New onset seizures without fever (6mo-18 years) - Curbside
New onset seizures without fever (6mo-18 years)
Editors: Dan Imler, MD
Inclusion Criteria  (Any one criteria present)
  • History or direct observation consistant with a seizure
  • First seizure (excluding previous simple febrile seizures)
Exclusion Criteria
  • Complex past medical history (neurologic, metabolic, genetic or other)
  • VP shunt or intercrainal hardware
  • Immunocompromised or oncologic history
  • Previous afebrile seizure
  • History of coagulopathy or disease process predisposing to coagulopathy
  • Anticoagulant or coagulopathic medications
  • Epileptic/infantile spasms

Consider neurology consultation

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Total Notes: 4

1 Background

Seizures are a common and concerning new symptom in pediatric patients. Epilepsy incidence rates in pediatric patients range from 0.5-8 per 1,000 person years with 0.5-1% of children having 1 or more afebrile seizures by adolescence. They may be the result of immune, infectious, genetic, structural, metabolic and/or idiopathic causes.

  1. ILAE official report: a practical clinical definition of epilepsy.
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    Epilepsia 2014 Apr;55(4):475-82.
  2. Prevalence of epilepsy in Rochester, Minnesota: 1940-1980.
    Hauser WA, Annegers JF, Kurland LT,
  3. Prevalence of childhood epilepsy and distribution of epileptic syndromes: a population-based survey in Okayama, Japan.
    Oka E, Ohtsuka Y, Yoshinaga H, Murakami N, Kobayashi K, Ogino T,
    Epilepsia 2006 Mar;47(3):626-30.
  4. A national profile of childhood epilepsy and seizure disorder.
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    Pediatrics 2012 Feb;129(2):256-64.
  5. Incidence and Prevalence of Childhood Epilepsy: A Nationwide Cohort Study.
    Aaberg KM, Gunnes N, Bakken IJ, Lund Søraas C, Berntsen A, Magnus P, Lossius MI, Stoltenberg C, Chin R, Surén P,
    Pediatrics 2017 May;139(5)

2 Epileptic symptoms

Differentiating between epileptic and non-epileptic symptoms is key to making the diagnosis of seizure disorders. Although there are many exceptions to typical findings, most true seizures follow stereotypical patterns.

  1. Psychogenic seizures in children and adolescents: outcome after diagnosis by ictal video and electroencephalographic recording.
    Wyllie E, Friedman D, Rothner AD, Luders H, Dinner D, Morris H, Cruse R, Erenberg G, Kotagal P,
    Pediatrics 1990 Apr;85(4):480-4.
  2. Predictive clinical factors for the differential diagnosis of childhood extratemporal seizures.
    Fogarasi A, Tuxhorn I, Hegyi M, Janszky J,
    Epilepsia 2005 Aug;46(8):1280-5.
  3. Peri-ictal lateralizing signs in children: blinded multiobserver study of 100 children < or =12 years.
    Fogarasi A, Janszky J, Tuxhorn I,
    Neurology 2006 Jan;66(2):271-4.
  4. ILAE classification of the epilepsies: Position paper of the ILAE Commission for Classification and Terminology.
    Scheffer IE, Berkovic S, Capovilla G, Connolly MB, French J, Guilhoto L, Hirsch E, Jain S, Mathern GW, Moshé SL, Nordli DR, Perucca E, Tomson T, Wiebe S, Zhang YH, Zuberi SM,
    Epilepsia 2017 Apr;58(4):512-521.
  5. Revised terminology and concepts for organization of seizures and epilepsies: report of the ILAE Commission on Classification and Terminology, 2005-2009.
    Berg AT, Berkovic SF, Brodie MJ, Buchhalter J, Cross JH, van Emde Boas W, Engel J, French J, Glauser TA, Mathern GW, Moshé SL, Nordli D, Plouin P, Scheffer IE,
    Epilepsia 2010 Apr;51(4):676-85.
  6. Instruction manual for the ILAE 2017 operational classification of seizure types.
    Fisher RS, Cross JH, D'Souza C, French JA, Haut SR, Higurashi N, Hirsch E, Jansen FE, Lagae L, Moshé SL, Peltola J, Roulet Perez E, Scheffer IE, Schulze-Bonhage A, Somerville E, Sperling M, Yacubian EM, Zuberi SM,
    Epilepsia 2017 Apr;58(4):531-542.
  7. Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology.
    Fisher RS, Cross JH, French JA, Higurashi N, Hirsch E, Jansen FE, Lagae L, Moshé SL, Peltola J, Roulet Perez E, Scheffer IE, Zuberi SM,
    Epilepsia 2017 Apr;58(4):522-530.

3 Neuroimaging

Most children with a first-time seizure do not require emergent neuroimaging. A prospective multicenter study showed a rate of an emergent/urgent finding in only 0.8% of patients. In certain subsets of patients however, emergent neuroimaging may be necessary.

MRI is the preferred method of neuroimaging for patients with new onset seizures. It is more sensitive than CT for many of the findings considered after a new seizure.

  1. Seizure recurrence risk following a first seizure in neurologically normal children.
    Arthur TM, deGrauw TJ, Johnson CS, Perkins SM, Kalnin A, Austin JK, Dunn DW,
    Epilepsia 2008 Nov;49(11):1950-4.
  2. Frequency, prognosis and surgical treatment of structural abnormalities seen with magnetic resonance imaging in childhood epilepsy.
    Berg AT, Mathern GW, Bronen RA, Fulbright RK, DiMario F, Testa FM, Levy SR,
    Brain 2009 Oct;132(Pt 10):2785-97.
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    Epilepsia 2015 Aug;56(8):1185-97.
  4. New-onset afebrile seizures in infants: role of neuroimaging.
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  5. Guidelines for imaging infants and children with recent-onset epilepsy.
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    Epilepsia 2009 Sep;50(9):2147-53.
  6. The Use of Magnetic Resonance Spectroscopy in the Evaluation of Pediatric Patients With Seizures.
    Rincon SP, Blitstein MB, Caruso PA, González RG, Thibert RL, Ratai EM,
    Pediatr. Neurol. 2016 May;58:57-66.
  7. New-onset temporal lobe epilepsy in children: lesion on MRI predicts poor seizure outcome.
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    Neurology 2006 Dec;67(12):2147-53.
  8. Reassessment: neuroimaging in the emergency patient presenting with seizure (an evidence-based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology.
    Harden CL, Huff JS, Schwartz TH, Dubinsky RM, Zimmerman RD, Weinstein S, Foltin JC, Theodore WH, Theodore WH,
    Neurology 2007 Oct;69(18):1772-80.
  9. Prevalence of and Risk Factors for Intracranial Abnormalities in Unprovoked Seizures.
    Dayan PS, Lillis K, Bennett J, Conners G, Bailey P, Callahan J, Akman C, Feldstein N, Kriger J, Hauser WA, Kuppermann N,
    Pediatrics 2015 Aug;136(2):e351-60.

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