Clinical and laboratory diagnosis of seizures in infants and children
- Angus Wilfong, MD
Angus Wilfong, MD
- Chief of Neurology
- Barrow Neurologic Institute at Phoenix Children's Hospital
This review highlights the aspects of the physical and neurologic examination, imaging studies, and laboratory investigation that are relevant to the assessment of the infant and child with epilepsy. The detailed pediatric neurologic examination, acute illnesses accompanied by seizures, and febrile seizures are discussed separately. (See "Detailed neurologic assessment of infants and children" and "Seizures and epilepsy in children: Classification, etiology, and clinical features" and "Clinical features and evaluation of febrile seizures" and "Clinical features, evaluation, and diagnosis of neonatal seizures".)
The majority of children with epilepsy have an idiopathic disorder with a normal neurologic examination and neuroimaging studies. Thus, a careful history is the cornerstones of an accurate diagnosis. A detailed account of the child's behavior preceding, during, and following a "spell" is critical. This account may require a follow-up visit with witnesses or a phone call to individuals, such as a teacher, who actually saw the "seizure." The physician should remember to include the child in the conversation; quite often the child provides valuable information.
The physician can ask the parent or witness to mime the event, or the physician can mimic different kinds of seizures to find a match for the child's episodes. Often the family or the initial physician involved with the child will describe the episode as simply a "grand mal" or "petit mal" seizure. Frequently, the physician is told that the child had "staring episodes" or "fell down and shook all over." These descriptions are not adequate for arriving at a definite diagnosis.
The physician should not accept a previous diagnosis of "epilepsy" without taking the child's history. The historians should be asked to describe the seizures in degree of severity (ie, the mildest to the most severe). Often the large seizures (ie, generalized tonic-clonic) are preceded by the identical symptoms that occur in the minor ones, confirming the suspicion of a focal seizure with secondary generalization. However, some children have two or more seizure types. The brief focal signs or aura prior to the more dramatic event, or the important localizing symptoms following the seizure, may be missed in a cursory history. A generalized tonic-clonic seizure may be preceded by brief twitching of one side of the face and followed by a transient language disorder consistent with a dysphasia, supporting the diagnosis of a focal seizure arising in the dominant hemisphere, with secondary generalization.
Setting in which episodes occur — Most seizures occur at random and without warning. In contrast, many nonepileptic spells have characteristic precipitating circumstances or occur in specific locations. Determining the time of day and the activity in which the child was engaged prior to the seizure is important.
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- Setting in which episodes occur
- Behavior immediately prior to the event
- Physical description
- Behavior during the event
- Behavior after the event
- Neuropsychological and social assessment
- Other elements of the history
- PHYSICAL EXAMINATION
- Sleep EEG
- Timing of the EEG
- Obtaining repeat EEGs
- Use of the EEG to determine the type of epilepsy
- Abnormal EEGs in healthy children
- LABORATORY TESTING
- Who should be tested?
- Laboratory screening in undiagnosed epilepsy
- GENETIC TESTING
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS