First seizure and seizure mimics — structured clinical encounter

Structured encounter testing the approach to a nine-year-old girl referred after a first generalised tonic-clonic seizure: the seizure-versus-mimic decision built from the eyewitness history, the classification and selective cause search led by a sleep electroencephalogram, the quantification of recurrence risk and its effect on the definition of epilepsy, and the shared decision with the family about waiting versus starting a daily antiseizure medication.

structured clinical encounter

Prompt

A nine-year-old girl is referred to your general paediatric clinic after a five-minute generalised tonic-clonic seizure at home, witnessed by her mother. The mother describes a brief odd smell, then a cry, loss of awareness, symmetrical stiffening of all four limbs followed by rhythmic jerking, cyanosis, urinary incontinence and a lateral tongue-bite, then fifteen minutes of confusion and drowsy sleep before she returned to normal. There is no fever, no recent head injury, and no family history of epilepsy. She is developmentally normal, plays sport, and is on no medication. On examination she is back to her baseline, with a normal neurological examination, no neurocutaneous stigmata, a normal head circumference and a normal cardiovascular examination including a regular pulse with no murmur.

Task 1 — Decide whether it was a seizure (3 minutes)

Working from the eyewitness account, explain which features of this event confirm that it was a genuine epileptic seizure rather than syncope, a breath-holding spell or a psychogenic event, and state why the postictal phase matters. Explain the value of asking the family to film any further event. [9]

Task 2 — Classify and work up the cause (4 minutes)

Classify this seizure by the 2017 ILAE scheme, and outline the selective investigation strategy appropriate for this child. Name the highest-yield investigation, state how you would optimise it, and explain the indications under which you would and would not order a magnetic resonance imaging scan of the brain. [1] [4] [6]

Task 3 — Quantify the recurrence risk (3 minutes)

State the baseline recurrence risk after a first unprovoked seizure and list the predictors that raise it. Explain how an epileptiform electroencephalogram would change her risk, and state the recurrence threshold at which a single unprovoked seizure meets the ILAE definition of epilepsy. [2] [7]

Task 4 — The treatment decision and the family conversation (5 minutes)

The parents ask whether their daughter should start an antiseizure medication today. Outline the evidence on early treatment of a first unprovoked seizure, the factors that would justify starting treatment, and the shared decision you would lead. Give the first-aid and safety advice and the safety-netting you would provide if the decision is to wait, and explain how you would discuss the risk of sudden unexpected death in epilepsy honestly but proportionately. [5] [7]

References

[1]Fisher RS; Cross JH; French JA; et al Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology Epilepsia, 2017.PMID 28276060
[2]Fisher RS; Acevedo C; Arzimanoglou A; et al ILAE official report: a practical clinical definition of epilepsy Epilepsia, 2014.PMID 24730690
[3]Trinka E; Cock H; Hesdorffer D; et al A definition and classification of status epilepticus--Report of the ILAE Task Force on Classification of Status Epilepticus Epilepsia, 2015.PMID 26336950
[4]Hirtz D; Ashwal S; Berg A; et al Practice parameter: evaluating a first nonfebrile seizure in children: report of the quality standards subcommittee of the American Academy of Neurology, The Child Neurology Society, and The American Epilepsy Society Neurology, 2000.PMID 10980722
[5]Hirtz D; Berg A; Bettis D; et al Practice parameter: treatment of the child with a first unprovoked seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society Neurology, 2003.PMID 12552027
[6]Baldin E; Hauser WA; Buchhalter JR; et al Yield of epileptiform electroencephalogram abnormalities in incident unprovoked seizures: a population-based study Epilepsia, 2014.PMID 25041095
[7]Haut SR; Shinnar S Considerations in the treatment of a first unprovoked seizure Semin Neurol, 2008.PMID 18777475
[8]Subcommittee on Febrile Seizures Neurodiagnostic evaluation of the child with a simple febrile seizure Pediatrics, 2011.PMID 21285335
[9]Leibetseder A; Eisermann M; LaFrance WC Jr; et al How to distinguish seizures from non-epileptic manifestations Epileptic Disord, 2020.PMID 33399092
[10]Doss J Psychogenic non-epileptic seizures in youth: Individual and family psychiatric characteristics Front Psychiatry, 2022.PMID 36590633
[11]Dalziel SR; Borland ML; Furyk J; et al Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial Lancet, 2019.PMID 31005386
[12]Berg AT; Shinnar S Complex febrile seizures Epilepsia, 1996.PMID 8635422

First seizure and seizure mimics — structured clinical encounter

structured clinical encounter

Task 1 — Decide whether it was a seizure (3 minutes)

Task 2 — Classify and work up the cause (4 minutes)

Task 4 — The treatment decision and the family conversation (5 minutes)

References

[1]Fisher RS; Cross JH; French JA; et al Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology Epilepsia, 2017.PMID 28276060
[2]Fisher RS; Acevedo C; Arzimanoglou A; et al ILAE official report: a practical clinical definition of epilepsy Epilepsia, 2014.PMID 24730690
[3]Trinka E; Cock H; Hesdorffer D; et al A definition and classification of status epilepticus--Report of the ILAE Task Force on Classification of Status Epilepticus Epilepsia, 2015.PMID 26336950
[4]Hirtz D; Ashwal S; Berg A; et al Practice parameter: evaluating a first nonfebrile seizure in children: report of the quality standards subcommittee of the American Academy of Neurology, The Child Neurology Society, and The American Epilepsy Society Neurology, 2000.PMID 10980722
[5]Hirtz D; Berg A; Bettis D; et al Practice parameter: treatment of the child with a first unprovoked seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society Neurology, 2003.PMID 12552027
[6]Baldin E; Hauser WA; Buchhalter JR; et al Yield of epileptiform electroencephalogram abnormalities in incident unprovoked seizures: a population-based study Epilepsia, 2014.PMID 25041095
[7]Haut SR; Shinnar S Considerations in the treatment of a first unprovoked seizure Semin Neurol, 2008.PMID 18777475
[8]Subcommittee on Febrile Seizures Neurodiagnostic evaluation of the child with a simple febrile seizure Pediatrics, 2011.PMID 21285335
[9]Leibetseder A; Eisermann M; LaFrance WC Jr; et al How to distinguish seizures from non-epileptic manifestations Epileptic Disord, 2020.PMID 33399092
[10]Doss J Psychogenic non-epileptic seizures in youth: Individual and family psychiatric characteristics Front Psychiatry, 2022.PMID 36590633
[11]Dalziel SR; Borland ML; Furyk J; et al Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial Lancet, 2019.PMID 31005386
[12]Berg AT; Shinnar S Complex febrile seizures Epilepsia, 1996.PMID 8635422