Diagnostic Procedures

As an initial step, non-epileptiform conditions need to be considered and evaluated as appropriate. This would include cardiac arrhthymias, etc. Evaluation of seizures per se needs to be individualized, but typically includes  blood tests such as a Complete Blood Count (CBC), blood chemistry panel, an electroencephalogram (EEG)--preferentially containing sleep; and an MRI. A non-contrast CT scan is frequently used as an initial screen in the emergency room, but is not by itself generally a sufficient neuroimaging technique when evaluating seizures. It should be followed soon by a contrast CT scan, or quite preferentially, a MRI scan. Lumbar puncture should be performed if meningitis or encephalitis is a consideration. Toxicology screen may also be appropriate.

(EEG) Electroencephalogram

Wired for EEG                                              Video EEG in-patient monitoring

An EEG is a painless, non-invasive test which monitors electrical activity in the brain.   Ideally, the EEG would capture one of the events.  (However, this is rarely possible except during  continuous in-patient video EEG monitoring.)   Even in between clinical symptoms, though,  we can learn a lot about a child's tendency towards seizures from the routine EEG.  Sometimes, the test is also indicated for the evaluation of developmental, behavioral or movement issues. 

MRI (Magnetic Resonance Imaging)

An MRI is an imaging technique that uses no ionizing radiation (no X-rays) in order to provide high quality images of the brain, spine, or other areas.  Only occasionally is a safe intravenous contrast injection required.  If needed, this will be discussed in advance.

MRIs are painless.  Usually, children five years or older do fine without any sedation.  (See Sedation below.) Most children do not have claustrophobia.  (Think about it:  they like hiding under beds.)  If claustrophobia is an issue, an open MRI can be arranged. 

The decision to treat or not

The family needs to know that it is unlikely--although certainly not impossible--to be hurt or die from a seizure. The decision to treat with anticonvulsants is often jointly made by the family, the primary doctor, and the neurologist. Factors in the decision include: the type of seizures (including focality and duration), type of epilepsy syndrome, age of the child, family concerns, EEG, and MRI.

In general, most neurologists do not give anticonvulsants to children with a first, generalized, brief seizure in the setting of a normal EEG and MRI. Overall, a child with a single seizure has less than a 1/3 chance of having another; and the risk is considerably lower still if the EEG and MRI are normal. However, the care for each child must be individualized, taking into account the risks of seizures vs. the risks of medication.

Choice of anticonvulsants

An appropriate anticonvulsant is chosen on the basis safety, side effects, and the type of epilepsy. As demonstrated in table 18- , certain anticonvulsants work better for particular types of seizures. Oxcarbazepine (Trileptal TM), carbamazepine (Tegretol TM), phenytoin (Dilantin TM), and phenobarbital are targeted mainly at the partial seizures, but additionally work well for tonic/clonic seizures. When possible, carbamazepine or oxcarbazepine is usually chosen in order to avoid the hyperactivity frequently seen with phenobarbital; and the gum hypertrophy and facial hirsuitism of phenytoin. However, phenobarbital is usually used first in children less than a few years of age. Valproic acid--also known as valproate--(Depakene or Depakote TM) works particularly on generalized seizures, including primarily generalized tonic/clonic and absence seizures. Valproate appears effective with partial seizures as well. Risk factors for valproate hepatic failure include young age, neurological impairment, and concommitent use of other anticonvulsants. Ethosuximide (Zarontin TM) is limited to absence seizures. The newer anticonvulsants such as gabapentin (Neurontin TM), topiramate (Topamax TM), tiagabine (Gabatril TM), and lamotrigine (Lamictal TM) are generally currently indicated as add-on therapy for partial seizures in children >12 years of age.

Anticonvulsants

For information on specific medications, click here for Internet Mental Health's excellent pharmacy page.

        Spectrum of Standard Anticonvulsants

Laboratory testing on these anticonvulsants needs to be individualized. In general, though, Complete Blood Count (CBC), differential, liver function tests (LFT's), and drug levels are typically monitored several weeks into treatment, then monthly for several months, and then every six months.

 Other treatments

There are other treatments to be considered if standard anticonvulsants fail to work or are not well tolerated. These include the ketogenic diet (a strict diet of almost pure fat and protein), the vagal nerve stimulator, and sometimes surgery.  For more information, see The Epilepsy Foundation of America's site including its Answer Place.

Discontinuation

Typically, children are treated with anticonvulsants for a period of two years without seizures. At that point, the EEG is repeated, and consideration with the family is given to the taper of the anticonvulsant over a two month period. Risk factors for a relapse include: difficulty obtaining seizure control initially, partial seizures, and an abnormal EEG.

Disclaimer: This web site is presented as a resource to patients by Pediatric Neurological Associates. There are no commercial sponsors.  This information does not constitute medical advice; nor is it a substitute for discussion between patients and their doctors.  The views of cited references do not necessarily represent  the views of our staff.  This information was last modified 06/10/06.

Return to Childhood Seizure e-Book

Get the complete book from Amazon.com or your bookstore

since 7/02