Algorithm 1 Concern For Possible Seizure-Books Download

ALGORITHM 1 CONCERN FOR POSSIBLE SEIZURE

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Seizure: A transient ... Note: Epilepsy is considered resolved for individuals who had an age-dependent epilepsy syndrome and are past the applicable age or those who have remained seizure-free for the past 10 years, with no seizure medicines for the last 5 years2. Incidence of epilepsy: The estimated annual incidence in the U.S. is 48 cases of epilepsy for every 100,000 people. The incidence ...



CLINICAL PATHWAY
ALGORITHM 2 NEW ONSET UNPROVOKED SEIZURE
Inclusion Criteria
Age 6 months to 21 years
New onset unprovoked First time unprovoked seizure
seizure Newly recognized seizure or epilepsy syndrome
Exclusion Criteria
Provoked seizure any seizure as a symptom of
fever illness acute traumatic brain injury TBI
Has central nervous system CNS infection tumor
patient returned ingestion intoxication or electrolyte imbalance
Consult inpatient Seizure disorder under the care of a neurologist
to baseline within No
Neurology Status epilepticus refer to status
2 hours of
epilepticus pathway
seizure Infantile spasm requires urgent
consultation with neurology
Focal Consider imaging Off pathway
Yes results No
seizure referYes
to p 8 9 Address findings
Review seizure safety
Review rescue medication
plan if indicated
Patient Less Call OneCall to triage urgency of
age than 3 years outpatient referral to Neurology
Outpatient EEG ideally within 1 2 weeks
3 years or greater
Patients who meet ALL of the following criteria can
Outpatient referral to Neurology be discharged with outpatient referral to Neurology
Outpatient EEG ideally within
1 2 weeks Age 3 or greater
Returned to baseline
Normal exam
If any of the above criteria is NOT met a neurology
consult is recommended for disposition
NEED REAL TIME HELP CALL US
Call OneCall at 720 777 3999 or 719 305 3999 Colorado Springs
Page 2 of 17
CLINICAL PATHWAY
TABLE OF CONTENTS
Algorithm 1 Concern for Possible Seizure
Algorithm 2 New Onset Unprovoked Seizure
Target Population
Background Definitions
Common Seizure Types
Differential Diagnoses for Seizures
Initial Clinical Evaluation
Event History
Past Medical History
Examinations
Laboratory Studies I Imaging
Initial Clinical Management
Therapeutics
Indications for Consultation with a Neurologist
Parent Caregiver Education
Community Resources
References
Appendix Common Epilepsy Syndromes
Clinical Improvement Team
Page 3 of 17
CLINICAL PATHWAY
TARGET POPULATION
Inclusion Criteria
Patients age 6 months to 21 years
Patients with first time unprovoked seizure
Patients with newly recognized seizure or epilepsy syndrome
Exclusion Criteria
Patients with provoked seizure as a symptom of
o Fever illness
o Acute traumatic brain injury TBI
o Central nervous system CNS infection
o Ingestion
o Intoxication
o Electrolyte imbalance
Patients with seizure disorder under the care of a neurologist
Patients with status epilepticus refer to Status Epilepticus Clinical Pathway
Patients with infantile spasms requires urgent consultation with neurology
BACKGROUND DEFINITIONS
Seizure A transient occurrence of signs and or symptoms due to abnormal excessive or synchronous neuronal
activity in the brain A seizure does not necessarily mean that a person has epilepsy1
The recurrence risk following a single seizure is less than 50 The risk increases with each of the following factors2
1 An abnormal EEG
2 Developmental delay
3 Abnormal exam findings
4 Family history of epilepsy
5 Abnormal brain imaging
6 Seizure onset less than 3 years old
Epilepsy Clinically defined as
1 At least 2 unprovoked or reflex to certain stimuli seizures occurring more than 24 hours apart
2 One unprovoked or reflex to certain stimuli seizure and a probability of further seizures similar to the general
recurrence risk at least 60 after two unprovoked seizures occurring over the next 10 years
3 Diagnosis of an epilepsy syndrome
Note Epilepsy is considered resolved for individuals who had an age dependent epilepsy syndrome and are past the
applicable age or those who have remained seizure free for the past 10 years with no seizure medicines for the last 5
Incidence of epilepsy The estimated annual incidence in the U S is 48 cases of epilepsy for every 100 000 people
The incidence is higher in young children and older adults When considered over a lifetime approximately 1 in 26
people will develop epilepsy3
Page 4 of 17
CLINICAL PATHWAY
COMMON SEIZURE TYPES
Fisher et al Operational classification of seizure types by the International League Against Epilepsy5
DIFFERENTIAL DIAGNOSES FOR SEIZURES
Breath holding spells
6 months through 6 years of age most common from 1 to 3 years of age
Preceding cry and or precipitating injury or surprise followed by a long exhalation and respiratory pause
breath holding
Children might stiffen or have clonic movements briefly as part of the syncopal portion of the event
Not unusual to have a few seconds of stiffening or jerking with a loss of consciousness
Helpful history includes
o Preceding triggers such as standing up quickly
o Review of systems with pre syncopal or other cardiac symptoms
o Quick return to alertness is less likely to be seizure
Gastroesophageal reflux GERD Sandifer syndrome
Age of patient is typically in the first years of life
Sandifer syndrome refers to posturing arching with reflux
Timing with feeding and other reflux symptoms like spitting up are more suggestive of symptomatic reflux
Page 5 of 17
CLINICAL PATHWAY
Nonepileptic events pseudo seizures psychogenic should be considered with
Eyes closed during the ictus
Other behavioral concerns in review of history
Flailing rather than rhythmic movement
Pelvic thrusting
No change in color
Prolonged or stuttering course without a postictal period
Staring episodes are more likely to be a seizure when
o Spells noted in multiple environments absence
o Spells interrupt activities absence or have postictal manifestations focal
o Spells don t stop with physical touch
o Spells precipitated by hyperventilation during exam
o Children sometimes describe a sense of lost time or people suddenly moving to a new location
Other nonepileptic events including abnormal movements such as stereotypies tics or tremor
If the events can be interrupted or suppressed they are unlikely to be seizures Calling someone s name or
waving a hand is not enough to interrupt a behavioral event
Tip Direct the family to immediately and physically stimulate the patient such as picking the child up or giving a
firm nudge to assess future events
Consider underlying electrolyte imbalance if concern for new onset abnormal movement such as tremor
INITIAL CLINICAL EVALUATION
Event History
It is critical to obtain as detailed a history as possible at the time of presentation The determination that a seizure has
occurred is typically based on a detailed history provided by a reliable observer Keep in mind there might be multiple
types of events each of which should have its own description
Components of event history should include the following when possible
Description
It is useful to note the term the family uses for an event if there is more than one type for ease of communication
Include what is happening before the event starts such as awake asleep crying arising etc
Ask in detail about preceding symptoms such as fear behavior or sensation autonomic symptoms like
pupillary dilatation drooling change in respiratory or heart rate incontinence pallor vomiting
Obtain detail about the event from patient and all observers including details such as eyes open closed closed
eyes are less likely to be a seizure automatisms such as lip smacking or hand fumbling limp stiff jerking at
different points in the event incontinence and length
o Clear loss of consciousness from the onset suggests a generalized seizure Inability to interact normally
without complete loss of consciousness suggests focal seizure previously called complex partial or
absence if brief
Ask in detail about behaviors after the event such as sleepiness confusion weakness and aggression
Find out when the events started how often they are occurring and the date of the last event
Page 6 of 17
CLINICAL PATHWAY
Length of Time
Note For first time seizures people often greatly overestimate the length so it is helpful to compare to
something familiar like the length of a commercial getting in the car or events that did occur like calling 911
Common triggers for seizures are illness fever and sleep deprivation
Trauma and crying as triggers may suggest breath holding or syncope rather than seizures
History of medication exposure or ingestion could suggest an underlying cause of provoked seizure
Past Medical History and Review of Systems
Birth history To suggest an in utero or perinatal insult e g loss of fetal movement or a complicated
delivery abnormal placenta might suggest an acquired brain insult as a cause of seizures
Bed wetting or daytime incontinence in a child who is usually dry might be a sign of seizures
Review of systems for jerking in the morning sudden falls staring spells episodes of loss of awareness
developmental history regression in skills change in academic performance
Family History
In addition to asking about seizures and developmental disabilities in family members also ask specifically about
febrile seizures and unexplained injuries one car accidents or drowning which might represent a seizure Sometimes
families have new family history at a follow up visit so ask at follow up visits as well
Examinations
General exam A thorough general exam is important and should include
Head size compared to body size Limb asymmetry might suggest a remote insult or developmental brain
malformation
Skin markings including Wood s lamp examination in light skinned children Skin markings may suggest a
neurofibromatosis or tuberous sclerosis Unusual moles or discolored hair patches in the scalp can overlay a
cortical malformation Dysmorphic features can be a clue to an underlying genetic condition
Tip consider head imaging more strongly with such findings
Screening neurologic exam May indicate new or old neurologic injury
Cranial nerves pupil reactivity nystagmus facial symmetry strength palate elevation tongue protrusion
Motor muscle bulk tone and strength assess for asymmetries reflexes including plantar response
Coordination finger to nose movements assess for focal tremors
Gait Look for asymmetry
Ophthalmoscopic exam for papilledema especially if acutely ill
Additional exams
Hyperventilation is helpful to reveal absence seizures during a visit You might use a pinwheel or ask patients to
blow forcefully on a piece of tissue to make it move for 2 minutes and observe during that time and for several
minutes after it is completed
Page 7 of 17
CLINICAL PATHWAY
LABORATORY STUDIES I IMAGING
Note Labs are rarely helpful to identify etiology during the initial presentation if the patient returns to baseline without
intervention
Routine laboratory testing other than blood glucose testing is not indicated after a first unprovoked seizure Laboratory
tests should be ordered based on individual clinical circumstances that include suggestive historic or clinical findings
such as vomiting diarrhea dehydration or failure to return to baseline alertness
Urine toxicology
Consider if patient has prolonged post ictal state or if there is any suspicion of drug exposure or substance
Blood glucose or electrolytes
Consider if clinical picture suggests possible hypoglycemia or electrolyte changes i e prolonged vomiting poor
feeding or if the patient has not returned to baseline neurologic status after 2 hours
Lumbar puncture LP
If concern for possible meningitis or encephalitis based on the whole clinical picture with a lower threshold to
obtain for children under 6 months of age who are not returning to baseline
Electroencephalogram EEG
Electroencephalogram EEG is the most useful test in evaluation of seizures It is acceptable and practical to obtain
the initial EEG on an outpatient basis ideally within 1 2 weeks of the seizure If possible a sleep deprived outpatient
EEG capturing both wakefulness and sleep during the recording is preferred
NOTE Consider urgent inpatient EEG for persistent mental status changes to rule out subclinical
It is possible and common to have normal EEGs even with definitive epilepsy EEG abnormalities in between
seizures inter ictal are not uncommon and do not necessarily confirm a diagnosis of epilepsy so it is important to
confirm that the EEG findings support a specific diagnosis
The EEG is usually diagnostically reliable with conditions such as
Absence epilepsy
Juvenile myoclonic epilepsy
Childhood epilepsy with centrotemporal spikes
Infantile spasms and other epileptic encephalopathies not in scope of this pathway
Brain imaging uncovers abnormalities requiring acute intervention in only 2 of children at the time of first
Abnormalities which affect prognosis and management are found in 10 20 of non urgent studies for first
Infants are more likely to have seizures from a remote symptomatic etiology such as perinatal stroke or focal
cortical dysplasia5
Brain imaging is often not needed for generalized seizures or recognizable self limited epilepsy syndromes
Page 8 of 17
CLINICAL PATHWAY
Brain imaging IS indicated for
Patients of any age with focal findings during or after the seizure
Focal EEG abnormality unless the features are consistent with a known epilepsy syndrome
Abnormal patient exam such as motor or limb size asymmetry or skin findings associated with brain
abnormalities such as neurofibromatosis tuberous sclerosis and patches of discolored hair which can be
associated with underlying focal cortical dysplasia
Any concern for child abuse or traumatic cause of seizures in this case consider CT for evaluation
Imaging Modalities
Magnetic resonance imaging MRI
If a neuroimaging study is obtained MRI is the preferred modality for most cases
MRI is more sensitive for subtle findings such as developmental brain abnormalities and remote insult
Computed tomography CT scan
Useful to assess acutely for blood bone windows for skull fracture and is adequate to assess for hydrocephalus
First line study to obtain if concerned about traumatic cause or non accidental injury
INITIAL CLINICAL MANAGEMENT
The first phone call or visit after a first seizure with quick return to neurologic baseline should
1 Provide reassurance
2 Confirm all caregivers know basic choking intervention and seizure safety see caregiver education
3 Result in a seizure action plan for all settings of the child s life including school grandparents sleep overs etc
see caregiver education
4 Discuss treatment antiseizure medications are usually not indicated for first time seizure Consider medications
after a first recognized seizure if history uncovers a strong suspicion of absence petit mal seizures or
previously unrecognized seizures see therapeutics Consider consultation with Pediatric Neurologist if
suspected need for antiseizure medication
5 Discuss return precautions and indications for EMS activation 911
For self limited seizures a patient does not need to return to the emergency room for each similar event
Education at the first visit or call can prevent unnecessary emergency room visits
Tip Epilepsy com also has resources for providers
Page 9 of 17
CLINICAL PATHWAY
THERAPEUTICS
At home Rescue Medications
Generic Brand
Dosing Recommendations Side Effects Helpful Tips
Formulation
Drowsiness
Diazepam Age Dose
Diastat Rectal Age 2 5 years 0 5 mg kg rectally x 1
Maximum total dose 20 mg
Unsteadiness
Respiratory depression in
Diastat AcuDial Age 6 11 years 0 3 mg kg rectally x 1 overdose or with other CNS
Maximum total dose 20 mg depressants
2 5 mg kit Age 12 years or 0 2 mg kg rectally x 1
10 mg kit delivers 5 7 5 and greater Maximum total dose 20 mg Common guidelines for use
10 mg doses
include a single seizure more than
20 mg kit delivers 12 5 15
5 minutes and more than 6
17 5 and 20 mg doses When calculating dose round UPWARD to next seizures in an hour with case by
available dose case exceptions
We typically recommend calling
911 the first time it is used
High risk medication Nasal burning irritation
Midazolam Local irritation sneezing dry
Versed 0 2 0 3 mg kg dose mouth coughing tears
Drowsiness
Deliver half the drug volume in one nostril and Respiratory depression in
Vials for IV administration administer the remaining volume in opposite nostril overdose or with other CNS
multiple concentrations and vial Max volume 1 ml per nostril depressants
sizes Make sure to order 5
mg mL concentration Consult phone neurology referral
Weight Dose Volume for initiation of this medication At
Less than Children s we do not provide the
Refer to Diastat section above prescription until caregivers have
had hands on training from our
10 15 kg 3 mg 0 6 mL total 0 3 mL per nostril nurses regarding use
16 26 kg 5 mg 1 mL total 0 5 mL per nostril
Midazolam Versed IV formulation
27 32 kg 8 mg 1 6 mL total 0 8 mL per nostril Caution high risk for pharmacy
errors such as use of oral syrup
33 kg or incorrect rather than IV
10 mg 2 mL total 1 mL per nostril
greater formulation There are a variety of
vial sizes and concentrations so
clear communication about dosing
Intranasal infuser device atomizer
and needle free systems for
withdrawing can be hard to obtain
Nasal atomizers are available in
the Walgreens in Children s
Dissolve in oral cavity Fatigue
Clonazepam Dizziness
Klonopin Used more often for seizure clusters including more Increased saliva
than six seizures in 1 hour less commonly used for
prolonged seizures
Oral Disintegrating Tablet
0 01 0 03 mg kg max 2mg
Page 10 of 17
CLINICAL PATHWAY
Anti seizure Medications Commonly Used First Line for New Onset Seizure in Pediatrics
Generic Brand Dosing Recommendations Monitoring Side Effects
Formulation and Clinical Pearls
Dosing Common
Levetiracetam Initial 7 5 mg kg dose BID x 1 week then 15 Sleep changes
Keppra mg kg dose BID Irritability
Increase total daily dose by 20 25 every week Behavior disturbance
Solution 100 mg mL based on clinical response and tolerability Increased blood pressure
Tablet IR 250 mg 500 mg Target dose 15 30 mg kg dose BID
750 mg 1000 mg 62 5 mg and Idiosyncratic and or Less
Maximum dose 30 mg kg dose BID or 1500 mg BID
125 mg available by Common
NOTE doses 3000 mg day have been used in
compounding Anaphylaxis and angioedema
trials however there is no evidence of increased
Pancytopenia
Tablet ER 500 mg 750 mg Psychosis
non formulary at CHCO Monitoring and Clinical Pearls Hypogammaglobulinemia
Easy titration
Less drug interactions
Monitor blood pressure in patients aged 4 years
periodically
Dosing Common
Ethosuximide Initial 250 500 mg PO daily Nausea vomiting diarrhea
Zarontin Increase daily dose by 250 mg every 4 7 days GI upset
based on clinical response serum levels and Hiccups
Syrup 250 mg 5mL tolerability Headaches
Sedation drowsiness
Capsule 250 mg Target dose 20 mg kg day Sleep disturbance
If clinical response not achieved serum levels can Hyperactivity
be checked to see if they are within accepted
therapeutic range 40 100 mcg mL Idiosyncratic and or Less
Monitoring and Clinical Pearls
Blood dyscrasias aplastic
Laboratory monitoring baseline CBC with diff and
LFTs repeat in 6 weeks and periodically thereafter
Drug level monitoring to assist with titration and or
Hepatic failure
toxicity if needed therapeutic range 40 100
Dermatitis rash
Serum sickness
Drug Interactions may increase or decrease serum
concentrations of other anticonvulsant medications
Take with food or milk to minimize GI upset
Dosing Common
Oxcarbazepine Initial 4 5 mg kg dose BID Unsteadiness
Trileptal If 20kg initial 8 10 mg kg dose BID Dizziness
Increase total daily dose by 5 mg kg every 3 days Blurry vision
Suspension 300 mg 5mL based on clinical response and tolerability N V
Tablet IR 150 300 600 mg Abdominal pain
Target dose 15 22 5 mg kg dose BID Diplopia
Nonformulary for Kaiser Nystagmus
Maximum dose 30 mg kg dose BID although more
Tablet XR Oxtellar brand only
than 25 mg kg dose BID not often used 2400 mg day
150 300 600 mg Idiosyncratic and or Less
commonly considered maximum dose
Monitoring and Clinical Pearls
Hyponatremia higher incidence
Laboratory monitoring
than carbamazepine
Serum Na if indicated clinically or if patient at high
Osteoporosis
risk of hyponatremia i e pt at risk for electrolyte
Prodrug rapidly converted to active component 10
monohydrate derivative MHD
Drug interactions Cyp 3A4 Inducer
Risk of SJS TEN increased in Han Chinese Thai
and Philippines populations due to association with
HLA B 1502
Page 11 of 17
CLINICAL PATHWAY
INDICATIONS FOR CONSULTATION WITH A NEUROLOGIST
Referral to Neurology should happen at any point in which the practitioner feels the patient is beyond their comfort
level or scope of practice In particular consider referral or consultation with neurology for the following
New onset unprovoked seizures under 3 years of age
Complex past medical history with new onset seizure
Suspected infantile spasms
Not clear if event is seizure or type of seizure is uncertain
PARENT CAREGIVER EDUCATION
Basic seizure safety information
Epilepsy Foundation
Seizure First Aid
Seizure action plan
Description of seizure type s
Action plan multiple tiers including what should be treated as an emergency
Rescue medication instructions
Seizure Action Plan Resource
Home therapy for seizures
Using Intranasal Midazolam Versed How to Prepare and Give for Seizures English I Spanish
Community Resources
AAP Center on Epilepsy
Epilepsy Foundation of America this site is sometimes adult focused so not all information pertains to children
Epilepsy Foundation of Colorado
Wyoming Epilepsy Association
Family Voices services are limited but include navigators in large facilities like Children s Colorado
Parent to Parent of Colorado helps link families to other families with similar issues
Grupo Vida Spanish friendly family support
County public health nurse can assist with case management anyone can initiate a request for case
management by contacting the family s county health department
Local school nurse can assist with seizure safety at school
Page 12 of 17
CLINICAL PATHWAY
REFERENCES
1 Blume WT Luders HO Mizrahi E Tassinari C van Emde Boas W Engel J Jr Glossary of descriptive
terminology for ictal semiology report of the ILAE task force on classification and terminology Epilepsia
2001 42 1212 8
2 Shinnar etal The risk of seizure recurrence after a first unprovoked afebrile seizure in childhood an extended
follow up Pediatrics 1996 98 2 Pt 1 216 25
3 Fisher et al A practical clinical definition of epilepsy Epilepsia 55 4 475 482 2014 doi 10 1111 epi 12550
4 Russ SA Larson K Halfon N A national profile of childhood epilepsy and seizure disorder Pediatrics
2012 129 256 64
5 Fisher et al Operational classification of seizure types by the International League Against Epilepsy Position
Paper of the ILAE Commission for Classification and Terminology Epilepsia 58 4 522 530 2017 doi
10 1111 epi 13670
6 Gaillard WD Chiron C Cross JH et al Guidelines for imaging infants and children with recent onset epilepsy
Epilepsia 2009 50 2147 53
7 Wallace A Wirrell E Payne E Seizure Rescue Medication Use Among US Pediatric Epilepsy Providers A
Survey of the Pediatric Epliepsy Research Consortium J Pediatr 2019 212 111 116
Page 13 of 17
CLINICAL PATHWAY
APPENDIX COMMON EPILEPSY SYNDROMES
This list focuses on common syndromes and is not inclusive references epilepsy com and epilepsydiagnosis org
1 Childhood epilepsy with centrotemporal spikes
formerly called benign childhood epilepsy with centrotemporal spikes BECTS or Rolandic epilepsy
Self limiting epilepsy remitting at predictable age
Age Onset is between 3 and 14 years peak 8 9 years Seizures usually resolve by age 15 years
Gender Both sexes are affected
History Physical Antecedent birth and neonatal history is normal A history of febrile seizure is seen in 5 15
cases Neurological exam is normal
Deficits During the course of the active epilepsy behavioral and neuropsychological deficits may be found
particularly in language and executive functioning
Seizures Patients and their families often describe nocturnal and very early morning seizures with facial
twitching arrest of speech and drooling The child often remembers the event Seizures can include jerking of a
limb or progress to a generalized seizure
Treatment Seizures are often sporadic and usually brief so treatment is not always indicated even after a
second seizure depending on the family s preference
Tip if the EEG and story are diagnostic imaging is not needed since it is typically normal
2 Childhood Absence Epilepsy CAE
Typically a self limiting epilepsy
Age Onset between the ages of 2 to 12 years peak 5 to 6 years Seizures usually resolve by puberty
Gender Both sexes are equally affected
History Physical Antecedent and birth history is normal A history of febrile seizures is seen in 15 20 of cases
Neurological examination and head size are normal Development and cognition are typically normal
Deficits Attention deficit hyperactivity disorder and learning difficulty may occur for some children
Seizures brief episodes of alteration in awareness lasting 10 15 seconds and then immediate return to baseline
A small percentage of patients have generalized convulsions
Treatment Seizures respond well to medication for the majority of patients
Tip Consider Juvenile absence epilepsy JAE with onset after age 8 and less frequent absence seizures along
with generalized tonic clonic seizures JAE has a lower likelihood of spontaneous remission Imaging is typically
normal and is not needed
3 Juvenile Myoclonic Epilepsy JME
Typically a chronic epilepsy with many patients requiring long term treatment with anti seizure medications
Age Onset between 8 to 25 years of age A small number approximately 5 of cases evolve into this
syndrome from childhood absence epilepsy Seizures continue into adulthood
Gender Both males and females are equally affected
History Physical Antecedent and birth history is normal A history of febrile seizures is seen in 5 10 of cases
Development and cognition are typically normal Neurological examination and head size are normal
Seizures three types of characteristic seizures including myoclonic seizures often in the morning absence
seizures and generalized tonic clonic seizures
Treatment anti seizure medication that can be effective for the three types of seizures in this syndrome
absence myoclonic and generalized tonic clonic
Page 14 of 17
CLINICAL PATHWAY
Tip Ask about early morning jerking movements i e dropping toothbrush or fork in the morning due to
myoclonic jerks for teens presenting with generalized convulsions Counsel patients on seizure triggers such as
sleep deprivation and alcohol Imaging is typically normal and is not needed
4 Mesial Temporal Lobe Epilepsy
Less common in pediatric patients compared to adult epilepsy
Seizure Behavioral arrest with loss of awareness Automatisms are common and include oro alimentary and or
gestural automatisms Seizures often start with a subjective psychic or sensory phenomenon aura which can
be experiential such as fear or d j vu Epigastric and auditory phenomena also occur Autonomic features are
common including pallor and palpitations There is typically confusion after the seizure
Note Temporal focal seizures with impaired awareness need to be distinguished from absence seizures While both
may have automatisms temporal lobe seizures are typically longer 30 seconds associated with pallor and
followed by confusion after the seizure
Deficits Co morbid mood and learning conditions can significantly affect quality of life
Treatment Focal or broad spectrum anti seizure medications can be used
Tips These seizures can be difficult to treat so consider referral to a neurologist more quickly than you might
other syndromes
Brain imaging with MRI warranted
5 Panayiotopoulos syndrome
Age Onset is between 1 and 14 years of age majority between 3 and 6 years Seizures usually resolve by age
11 13 years
Gender Both sexes are affected equally
History Physical Antecedent and birth history is normal Head size and neurological examination are usually
normal Development and cognition are normal However during active seizure periods subtle
neuropsychological deficits in language and executive functioning have been reported EEGs are abnormal with
occipital spikes but not slowing in the majority of cases
Seizures characterized by autonomic mainly emetic symptoms and often with unilateral deviation of the eyes or
head deviation About two thirds start in sleep the child may wake up with similar complaints while still
conscious or else may be found vomiting conscious confused or unresponsive Other autonomic
manifestations include pallor flushing or cyanosis change in pupil size coughing incontinence of urine or feces
In most seizures children eventually become unresponsive and might manifest more easily recognizable seizure
Treatment This disorder is not common but is worth mentioning because the seizures are rare and often to do
not warrant treatment even after a second seizure
Tips Seizures can be confused with migraine headache Imaging is not necessary if the clinical description and
EEG support the diagnosis
Page 15 of 17


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