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Key Features

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Essentials of Diagnosis
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  • Recurrent unprovoked seizures

  • Single seizure with an electroencephalogram (EEG) or risk factors suggesting high risk of recurrent events

  • Often, interictal EEG changes

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General Considerations
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  • Defined as two seizures that are separated by at least 24 hours, a single seizure associated with a > 60% risk of recurrence or the diagnosis of an epilepsy syndrome

  • During childhood, the incidence is highest in the newborn period

  • Prevalence flattens out after age 10–15 years

  • The chance of having a second seizure after an initial unprovoked episode in a child is about 50%

  • Risk of recurrence after a second unprovoked seizure is 85%

  • With appropriate medication, seizure remission is achieved in 65–70% of children

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Classification
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  • Focal seizures

    • Previously called partial (with suspected seizure onset that can be localized to one part of the brain)

    • New nomenclature is based on the presentation of the seizure rather than based on the loss of awareness; terms that will allow for better description include

      • Without impairment of consciousness

      • With motor involvement

      • Hypomotor seizure

  • Generalized seizures (likely involving the whole brain or a network of the brain) can be categorized into 7 groups

    • Tonic-clonic

    • Absence (typical, atypical, and with special features)

    • Myoclonic

    • Myoclonic atonic

    • Tonic

    • Clonic

    • Atonic seizures

  • Epilepsy syndromes

    • Defined by the nature of the seizures typically present, age of onset, EEG findings, and other clinical factors

    • Recommended terms

      • Genetic, to indicate a known or presumed genetic etiology

      • Structural/metabolic, to indicate a known structural or metabolic etiology to an epilepsy syndrome (an example would be tuberous sclerosis or underlying stroke)

      • Unknown, for those patients for whom a cause has not yet been identified.

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Clinical Findings

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  • Obtaining a detailed history is crucial

  • Patient may describe a feeling of fear, numbness or tingling in the fingers, or bright lights in one visual field

  • Specific symptoms may help define the location of seizure onset (eg, déjà vu suggests temporal lobe onset)

  • Postictal states can be helpful in diagnosis

    • After many focal seizures and most generalized convulsive seizures, postictal sleep typically occurs

    • Postictal changes are not seen after generalized absence seizures

    • Motor activity without impaired awareness supports the diagnosis of focal seizures as do impaired awareness and automatisms previously defined as a "complex partial seizure"

  • In generalized seizures, acute loss of consciousness, usually with generalized motor activity, usually seen; tonic posturing, tonic-clonic activity, or myoclonus (spasms) may occur

  • In generalized absence seizures, behavioral arrest may be associated with automatisms such as blinking, chewing, or hand movements, making it difficult to differentiate between absence seizures and focal seizures

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Diagnosis

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  • Every child with new-onset unprovoked seizures should be evaluated with an EEG and MRI

  • Metabolic abnormalities are seldom found in a healthy child with seizures

  • Routine laboratory tests rarely yield clinically significant information, unless there is a high clinical suspicion of ...

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