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A child’s first seizure is most often a brief, less than 5 minutes in duration, generalized convulsion that is justifiably concerning to physicians and parents. The overall incidence of a single unprovoked seizure approximates 60 per 100,000 persons/year with a peak incidence in the first year of life approximating 130 per 100,000 persons/year.1 In some instances, the first seizure is provoked by an underlying acute illness. In others, it is a manifestation of a chronic syndrome. In about half of the cases, a seizure recurs and the child meets diagnostic criteria for epilepsy.2 Accordingly, the evaluation of a new-onset seizure is centered on identifying its cause and predicting likelihood of recurrence.

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Broadly, by the initial history and examination, a first seizure can be categorized into 1 of 3 groups: febrile, acute symptomatic, and remote symptomatic. Management of febrile seizures is discussed in Chapter 559, and of status epilepticus (seizure lasting greater than 5 minutes) in Chapter 561.

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An acute symptomatic seizure is triggered by a recent or ongoing neurologic insult such as infection, trauma, stroke, or metabolic disturbance. Examples include seizures in the setting of encephalitis, head injury, or intoxication. Evaluation of an acute symptomatic seizure, even if the seizure is brief, is often emergent and guided by the overall clinical picture. If the history and examination suggest that a seizure is acutely provoked, then tests typically include blood tests to diagnose infection or metabolic disturbance, toxicologic screening, and head computerized tomography (CT) if trauma or hemorrhage is suspected. Lumbar puncture may also be warranted if there is suspicion that an intracranial infection caused the seizure. If after the seizure the patient has not recovered fully, has persistent focal neurologic deficits, or has not regained baseline consciousness, testing may be followed by magnetic resonance imaging (MRI) to evaluate for a structural abnormality, or electroencephalography (EEG) to evaluate for nonconvulsive seizures (see Chapter 561).

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If the history and examination indicate that a child’s first seizure occurred without accompanying illness or trauma, and the child has recovered to his or her usual state of health, the seizure can be assumed to be remote symptomatic. In contrast to acute symptomatic seizures, remote symptomatic seizures reflect a chronic underlying vulnerability to seizure, such as a genetic seizure susceptibility or a relatively old brain injury. A common example of a remote symptomatic seizure is one that occurs in a child who had perinatal hypoxic/ischemic brain injury but did not develop seizures until a few years of age. In some reports, remote symptomatic seizures are distinguished from cryptogenic seizure by the presence of neurologic symptoms such as a static encephalopathy or a brain MRI abnormality in the remote symptomatic group, and an otherwise normal neurologic picture (normal neurologic exam, normal development, and normal brain MRI) in the cryptogenic group.3 However, for practical purposes of first seizure management, grouping cryptogenic seizures together with remote symptomatic seizures is useful.

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