures.
– A normal EEG does not exclude a diagnosis of
seizure.
Diagnostic workout
■ Imaging procedures
– CT scan is not the procedure of choice but is
appropriate in emergencies, especially trauma
– MRI is the imaging procedure of choice
■ Abnormal neurological examination
■ Focal seizure activity
■ Focal findings on EEG
– PET scanning is a specialized procedure done in
limited circumstances (usually as part of
evaluation of intractable seizures or when a
surgical treatment is proposed.
Algorithm
Initial Event

History- eyewitness report if possible

Probable seizure

Physical Examination

Normal Abnormal

EEG, imaging study if EEG,Imaging study, consider

EEG focal more emergent evaluation

If isolated event, no If multiple episodes

treatment or Rectal discuss medication
valium
Historical Clues
■ Precipitating factors
– Seizures may be precipitated by flashing lights,
hyperventilation, illness or being overtired (stress?)
– Syncope is precipitated by standing up, being
overheated, sight of blood, frightening event
■ State of alertness- syncope doesn’t occur in sleep,
Seizures may occur in sleep or wakefulness.
Parasomnias only occur in sleep.
Further historical cues
■ Position- seizures may occur in any position,
syncope usually occurs when sitting or standing
■ Eye movements- eyes are usually closed or
partially open during a syncopal episode, more
likely to be open during a seizure. The presence of
deviation of the eyes to one side or another
suggests a partial seizure.
■ Seizures that affect one side of the body more
than the other are likely to be focal in origin.
Syncopal episodes are usually symmetrical.
Staring vs. Absence vs.
Partial Complex seizures
■ Staring spells are more apt to occur when the
patient is passive, listening to a teacher, or parent
or watching TV. They can be of indeterminate
length and are interruptible by voice or touch.
■ Absence seizures can occur in the midst of activity,
usually brief 10-20 seconds. There may be eye
blinking/fluttering or subtle head movements. The
patient recovers very quickly. Incontinence may
occur.
■ Partial complex seizures are usually 1-2 minutes in
length, and can not be interrupted. There are often
stereotypic movements and postictal confusion is
common.
Generalized seizures vs
Partial Seizures
■ Generalized seizures have sudden onset
without warning. Motor symptoms are
symmetrical. Postictal state is common
when there is convulsive activity but not for
absence or myoclonic seizures
■ Partial seizures may begin with localized
symptoms that the patient is aware of
(aura) and may have asymmetric motor
symptoms. Postictal state is common, even
without convulsive activity.
Management

■ The decision to treat depends on

evaluation of risks and benefits
– Risk of subsequent seizures
– Risk of treatment
– Particular circumstances of patient
Treatment
■ Discuss risks and benefits with patient and
parent based on available statistics
■ If 1st seizure with lower risk of recurrence,
consider no treatment.
■ Use of rectal diazepam as a “rescue
measure”
■ If decision to treat, choose a medication
based on seizure type, age of patient and
side effect profile.
■ Monotherapy is generally preferable,
especially in first line treatment.
Anticonvulsant
medications
■ Generalized seizures ■ Partial Seizures
■ Sodium valproate – Carbamazepine
■ Lamotrigine – Lamotrigine
■ Ethosuximide – Phenytoin
– Phenobarbital
Febrile convulsions
Introduction

-The most common seizure disorder during childhood.

-Generally have an excellent prognosis
-May also signify a serious underlying acute infectious
disease such as sepsis or bacterial meningitis.

Therefore, each child with a seizure associated with

fever must be carefully examined and appropriately
investigated for the cause of the fever , especially
when it is the first seizure.
Febrile seizures are age dependent and are rare before 6 months
and after 6 years of age.

The peak age of onset is approximately 14-18 months of age.

A strong family history of febrile convulsions in siblings and
parents suggests a genetic predisposition.
Clinical manifestations

Simple febrile convulsion is usually associated with a core

temperature that increases rapidly to 39°C or greater.

The seizure is usually generalized, is tonic-clonic and lasts a few

seconds to 15 min, and is followed by a brief postictal period of
drowsiness.

Atypical or complicated febrile convulsion:

Duration is longer than 15 min
Repeated convulsions occur within the same day, or
When focal seizure activity or focal findings are present during
the postictal period.
Risk factors for epilepsy

1. Presence of atypical features of the seizure or

postictal period
2. Positive family history of epilepsy
3. Initial febrile seizure before 9 months of age
4. Delayed developmental milestones
5. Pre-existing neurologic disorder
Evaluation

Most important responsibility is to determine the cause

of the fever.

1.Viral infections of the upper respiratory tract, roseola, and

acute otitis media are most frequently the causes of febrile
convulsions.
2.EEG is not warranted after a simple febrile seizure
3.Neuroimaging is also not useful for children with simple febrile
convulsions
Management

Routine treatment of a normal infant with simple febrile

convulsions includes:
1. A careful search for the cause of the fever
2. Active measures to control the fever, including the use of
antipyretics
3. Reassurance of the parents.

Prolonged anticonvulsant prophylaxis for preventing recurrent

febrile convulsions is controversial and no longer recommended.
QUESTIONS ?