Seizures

Key Points

• Febrile seizures usually occur between age 3 months and 5 years and represent the most common convulsive disorder of young children (2%-5%).

• Risk factors for a first febrile seizure include family history, developmental delays, high fever, and child care attendance.

One in 11 Americans who lives to the age of 80 years experiences at least one seizure. About 1% of the U.S. population have epilepsy or recurrent unprovoked seizures. Treatment of patients with epilepsy reduces the risk of recurrent seizures while optimizing quality of life. This requires minimizing the adverse effects of antiepileptic medications and maximizing the patient's ability to engage in normal activities and responsibilities (Scheuer and Pedley, 1990).

Seizures are a manifestation of disturbed neurologic function and therefore often associated with acute neurologic disorders such as meningitis. In some patients the seizures are self-limited and resolve when an acute neurologic disturbance resolves. In others the seizures persist and result in a diagnosis of epilepsy. Some patients who appear medically and neurologically normal after appropriate evaluation may experience a single seizure and the cause never determined. Such patients do not have epilepsy.

Seizures are typically classified as partial or generalized. Partial, or focal, seizures arise in a portion of one cerebral hemisphere and are accompanied by focal EEG abnormalities, whereas generalized seizures appear to involve simultaneously all or large parts of both cerebral hemispheres from their onset. Partial seizures are subclassified according to whether consciousness is preserved (simple partial seizures) or impaired (complex partial seizures). Generalized seizures are subclassified by their associated patterns of convulsive movements (Box 42-7).

It is not always possible to classify accurately a seizure based exclusively on clinical observations. A seizure with generalized convulsive activity may have a focal onset with rapid generalization. Such a seizure would best be classified as a partial seizure with secondary generalization, rather than as a generalized tonic-clonic seizure. Accurate classification of such a seizure could not be accomplished, however, without EEG. Also, not every paroxysmal event that appears to be a seizure is a seizure. Movement disorders, psychological disorders, and sleep disorders can produce activity that is similar to seizure activity. Thus, accurate seizure diagnosis often requires both clinical observation and corroborative EEG. Because EEG is usually done in the absence of seizures, certain steps should be taken to increase its diagnostic yield. Both sleep and sleep deprivation increase the likelihood of recording epileptiform abnormalities by EEG. Obtaining multiple recordings can also increase the diagnostic yield. In some cases, accurate diagnosis can be accomplished only with continuous video and EEG monitoring. A small number of patients with seizure disorders have normal interictal EEG recordings, despite efforts made to record epileptiform abnormalities.

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