A Practical Approach to

The Diagnosis and

Evaluation of Seizures
Carol Leicher MD
Connecticut Childrens Medical Center
University of Connecticut School of
Medicine

Three basic questions

1. Is it a seizure?
If so, what kind?

2. What caused it?

3. What should be done?

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

Generalized seizures

Focal (or partial seizures)

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

Focal (Partial seizures)

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

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 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

*Is it a seizure, if so what kind?

Etiology of Seizure
Symptomatic seizures

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

Symptomatic seizures,
part 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 childs 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.

*What caused it?

Diagnostic Studies

Bloodwork - 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 studies #2

Ambulatory EEG
Allows for Ictal recording- ie, EEG activity
during a suspected episode

Drawbacks- technical, availability, depends on

patient/parent to indicate when the episodes are
occurring

Videotelemetry
Simultaneous recording of EEG and video of
patient.
Can be done as a day procedure or as
inpatient
Episodes must occur with some frequency

Diagnostic Studies#3

Imaging procedures
CTT 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.

Treatment Decisions*

The decision to treat depends on

evaluation of risks and benefits

Risk of subsequent seizures

Risk of treatment
Particular circumstances of patient

*What to do about it?

Risks of further
seizures

Risk of a second seizure is 20-30% if:

Examination, EEG and CTT (imaging study)
is normal (and careful review of history
discloses no other events)
Exceptions: Absence seizures. Myoclonic
seizures

Risk of a second seizure if EEG is

abnormal is 60%
Risk of a third seizure is 70%

Risk of having another

seizure

Most seizures do not produce

injury to the brain.
Seizures in a bad place- bath, driving a
car, climbing, riding a bicycle etc.
Prolonged seizure which can lead to
hypoxia or secondary complications.
Sudden unexplained death- a very rare
complication of seizures, particularly in
children.

Risk of treatment

Medication side effects

Severe- liver failure, aplastic
anemia, severe allergic reaction
(Stevens-Johnson syndrome)
Decreased alertness,
personality/behavior changes,
weight loss/gain

Social stigma

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 valium 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

Divalproex sodium
Zonisamide
Topiramate
Lamotrigine
Levetiracetam
Rufinamide
Ethosuximide*

Partial Seizures
Carbamazepine
Oxycarbazepine
Zonisamide
Topiramate
Levetiracetam
Lamotrigine
Phenytoin
Phenobarbital*

Other Treatment
Alternatives

Dietary treatment
Ketogenic diet
Modified Atkins diet

Surgical treatment
Vagal nerve stimulator
Surgical removal of seizure focus

Algorithm
Initial Event
History- eyewitness report if possible
Probable seizure

Other

Another lecture

Physical Examination
Normal
EEG, imaging study
if EEG focal
If isolated event, no
treatment or Rectal
valium

Abnormal
EEG,Imaging study,
consider more emergent
evaluation
If multiple episodes
discuss medication

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 doesnt 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.

Algorithm
Initial Event
History- eyewitness report if possible
Probable seizure

Other

Another lecture

Physical Examination
Normal
EEG, imaging study
if EEG focal
If isolated event, no
treatment or Rectal
valium

Abnormal
EEG,Imaging study,
consider more emergent
evaluation
If multiple episodes
discuss medication