Treatment Following a First Seizure
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1 Treatment Following a First Seizure 6 year old developmentally normal child brought to the ED with a history of a 5 minute generalized tonic seizure in sleep. Seizure occurred about 60 minutes after falling asleep. Onset not witnesssed but older brother heard him shaking and called parents. On exam, afebrile and sleepy. Normal exam once more awake. What do you do?
2 Neurology 2000;55:
3 Diagnostic Evaluation Following a First Unprovoked Seizure in Children : AAN Practice parameter The EEG is recommended as part of the diagnostic evaluation of a child with an apparent first unprovoked seizure (Standard) There is sufficient Class I evidence, which involves a well executed prospective study, to provide a recommendation with the highest degree of clinical certainty i.e., a Standard that an EEG be obtained in all children in whom a nonfebrile seizure has been diagnosed, to predict the risk of recurrence and to classify the seizure type and epilepsy syndrome. Hirtz et al Neurology 2000;55:
4 Rolandic spikes: Horizontal and perpendicular dipoles
5 Recurrence Risk Following First Unprovoked Seizure EEG in Idiopathic/Cryptogenic Cases (N=305) 1.0 Risk of Seizure Recurrence Non epileptiform EEG (n=27) Epileptiform EEG (n=97) Normal EEG (n=181) Time (yrs) p < Shinnar et al 2005
6 Recurrence Risk Following First Unprovoked Seizure Sleep State in Benign Rolandics (N=36) 1.0 Risk of Seizure Recurrence Awake (n=9) Asleep (n=27) Time (yrs) p = 0.11 Shinnar et al 2005
7 Recurrence Risk Following First Unprovoked Seizure Status Epilepticus (N=407) 1.0 Risk of Seizure Recurrence Status epilepticus (n=48) Seizure < 30 min (n=359) Time (yrs) p = 0.22 Shinnar et al 2005
8 Treatment Following a First Seizure 8 months later child has another seizure. This one occurs as he is falling asleep. Has Right facial and arm twitching with speech arrest and then briefly generalizes. Entire episode lasts 2 minutes. What do you do?
9 Prognosis Following First Unprovoked Seizure Risk of Third Seizure After Initial Recurrence (n=185) 1.0 Cumulative Risk of Seizure Recurrence Time (yrs) Shinnar et al 2005
10 Effect of Treatment on Recurrence Risk Following First Unprovoked Seizure p = Beghi et al 1993
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12 Efficacy of AED Therapy of Provoked Seizures in Preventing Later Epilepsy Provoked Later Seizures Unprovoked Seizures Treatment Control Treatment Control Parameter / reference (%) (%) (%) (%) Recurrent febrile seizures Knudsen, Wolf and Forsythe, Rosman et al Acute posttraumatic seizures Temkin, Postcraniotomy Foy et al Berg and Shinnar, 1996
13 Risks of AED Therapy and of Seizures Risks of Therapy Risks of Seizures Systemic toxicity Idiosyncratic Dose-related Chronic Teratogenic Higher cortical functions Cognitive impairment Adverse effects on behavior Psychosocial Need for daily medication Labeling as chronic illness Economic Cost of medications Cost of physician visits Cost of laboratory tests Physical injury Loss of consciousness Secondary to falls Status epilepticus Psychosocial Restrictions on activity Social stigma of seizures Fear of subsequent seizures Shinnar and O Dell, 1995
14 Neurology 2003;60:
15 Treatment Following a First Unprovoked Seizure in Children : AAN Practice parameter Treatment with AED is not indicated for the prevention of the development of epilepsy (Level B) Treatment with AED may be considered in those circumstances where the benefits of reducing the risk of a second seizure outweigh the risks of pharmacologic and psychosocial side effects (Level B) TREATMENT FOLLOWING A FIRST SEIZURE IS RARELY INDICATED Hirtz et al Neurology 2003;60:
16 Treatment- how long After 4 more seizure over a few months you decide to treat on risk benefit basis - what drug would you use?
17 Treatment- how long After 4 more seizure over a few months you decide to treat on risk benefit basis - what drug would you use? Child is not seizure free for 2 years, EEG still demonstrates Rolandic spikes but no other abnormality. Parents are interested in discontinuing meds. What do you tell them??
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