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NEUROLOGY 2005;64:774775 Editorial

The first seizure in childhood

Dont just do something, stand there!

Mary L. Zupanc, MD

The question of which patients to treat after a sei-zure in childhood remains problematic. In this issueof Neurology, Shinnar et al.1 address this often vex-ing situation in one of a series of articles based on acohort of 407 patients who have now been followedfor more than 14 years. This longitudinal, prospec-tive study focuses on the natural history of an un-treated cohort and has addressed a childs risk ofseizure recurrence following a first unprovoked sei-

zure, the subsequent risk of developing intractableepilepsy, and, in the present study, the risk of mor-tality following a first unprovoked seizure. Such pro-spective studies are difficult, requiring carefulfollow-up and rigorous analysis of the data. The rel-atively small sample size is a limiting factor.Follow-up has been predominantly through tele-phone interviews by nurses for ascertainment of sei-zure recurrence and current treatment. Suchinterviews can be inaccurate unless confirmatorymedical records are obtained. If a patient died, med-ical records were reviewed; otherwise, the interviewwas the sole source of data. The data obtained from

this cohort of patients provide insight into the natu-ral history of seizures in children, as previous stud-ies have typically been observational andretrospective, focusing on the risk of seizure recur-rence with and without antiepileptic drug (AED)treatment.

The results are noteworthy. Of the 407 patientswho had a first unprovoked seizure, 45% had recur-rent seizures. Of those who developed intractableseizures, many had remote symptomatic CNS pa-thology (in most cases, cerebral dysgenesis) and pre-sented with status epilepticus. Even so, none died

prior to initiation of antiepileptic medication. Of thefour whose death could have been a result of theirepilepsy, all had difficult-to-control seizures; three ofthe four patients had remote symptomatic epilepsy.

Any parent whose child has had a seizure knowshow frightening it can be. Parents want to protect

and safeguard their children. They grow to feel com-fortable with most of the responsibilities of parent-ing, even illnesses. However, when a child has aseizure, unprovoked and seemingly out of the blue, itis a jarring experience and most parents suddenlyfeel out of control. They are frightened and want aphysician or allied health professional to tell themthat their child will be okay. Most parents also wantto know whether this will ever happen again.

Emergency department physicians and pediatri-cians usually provide little information to familiesregarding prognosis or treatment plan, pending a

visit to the child neurologist. The information pro-vided by Shinnar et al. deserves wide disseminationto general physicians and care providers: pediatri-cians, family practitioners, and nurses. This article1

and others2-5 suggest the following:There should be no haste in starting antiepileptic

medication following a first unprovoked seizure. Theside effects of antiepileptic medication, particularlysubtle cognitive and behavioral side effects, need tobe considered. Physicians are often less familiar with

the newer antiepileptic medications, which may bebetter tolerated.

The diagnostic evaluation for a first unprovokedseizure is only an emergency if it is status epilepti-cus. Emergency CT scans need not be performed un-less head trauma is suspected. Otherwise, anoutpatient EEG (awake and sleep) and a non-urgentbrain MRI scan should be obtained.

For a single unprovoked seizure, the risk of recur-rence is less than 50%. The EEG and brain MRI scanmay contribute additional information with respectto risk of recurrence and prognosis. Specifically, if

the EEG and brain MRI scan are normal, seizureswill not recur in two-thirds of patients. In addition,the history, examination, EEG, and brain MRI scanmay identify a specific epilepsy syndrome with a de-fined prognosis.

The predictors of seizure recurrence include re-

See also page 880

From the Department of Neurology and Pediatrics, Division of Pediatric Neurology, Pediatric Comprehensive Epilepsy Program, Childrens Hospital of

Wisconsin, Medical College of Wisconsin, Milwaukee.

Address correspondence and reprint requests to Dr. Mary L. Zupanc, Professor, Department of Neurology and Pediatrics, Chief, Division of Pediatric

Neurology, Director, Pediatric Comprehensive Epilepsy Program, Childrens Hospital of Wisconsin, Medical College of Wisconsin, 9000 W Wisconsin Ave.,

Milwaukee, WI 53226; e-mail: mzupanc@mcw.edu

774 Copyright 2005 by AAN Enterprises, Inc.

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mote CNS injury (such as cerebral dysgenesis), anabnormal EEG, a seizure occurring while asleep, ahistory of prior febrile seizures, and the occurrence ofTodds paresis.

Even in children who have one or two additionalseizures, the mortality, with or without antiepilepticmedication, is extremely low.

The risk of sudden unexplained death in epilepsy(SUDEP) need not be discussed with families at the

first seizure in children with epilepsy. SUDEP usu-ally occurs only in children with intractable epilepsy.

There are still unanswered questions, particularlyregarding children with intractable epilepsy. Whencan a child be labeled as having intractable epilepsy?Is the definition similar in children and adults,6 thefailure of one or two appropriately chosen AEDs pre-dicting that the childs seizures are going to be diffi-cult to control? How do children with intractableepilepsy differ from those with easily controlled epi-lepsy? What is the long-term outlook for these chil-

drenwith respect to seizure control, cognitiveabilities, school performance, developmental out-come, and psychosocial outcome? What happens totheir familiesprevalence of divorce, risk of depres-sion, and sibling outcome? Such answers will be par-amount in advising parents fully about their childsprognosis.

References

1. Shinnar S, ODell C, Berg AT. Mortality following a first unprovokedseizure in children: a prospective study. Neurology 2005;64:880882.

2. Shinnar S, Berg AT, Moshe SL, et al. The risk of seizure recurrencefollowing a first unprovoked afebrile seizure in childhood: an extendedfollow-up. Pediatrics 1996;98:216225.

3. Hirtz D, Berg AT, Bettis D, et al. Practice parameter: treatment of thechild with a first unprovoked seizure. Report of the QSS of the AAN andthe Practice Committee of the CNS. Neurology 2003;60:166175.

4. Shinnar S, Berg AT, ODell C, et al. Predictors of multiple seizures in acohort of children prospectively followed from the time of their firstunprovoked seizure. Ann Neurol 2000;48:140147.

5. American Academy of Pediatrics, Committee on Drugs. Behavioral andcognitive effects of anticonvulsant therapy. Pediatrics 1995;96:538540.

6. Kwan P, Brodie MJ. Early identification of refractory epilepsy. N EnglJ Med 2000;324:314319.

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