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Seizures in Children: LaboratoryDiagnosis and ManagementPhilippe
Major, MD,*
Elizabeth A. Thiele, MD,
PhD*
Author Disclosure
Dr Major did not
disclose any financial
relationships relevant
to this article. Dr.
Thiele disclosed that
she is a consultant to
Abbott Laboratories.
Objectives After completing this article, readers should be able
to:1. Formulate an appropriate diagnostic plan for a child who has
seizures.2. Discuss the management of epilepsy.
IntroductionThe initial article on seizures in childhood
(October 2007) focused on the diagnosis andclassification of
seizures in children. This second article reviews investigational
tools andmanagement. The evaluation of a child who has a seizure
disorder must be tailored to thefindings on history and physical
examination. The electroencephalogram (EEG) is theprimary
electrophysiologic tool; brain neuroimaging is the primary modality
for evaluatingneuroanatomic and functional features.
ElectrophysiologyThe EEG can help confirm the clinical diagnosis
of epilepsy, classify the type of epilepsy,localize the epileptic
focus, and help determine if treatment can be discontinued safely.
Ingeneral, 21 electrodes placed on specific locations on the
patient’s scalp measure voltagefluctuations of superficial neurons
in relation to time. Figure 1 shows the position andlabeling of the
scalp electrodes; Figures 2 through 6 show examples of typical
EEGtracings. Generalized epileptic syndromes are characterized by
discharges recorded simul-taneously at each electrode; partial
epilepsy syndromes show localized spikes or slowing inthe
epileptogenic region. Epilepsy is a clinical diagnosis that cannot
be made on the basisof abnormal EEG findings. In fact, EEG
abnormalities can be found in 5% of children whohave no history of
seizures.
On the other hand, a normal EEG is noted in 10% to 20% of
children who have epilepsy.EEG sensitivity can be enhanced by the
use of activation methods such as hyperventilation,photic light
stimulation, and sleep deprivation. Hyperventilation can trigger
epilepticdischarges in 80% of patients who have generalized absence
epilepsy, and photic stimula-tion induces EEG abnormalities in up
to 40% of patients who have generalized epilepsy.When the routine
EEG appears normal but the clinical suspicion of epilepsy remains
high,a sleep-deprived EEG sometimes demonstrates occult
abnormalities.
Long-term video-EEG monitoring is indicated primarily if the
diagnosis of epilepsy is inquestion or when the seizures are
intractable to medical treatment. The goal of thistechnology is to
record seizures to characterize the electrical pattern on EEG
during theepisodes, which often helps to pinpoint their origin.
Video-EEG monitoring is essential forpresurgical evaluation if
surgical ablation of an epileptic focus is being
considered.Video-EEG analysis also is helpful to identify the
nature of paroxysmal episodes, particu-larly in cases of
pseudoseizures or nonepileptic events, frontal seizures, or
paroxysmalmovement disorders.
When more precise seizure focus localization is needed prior to
resective epilepsysurgery, subdural grids or depth electrodes can
be placed by a neurosurgeon. Subduralgrids consist of strips of
electrodes embedded in a flexible sheet of polyurethane com-pound.
The grids are inserted surgically over suspected epileptogenic
areas of the brain.Compared with standard EEG, subdural grids
provide an electroencephalographic record-ing unaffected by
artifacts and diffusion caused by the structures between the brain
and thescalp. Each electrode in the grid also can be stimulated
individually to delineate the
*Department of Neurology, Massachusetts General Hospital,
Boston, Mass.
Article neurology
Pediatrics in Review Vol.28 No.11 November 2007 405
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“eloquent” brain regions (eg, hand area) that should bespared
during epilepsy surgery. Depth electrodes allowrecording of
electrical activity coming from deep brainstructures (eg,
hippocampus).
Brain ImagingComputed tomography (CT) scan and magnetic
reso-nance imaging (MRI) provide precise anatomic brainimages and
can identify potential epileptogenic lesions.Single-photon emission
computed tomography (SPECT)scan, positron emission tomography
(PET), and func-tional magnetic resonance imaging (fMRI) are
func-tional brain imaging techniques that measure local vas-cular
or metabolic changes associated with neuronalactivity. Magnetic
resonance spectroscopy is used in se-lected cases to measure local
biochemical abnormalities.
The decision to order brain imaging and the choicebetween CT and
MRI depend on the child’s clinicalpresentation and the availability
of scans. Due to higherresolution, MRI is now the gold standard for
the neuro-imaging evaluation of epilepsy. Subtle lesions such
asmesial temporal sclerosis, developmental brain malfor-
Figure 1. Scalp electrode positions for EEG. By
convention,electrodes labeled with an even number are placed over
theright hemisphere, and odd-numbered electrodes are placedover the
left hemisphere. Fp�frontopolar, F�frontal,T�temporal, C�central,
P�parietal, O�occipital, z�midline
Figure 2. Normal EEG tracing showing a reactive posterior alpha
(9-Hz) rhythm in an 8-year-old boy who has no history of
seizures.The slow waves observed in the frontal areas are
associated with eye movements.
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406 Pediatrics in Review Vol.28 No.11 November 2007
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mations, and arteriovenous malformations sometimescan be
detected only on MRI. CT is reserved for caseswhen the MRI is not
available. Although brain imaging isrecommended for children who
have focal-onset sei-zures, it is not necessary for normally
developing childrenwho have generalized seizures or typical febrile
seizuresbecause the probability of finding a significant
brainabnormality is very low (�2%) compared with a proba-bility of
26% in children who have partial epilepsy.
Functional neuroimaging (SPECT, PET, and fMRI)generally is not
part of the routine epilepsy investigationbut can be useful for
presurgical evaluation. SPECT andPET aim to localize the epileptic
focus better. SPECTmeasures cerebral blood flow by using
radiotracers (eg,99mtechnetium-HMPAO) and takes advantage of
theobservation that cerebral blood flow is increased in
theepileptogenic focus during a seizure. The interictalSPECT image
is “subtracted” from the ictal SPECT tohighlight areas of increased
cerebral blood flow. PETestimates cerebral metabolism by using
molecules such as18F-2-deoxyglucose (FDG). The FDG-PET
specifically
measures cerebral glucose utilization, which is correlatedwith
neuronal activity. Focal hypometabolism generallyis associated with
an epileptogenic zone. The fMRIrecords blood oxygen variation in
different brain regionsduring the execution of specific tasks by
the patient. Thistechnique allows localization of cerebral
functions suchas language.
Neuropsychological EvaluationA large proportion of children
afflicted with epilepsysuffer from variable learning difficulties.
The neuropsy-chological evaluation is especially helpful for
characteriz-ing these specific learning deficits and for
developingstrategies for improving school performance. The
neuro-psychological evaluation also is performed in most casesas
part of the epilepsy presurgical evaluation to determinethe
patient’s cognitive deficits and, if surgery is notperformed, the
potential long-term consequences of ep-ilepsy. The Wada test (also
called Amytal® test) often isrequired prior to surgery to localize
the brain hemisphereresponsible for language and memory. This test
consists
Figure 3. EEG tracing showing frequent independent left and
right centrotemporal spikes in an 8-year-old child who has
benignpartial epilepsy with centrotemporal spikes (also called
benign rolandic epilepsy).
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Pediatrics in Review Vol.28 No.11 November 2007 407
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of language and memory testing after one brain hemi-sphere is
“anesthetized” following left or right internalcarotid injection of
sodium amobarbital.
TreatmentGeneral Principles
Appropriate care of a child who has epilepsy is crucialbecause
this condition carries significant emotional andsocial burdens. The
first step is to educate the child andthe parents about epilepsy.
Demystification of this con-dition relieves a significant amount of
anxiety. The pa-tient should be informed about potential
precipitatingfactors: sleep deprivation, hyperventilation,
alcoholabuse, recreational drugs, and photic light stimulation.The
child and the family should be instructed regardingseizure first
aid. (For an example of a seizure first aid plan,see:
http://www.massgeneral.org/childhoodepilepsy/pdf/seizure_first_aid.pdf.)
Children who have epilepsyusually can participate in sports, but
basic safety precau-tions must be taken to prevent serious
injuries(eg, no swimming or bathing alone). Physicians
shouldfamiliarize themselves with state regulations concerning
driving restrictions for patients who have a seizurehistory.
The second step involves discussing all strategies avail-able to
treat the seizures, which include antiepilepticdrugs (AEDs),
special diets, surgery, and vagus nervestimulation. The decision to
start an AED requires care-ful evaluation of the probability of
seizure recurrenceagainst the potential risks attributed to the
medication.Most neurologists do not recommend AED treatmentafter a
first seizure because only about 30% of patientshave a second
seizure. After two seizures, the risk ofhaving a third one
increases to about 75% without treat-ment. Thus, AED treatment
generally is initiated aftertwo seizures. Seizure control is
achieved in most patients,but seizures become refractory to
medication in aboutone third of patients.
ANTIEPILEPTIC DRUGS. Treatment is started with oneAED, with the
dose gradually increased until seizures arecontrolled with minimal
toxicity. If the first drug fails tocontrol seizures, the AED
should be replaced by another.We usually recommend introducing the
second drug
Figure 4. EEG tracing showing a right centroparietal spike
(spikes observed in P4-O2, C4-P4, and F4-C4 leads) in a 12-year-old
girlwho has partial epilepsy.
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408 Pediatrics in Review Vol.28 No.11 November 2007
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and, if the child tolerates this new medication, weaningthe
patient from the first drug after a few weeks. If thesecond drug
also is ineffective, a third medication can betried alone or added
in combination. The choice ofAED depends primarily on the drug’s
efficacy against aspecific seizure type, but the adverse effect
profile, pres-ence of other diseases, ease of use, and cost also
must beconsidered.
Classically, valproic acid was considered the firstchoice for
treating generalized epilepsy; carbamazepinewas used for partial
epilepsy. This scheme gradually isbeing modified as more experience
is acquired with thenewer AEDs, which appear to be as effective,
safer,and better tolerated than the traditional medications(Table
1). Table 2 shows a list of available AEDs andtheir associated
primary adverse effects. Classification ofthe patient’s seizure
type is crucial in choosing the ap-propriate AED. Some AEDs can
worsen epilepsy if usedto treat certain seizure types. For example,
carbamaz-epine is known to aggravate generalized epilepsy in
somepatients.
Prior to AED treatment, blood should be drawn for a
complete blood count and for liver enzyme and kidneyfunction
tests. Baseline complete blood count, liver en-zyme and kidney
function tests, and regular blood AEDconcentrations usually are
measured for the “traditional”AEDs (phenobarbital, phenytoin,
valproic acid, car-bamazepine). Blood AED concentrations are useful
inestimating the potential for increasing AED dosage inpatients
whose seizures are uncontrolled, to check com-pliance, to determine
dose-related toxicity, and to de-tect AED interactions in patients
taking multiple AEDs(polytherapy).
When AEDs are used in combination, pharmacologicinteractions can
be problematic. Carbamazepine, phe-nytoin, and phenobarbital are
well-known cytochromeP450 inducers and can increase the metabolism
of otherAEDs and of other medications (eg, oral
contraceptives,steroids, warfarin). Valproic acid increases the
plasmaconcentrations of phenobarbital, lamotrigine, and
car-bamazepine 10, 11-epoxide (toxic metabolite), but doesnot
affect the efficacy of oral contraceptives.
Because chronic AED treatment generates potentialmorbidity, the
benefits of discontinuing treatment must
Figure 5. EEG tracing showing a generalized 3-Hz spike and wave
discharge lasting 6 seconds in a 7-year-old girl who hasgeneralized
absence epilepsy.
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Pediatrics in Review Vol.28 No.11 November 2007 409
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be balanced against the risks of seizures recurring.Known risk
factors for seizure recurrence after AEDdiscontinuation are
abnormal findings on neurologicexamination, seizure onset before
age 2 years, EEGabnormalities, and specific epilepsy types (eg,
juvenilemyoclonic epilepsy). Neurologists generally wait for
aperiod of 1 to 2 seizure-free years before weaning a childoff an
AED.
DIETS. The ketogenic diet has been used for morethan 80 years to
treat children who have intractableepilepsy. For unknown reasons,
this high-fat and low-carbohydrate diet sometimes provides dramatic
improve-ment in seizure control and level of awareness. This
dietrequires extensive parent training and child supervision.The
potential adverse effects are renal stones, growthinhibition,
hyperlipidemia, vitamin deficiencies, and con-stipation. A new diet
(low-glycemic index diet) is beingdeveloped and has the advantage
of being less restrictiveand more palatable than the ketogenic
diet.
SURGERY. Epilepsy surgery is considered for patientswho have
seizures that seriously impair their quality of
life and who have a localized seizure focus that possiblycould
be resected without producing unacceptable se-quelae. Most surgical
techniques aim to remove the brainarea responsible for the
initiation of the seizure dis-charges. Such surgeries should be
performed in special-ized epilepsy centers. Extratemporal
resections are un-dertaken more commonly in children than in
adultsbecause seizure foci in children are more likely to be dueto
focal dysgenesis. Hemispherectomy is indicated forconditions in
which the entire hemisphere generates theepileptic activity (eg,
hemimegalencephaly, Sturge-Weber syndrome, Rasmussen encephalitis).
Corpus cal-losotomy is a palliative procedure used to prevent
thepropagation of epileptic activity from one hemisphere tothe
other. Corpus callosotomy is performed primarily inpatients who
have atonic seizures without any resectablelesion.
VAGUS NERVE STIMULATOR. The vagus nerve stimu-lator (VNS) is a
pacemakerlike device that transmitselectrical impulses to the left
vagus nerve. A lead isattached to the vagus nerve and is connected
to a stimu-lator inserted subcutaneously on the chest wall. The
Figure 6. EEG showing hypsarrhythmia in a 9-month-old girl who
has infantile spasms.
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410 Pediatrics in Review Vol.28 No.11 November 2007
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current indication for VNS is as adjunctive treatment
ofintractable partial seizures. The mechanism of action isunknown,
but presumably the stimulation modifies thebrain’s electrical
activity. The device usually is well toler-ated, but possible
adverse effects include hoarseness,coughing, throat paresthesias,
and dyspnea as well as thepotential complications of the surgery
itself.
PSEUDOSEIZURES. Management of nonepileptic events,or
pseudoseizures, often poses a special challenge forclinicians,
especially when a patient who has epilepsy alsohas pseudoseizures.
Patient cooperation is crucial. Afterthe diagnosis is made, an
appropriate strategy is to ex-plain that stress or emotions can
cause seizurelike eventsunconsciously. It is important for the
clinician to ac-knowledge the patient’s distress. The patient also
shouldbe reassured that these events are not harmful to the
brain. The help of a mental health professional often isneeded
to work on potential stressors and emotionalissues.
Specific DisordersBENIGN PARTIAL EPILEPSY WITH
CENTROTEMPORAL
SPIKES. Until recently, most neurologists believed thatthe
seizures associated with this condition (also known asbenign
rolandic epilepsy) did not require treatment withAEDs, but this
trend has changed, given the increasingliterature on cognitive
deficits associated with rolandicepilepsy. It now is recommended to
start AEDs after twoseizures. Almost all children enter long-term
remissionby mid-adolescence.
TEMPORAL LOBE EPILEPSY. Temporal lobe seizuresoften are
refractory to AEDs. Temporal lobectomy is
Table 1. Specific Use of Antiepileptic Drugs in Relation to the
EpilepsyTypes
Primary Generalized Partial Onset
AbsenceMyoclonic,
Atonic, Tonic Tonic-Clonic Simple Partial Complex
PartialSecondary Generalized
Tonic-Clonic
Ethosuximide Benzodiazepines Carbamazepine, Phenytoin,
Phenobarbital, Primidone, Gabapentin, Tiagabine,Oxcarbazepine,
Pregabalin
Valproate, Felbamate, Lamotrigine, Topiramate, Levetiracetam,
Zonisamide
Table 2. Primary Adverse Effects Associated with Antiepileptic
Drugs(AEDs)
AED (abbreviations) Primary Adverse Effects
Carbamazepine (CBZ) Hepatic or blood dyscrasia, ataxia,
diplopia, rashClobazam* (CLB) Somnolence, ataxia,
hyperactivityClonazepam (CLN) Somnolence, hyperactivityEthosuximide
(ESM) Somnolence, blood dyscrasiaFelbamate (FBM) Severe aplastic
anemia, severe hepatic toxicity, weight lossGabapentin (GBP)
Ataxia, fatigueLamotrigine (LTG) Rash, ataxia,
insomniaLevetiracetam (LEV) Somnolence, ataxia, behavioral
changesOxcarbazepine (OXC) Hepatic or blood dyscrasia, ataxia,
diplopiaPhenobarbital (PB) Somnolence, cognitive
impairmentPhenytoin (PHT) Ataxia, nystagmus, somnolence, gingival
hyperplasia, hirsutism, rashPregabalin (PGB) Ataxia,
fatigueTiagabine (TGB) FatigueTopiramate (TPM) Cognitive
impairment, weight loss, kidney stonesValproic acid (VPA) Severe
hepatic toxicity, weight gain, osteopeniaVigabatrin* (VGB)
Dizziness, retinal degenerationZonisamide (ZNS) Cognitive
impairment, somnolence, weight loss, dizziness, kidney stones
*Not available in United States.
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Pediatrics in Review Vol.28 No.11 November 2007 411
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effective in approximately 80% of cases if mesial
temporalsclerosis is observed on MRI.
FRONTAL LOBE EPILEPSY. Surgery is less beneficial forthis
condition than for temporal lobe epilepsy becausethe seizure focus
is harder to localize and lateralize andbecause larger brain areas
often need to be resected. Withimproving MRI resolution, better
outcomes are ex-pected after epilepsy surgery for frontal lobe
epilepsy.
CHILDHOOD ABSENCE EPILEPSY. A good treatmentresponse is expected
with valproic acid, ethosuximide, orlamotrigine. Seizures usually
remit by adolescence orearly adulthood.
JUVENILE MYOCLONIC EPILEPSY (JANZ SYNDROME).More than 80% of
patients who have this condition arewell controlled on
broad-spectrum AEDs, but the sei-zures frequently relapse when the
medication is discon-tinued, and treatment often is required into
adulthood.
INFANTILE SPASMS. Medication controls spasmscompletely in
approximately 75% of cases. Early controlof spasms is associated
with a better cognitive outcome.Commonly used first-line drugs are
vigabatrin (not avail-able in the United States) and
adrenocorticotropic hor-mone; benzodiazepines, valproic acid, and
topiramateare considered second-line therapy. The ketogenic dietand
other broad-spectrum AEDs also may be effective.Carbamazepine
sometimes precipitates the occurrence ofspasms.
LENNOX-GASTAUT SYNDROME. Seizure control inLennox-Gastaut
syndrome is very difficult, and poly-therapy is common. Valproic
acid, lamotrigine, topira-mate, and clonazepam are used commonly,
with variableeffects on the different seizure types. Felbamate can
beeffective but may be associated with significant morbid-ity. The
ketogenic diet and VNS also may improve sei-zure control. Corpus
callosotomy can reduce or abolishdrop attacks if there is no
underlying major diffuse brainmalformation, but that procedure
rarely influences theother seizure types seen in Lennox-Gastaut
syndrome.
FEBRILE SEIZURES. Administration of an antipyretic(acetaminophen
or ibuprofen) during febrile episodes isrecommended for children
who experience recurrentfebrile seizures. Preventive anticonvulsant
medicationshould be reserved for children who have frequent
febrileseizures. Intermittent prevention strategy involves
ad-ministering rectal diazepam (0.5 mg/kg) when the sei-
zure occurs or oral diazepam during the febrile episode(1 mg/kg
per day divided in three doses). If the inter-mittent strategy is
insufficient, continuous treatmentwith anticonvulsant medications
can be started.
Status EpilepticusThe initial management of a child in status
epilepticus isto secure the airway. The child should be placed on
his orher side to prevent aspiration, making sure that the
upperrespiratory airway is free and oxygen is provided by
mask.Blood pressure and electrocardiographic monitoringshould be
instituted. While gathering information fromthe parents and
examining the patient, blood should bedrawn for a complete blood
count, electrolytes, bloodglucose, calcium, and magnesium and
toxicologic screen.An intravenous (IV) line should be placed. If
the patientis known to have epilepsy and taking medication,
con-centrations of AEDs should be determined. Any poten-tially
epileptogenic metabolic imbalance should be cor-rected quickly.
If the seizure is not caused by metabolic derange-ment, the
general consensus is to start treatment with abenzodiazepine. IV
lorazepam at a dose of 0.1 mg/kg(0.15 mg/kg for patients already
receiving a benzodiaz-epine) up to a maximum of 4 mg is generally
the firstchoice. Diazepam at a dose of 0.3 mg/kg (0.5 mg/kgfor
patients already receiving a benzodiazepine) also is agood option
and can be administered intravenously,intrarectally, or
endotracheally. Lorazepam or diazepamcan be repeated at the same
dose if the seizure does notstop after 5 minutes.
The second step is to use IV phenytoin or phenobar-bital.
Phenytoin (or fosphenytoin) is given at a dose of20 mg/kg
intravenously (or 20 phenytoin equivalents/kg) up to a maximum of
1,250 mg. Phenytoin (or fosphe-nytoin) usually is ineffective for
febrile status epilepticus.Phenobarbital is administered at a dose
of 10 to 20 mg/kg,up to a maximum of 300 mg. If the seizure remains
uncon-trolled, the third step is to induce a “barbiturate coma.”
Atthis stage, intubation is mandatory, and an
anesthesiologistshould be involved. Status epilepticus treatment
protocolsvary at different institutions. Some physicians may use
mi-dazolam, valproic acid, or other AEDs.
ConclusionMany investigational tools are available to refine
theclinical evaluation of seizures in children. The
additionalinformation gained from these studies helps to
determineappropriate prognosis and treatment. Educating thechild
and family about seizure disorders is another keyelement in
effective management.
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412 Pediatrics in Review Vol.28 No.11 November 2007
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ACKNOWLEDGMENTS. We are very thankful to DrRon Thibert for his
help in the preparation of this article.
Suggested ReadingCommission on Classification and Terminology of
the Interna-
tional League Against Epilepsy. Proposal for a revised
clinicaland electroencephalographic classification of epileptic
seizures.Epilepsia. 1981;22:489–501
Commission on Classification and Terminology of the
Interna-tional League Against Epilepsy. Proposal for a revised
classifica-tion of epilepsies and epileptic syndromes. Epilepsia.
1989;30:389–399
Committee on Quality Improvement. Subcommittee on
FebrileSeizures. Practice parameter: long-term treatment of
thechild with simple febrile seizures. Pediatrics.
1999;103:1307–1309
Growing up With Epilepsy. An educational resource on
childhoodepilepsy created by the MGH pediatric epilepsy program
in
collaboration with the WBGH Educational Foundation. Avail-able
at: www.massgeneral.org/childhoodepilepsy.
Hirtz D, Ashwal S, Berg A, et al. Report of the Quality
StandardsSubcommittee of the American Academy of Neurology,
theChild Neurology Society, and the American Epilepsy
Society.Practice parameter: evaluating a first nonfebrile seizure
in chil-dren. Neurology. 2000;55:616–623
Hirtz D, Berg A, Bettis D, et al. Report of the Quality
StandardsSubcommittee of the American Academy of Neurology and
thePractice Committee of the Child Neurology Society.
Practiceparameter: treatment of the child with a first unprovoked
sei-zure. Neurology. 2003;60:166–175
Provisional Committee on Quality Improvement. Subcommitteeon
Febrile Seizures. Practice parameter: the neurodiagnosticevaluation
of the child with a first simple febrile seizure. Pediat-rics.
1996;97:769–775
Sharma S, Riviello JJ, Harper MB, et al. The role of
emergentneuroimaging in children with new-onset afebrile
seizures.Pediatrics. 2003;111:1–5
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PIR QuizQuiz also available online at www.pedsinreview.org.
1. A worried mother brings in her 16-year-old daughter for
concerns over seizures at school. Her teacherreported that within 1
hour, the girl had three episodes of groaning and shaking all over
with her eyes shuttight and her head moving from side to side. Each
episode lasted approximately 3 minutes. There was norespiratory
difficulty or urinary or fecal incontinence, and between episodes,
the girl was awake and quietbut appropriately responsive.
Additional history reveals no prior seizures and a recent move to
the newschool. Her physical examination findings are normal. Of the
following, the test that is most likely to revealthe diagnosis
is:
A. Antinuclear antibody measurement.B. Computed tomography scan
of the brain.C. Lumbar puncture.D. Urine toxicology screen.E. Video
electroencephalography.
2. A 17-year-old girl who has had seizures for the past 5 years
presents to your office. Her seizures have beenwell controlled
(none in 2 years) on her current antiepileptic medication, and she
asks you if it can bediscontinued. Physical examination findings
are normal. Of the following, the factor that is most likely
toincrease her risk of seizure recurrence after discontinuing her
medication is:
A. Diagnosis of benign rolandic epilepsy.B. Diagnosis of
juvenile myoclonic epilepsy.C. Family history of epilepsy.D.
History of developmental delay as a young child.E. History of
status epilepticus with initial seizure.
3. Of the following antiepileptic medications, which one is most
likely to cause nephrolithiasis?
A. Ethosuximide.B. Lamotrigine.C. Phenobarbital.D. Topiramate.E.
Valproic acid.
4. Of the following, which seizure type is matched correctly
with the appropriate antiepileptic medication?
A. Absence epilepsy � Gabapentin.B. Atonic epilepsy �
Phenytoin.C. Complex partial epilepsy � Carbamazepine.D. Simple
partial epilepsy � Midazolam.E. Tonic-clonic epilepsy �
Ethosuximide.
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414 Pediatrics in Review Vol.28 No.11 November 2007