Complex Febrile Seizures. Firm recommendations regarding the management of complex febrile seizures are currently lacking. These seizures carry a higher risk of intracranial infections and therefore warrant a low-threshold for both neuroimaging and CSF evaluation, especially in those patients younger than age 18 months.
Afebrile Seizures. Types of afebrile seizure disorders presenting in this age group include juvenile myoclonic epilepsy (JME) and benign rolandic epilepsy (BRE), both of which tend to present between ages 5 and 15 years. The majority of patients with first-time afebrile seizures do not require emergent neuroimaging; however, they should be referred to a pediatric neurologist for outpatient magnetic resonance imaging (MRI) of the brain and an electroencephalogram (EEG). Patients requiring emergent neuroimaging with either CT or MRI include those with signs or symptoms of elevated ICP, a focal seizure or focal findings on neurological examination, failure to return to neurological baseline, and a seizure in the setting of head trauma.1
Juvenile Myoclonic Epilepsy. Also known as Janz syndrome, JME is one of most common types of idiopathic generalized epilepsy in childhood. It presents most commonly in otherwise healthy teenagers with one or more of the following seizure types: myoclonic jerks, generalized tonic-clonic seizures (GTCS), or absence seizures. Myoclonic jerks are unique in that they occur during the morning hours, usually the first hour after awakening. They consist of rapid muscle contractions which are most often symmetric and bilateral. The GTCS occur in about 90% of patients with JME, typically just after awakening or during sleep. Both myoclonic jerks and GTCS are exacerbated by sleep deprivation.
Absence seizures are the least common type of seizure in JME. Intelligence in these patients is normal and there is often a family history of similar seizures. Most patients respond well to treatment with antiepileptic drugs, which are usually required for life.3,13
Benign Rolandic Epilepsy. This is the most common form of partial epilepsy in childhood. The name is derived from the central sulcus of the cerebral cortex (the rolandic fissure) around which these seizures originate. Onset of BRE typically occurs between ages 5 and 15 years, with a peak incidence of initial seizures occurring between ages 8 and 9 years. Males are more commonly affected than females (approximate distribution of 1.5:1).2
Simple partial seizures are the hallmark of this type of epilepsy, with the majority of these seizures occurring during sleep. Cardinal features include unilateral facial sensory-motor symptoms, oropharyngeal symptoms, speech arrest, and hypersalivation. Although all of these manifestations are often present, seizures may be marked by only a single symptom. Although it is uncommon, partial seizures may progress to generalized tonic-clonic activity. The hallmark finding on EEG is centrotemporal spikes. Most children do not require treatment, and the vast majority (98%) outgrow the seizures by age 18 years.3 Children with BRE have normal development and intelligence.
Early Adolescents and Teenagers.
Among this cohort, toxic ingestion and overdose tend to be the most common etiologies of first-time seizures presenting to the ED. Oral hypoglycemics (especially sulfonylureas), tricyclic antidepressants, and isoniazid are the most common prescription medications leading to seizures. Others drugs include salicylates, lithium, anticholinergic medications, and bupropion.1 With respect to nonprescription drugs, alcohol can cause seizures via hypoglycemia; cocaine and amphetamines also have a propensity to induce seizures.14 It is paramount to evaluate serum glucose levels and consider toxicologic etiology early in the management of seizures in this age group.
Case Conclusion
Given the focal nature of this patient’s probable seizures, a CT scan of the brain was ordered without contrast to rule out an intracranial mass lesion. Based on negative findings, no further testing was ordered. The patient remained at neurological baseline throughout the course of his stay in the ED, and was discharged home with a prescription for rectal diazepam and instructions on its use for seizures lasting longer than 5 minutes. He was referred to a pediatric neurologist for further evaluation, which included an EEG study that confirmed a diagnosis of BRE.
Dr. Schneider is a pediatric emergency medicine fellow, Eastern Virginia Medical School, Children’s Hospital of the King’s Daughters, Norfolk.
Dr. Clingenpeel is a fellowship director, pediatric emergency medicine, and associate professor of pediatrics, Eastern Virginia Medical School, Norfolk.