Evaluación y manejo de primera crisis epiléptica / Assessment and management of the first epileptic seizure

RESUMEN Las crisis epilépticas son una causa frecuente de consulta en la emergencia y en la atención ambulatoria. La evaluación de una primera crisis epiléptica reviste gran trascendencia en este contexto, ya que la ocurrencia de ésta no implica necesariamente el diagnóstico de epilepsia (dos o más crisis no provocadas separadas por más de 24 horas; una crisis única con alto riesgo de recurrencia (>60%); o la evidencia de un síndrome epiléptico - definición de la Liga Internacional para la Lucha Contra la Epilepsia, ILAE) y el tratamiento subsecuente. Por otro lado, no todo paciente con primera crisis debe ser dejado en observación sin recibir el manejo apropiado. Esta decisión está en función del riesgo de recurrencia de crisis. Para ello, la Academia Americana de Neurología (AAN de sus siglas en inglés) recomienda la clasificación de la primera crisis epiléptica en cinco grupos y dependiendo del riesgo de recurrencia de crisis establecido para cada uno de ellos, se tendrá una guía para proceder o no con el tratamiento antiepiléptico. Los grupos son: pacientes con crisis epiléptica provocadas; pacientes con crisis sintomáticas agudas; pacientes con crisis sintomática remotas; primera crisis asociada a síndromes epilépticos; primera crisis de causa desconocida. La guía publicada por AAN en el 2015 para el manejo de primera crisis, sugiere que los pacientes con crisis sintomáticas remotas (lesiones cerebrales pasadas no evolutivas), pacientes con anormalidades epileptiformes interictales; pacientes con estudios de imagen anormales (RMN y TC); y pacientes con crisis nocturnas, tienen un riesgo elevado para recurrencia de crisis (>60%) por lo que deben ser tratadas. La evidencia disponible a la fecha sugiere también que no hay diferencia significativa en el inicio precoz o diferido del tratamiento antiepiléptico para el control de las crisis a largo plazo.

SUMMARY Epileptic seizures are a common cause of medical consultation in the emergency room and in outpatient settings. The evaluation of the first epileptic seizure is of upmost importance as not all patients presenting with seizures have epilepsy (two or more unprovoked crises separated more than 24 hours; one single crisis with a high risk of recurrence (>60%); or evidence of an epileptic syndrome needing treatment based on the definition by the International League against Epilepsy). On the other hand, not every patient with a first episode should be just observed not offering proper treatment. This decision is based on the risk of recurrence. For that purpose, the American Academy of Neurology (AAN) recommends classifying the first seizures into five groups depending on the risk of recurrence, these groups are: patients with provoked seizures; patients with acute symptomatic seizures; patients with remote symptomatic seizures; first seizure associated with an epileptic syndrome, and first seizure of unknown origin. The AAN guidelines for the management of the first seizure published in 2015 suggests that patients with symptomatic remote seizures (non-evolutive and old cerebral lesions), patients with interictal epileptiform abnormalities, patients with abnormal findings on MRI or CT scan, and patients with nocturnal seizures had a high risk for recurrence (>60%) and should be treated. Current evidence suggests that there is no difference in early or delay treatment for controlling seizures at the long-term.

Acute Symptomatic Seizures in Patients with Acute Ischemic Stroke: Incidence and Predictive Factors

BACKGROUND: The aim of this study was to establish the incidence, predictive factors, characteristics, and clinical outcomes of acute symptomatic seizures (ASS) after acute ischemic stroke (AIS). METHODS: In total, 2,528 consecutive patients with first-ever AIS were included. Patients with a history of epilepsy or provoked seizures due to tumor, head trauma, brain surgery, or high fever were excluded. Onset seizure (OS) and ASS were defined as seizures occurring within 24 hours and 7 days after AIS, respectively. The incidence of ASS, type of seizures, presence of late unprovoked seizure (LUS), MRI, and electroencephalogram were analyzed. RESULTS: ASS and OS occurred in 23 patients (0.9%) and 15 patients (0.6%), respectively; 20 of the patients with ASS (87.0%) had partial seizures and 4 (17.4%) developed status epilepticus. The incidence rates of ASS were 1.3%, 0.3%, and 0.2% in AIS caused by large-artery atherosclerosis, small-vessel occlusion, and cardioembolism, respectively. Of the 23 patients with ASS, the cortex was involved in 19 (82.6%), 16 patients (69.6%) had medium-sized to large lesions, the anterior circulation territory was involved in 21 patients (91.3%), and 4 patients (17.4%) developed MRI-confirmed hemorrhagic transformation of the lesions. Epileptiform discharges were observed in 9 (45%) of the 20 patients with ASS. Three of the 23 patients with ASS (13.0%) developed LUS. CONCLUSIONS: The incidence of ASS was 0.9% and was highest in the large-artery atherosclerosis group. The development of ASS was significantly associated with cortical involvement, medium-sized to large lesions, and lesions in the anterior circulation territory. Three of 23 patients (13%) developed LUS.

Risk Factors of Unprovoked Seizures after Acute Symptomatic Seizures in Children / 소아과

PURPOSE: Acute symptomatic seizure is defined as a temporary seizure together with acute systemic, metabolic, or toxic insult in association with an acute central nervous system insult. And unprovoked seizure is defined as seizure without provocating factors. We studied the risk factors of unprovoked seizures after acute symptomatic seizure in children. METHODS: We retrospectively reviewed the records of one hundred and ten children with acute symptomatic seizures who were admitted to the pediatric department of Chungbuk National University Hospital between January, 1998 and December, 2003. We analyzed overall risk factors of unprovoked seizures after acute symptomatic seizures involving etiology, incidence, type of seizure, duration and neuroimaging. RESULTS: We analyzed records of 110 children with acute symptomatic seizures aged from 1 month to 17 years. 24 children had unprovoked seizures (21.8%) after acute symptomatic seizures. Causes in order of frequency were encephalopathy, central nervous system infection, brain tumor, cerebrovascular disease. The risk of unprovoked seizure was significantly greater for those with status epilepticus (68.4%) than without status epilepticus, with partial seizure (64.7%) than generalized seizure. And the risk of unprovoked seizure was strongly associated with abnormal finding of electroencephalogram (79.1%) and neuroimaging (41.6%). CONCLUSION: In conclusion, the leading cause of subsequent unprovoked seizure in children with acute symptomatic seizure was encephalopathy and age specific incidence was high in the group aged 24-72 months. The risk for subsequent unprovoked seizure was greater for those with partial seizure, status epilepticus, abnormal finding of neuroimaging and electroencephalography.

Risk Factors of Unprovoked Seizures after Acute Symptomatic Seizures in Children / 소아과

PURPOSE: Acute symptomatic seizure is defined as a temporary seizure together with acute systemic, metabolic, or toxic insult in association with an acute central nervous system insult. And unprovoked seizure is defined as seizure without provocating factors. We studied the risk factors of unprovoked seizures after acute symptomatic seizure in children. METHODS: We retrospectively reviewed the records of one hundred and ten children with acute symptomatic seizures who were admitted to the pediatric department of Chungbuk National University Hospital between January, 1998 and December, 2003. We analyzed overall risk factors of unprovoked seizures after acute symptomatic seizures involving etiology, incidence, type of seizure, duration and neuroimaging. RESULTS: We analyzed records of 110 children with acute symptomatic seizures aged from 1 month to 17 years. 24 children had unprovoked seizures (21.8%) after acute symptomatic seizures. Causes in order of frequency were encephalopathy, central nervous system infection, brain tumor, cerebrovascular disease. The risk of unprovoked seizure was significantly greater for those with status epilepticus (68.4%) than without status epilepticus, with partial seizure (64.7%) than generalized seizure. And the risk of unprovoked seizure was strongly associated with abnormal finding of electroencephalogram (79.1%) and neuroimaging (41.6%). CONCLUSION: In conclusion, the leading cause of subsequent unprovoked seizure in children with acute symptomatic seizure was encephalopathy and age specific incidence was high in the group aged 24-72 months. The risk for subsequent unprovoked seizure was greater for those with partial seizure, status epilepticus, abnormal finding of neuroimaging and electroencephalography.

A Clinical Study of Acute Symptomatic Seizures in Children / 대한소아신경학회지

PURPOSE: The present study was designated to sex, age, etiology of acute symptomatic seizures, which refer to the seizure caused by specific and transient pathophysiologic abnormalities in the central nervous system and other systems, and furthermore to analyze the incidence of acute symptomatic seizures before and during hospitalization. METHODS: The medical records of six hundred and ten convulsive children under fifteen years of age, who visited the Hallym University Sacred Heart Hospital from January 1999 to May 2001, were reviewed. One hundred and fourteen cases out of them were analyzed, and febrile seizures and unprovoked seizures were excluded. RESULTS: Among six hundred and ten children who had seizure during hospitalization, one hundred and fourteen(18.7%) had acute symptomatic seizures exclusive of febrile seizures and unprovoked seizures. The ratio of male to female was 1:2.1 and the peak age was three or less, accounting for 93.9%. Acute symptomatic seizures were caused by acute gastroenteritis(42.0%), metabolic/toxic disturbances(34.1%), cerebrovascular diseases(8.8%), CNS infections(8.0%), hypoxemia(4.4%), brain tumors(1.8%), and others(0.9 %). Remarkably, hypocalcemia and shaken baby syndrom were up to 82.1% of metabolic/ toxic distubances and 30.0% of cerebrovascular diseases, respectively. Among the one hundred and fourteen patients, 41.2% suffered from seizures before and during hospitalization and 11.4% did not before but did during hospitalization. CONCLUSION: Eighteen point seven percent of the cases of convulsions reviewed were classified into acute symptomatic seizures exclusive of febrile seizures and unprovoked seizures with the male to female ratio of 1:2.1 and high incidence age of three or less years. The leading causes of acute symtomatic seizures were acute gastroenteritis and hypocalcemia, comprising 70%. Shaken baby syrome and hyponatremia due to water intoxication can be prevented by public education about the danger, and central nervous system infection can be reduced by vaccine development and nationwide vaccination against the bacteria causing the central nervous system infection. In addition, appropriate prevention and management of seizure attacks are required for the patients with acute symptomatic seizures during hospitalization.

A Clinical Study of Acute Symptomatic Seizures in Children

PURPOSE: To determine the incidence, etiology, sex, age, seizure type and prognosis of acute symptomatic seizures in children and evaluate the hypothesis that acute symptomatic status epilepticus(SE) is associated with an increased risk of subsequent unprovoked seizure compared with the risk of acute syrnptomatic seizure without SE. METHODS: Five hundred and sixty-eight convulsive children visited the Pediatric Department of Chungbuk National University Hospital from February 1991 to February 1999. Of these, 109 patients were determined as acute symptomatic seizure, and their medical record were reviewed. RESULTS: One hundred and nine children(59#boys, 50#girls) had acute symptomatic seizures, the ratio of male to female and the ages at the onset of first seizure were 1.18: 1 and 1.58+/-2.53 years, respectively. Causes of acute symptomatic seizure in order of frequency were acute gastroenteritis(33.0%), encephalopathy(31.2%), metabolic/toxic disturbance(19.3%), CNS infection (11.0%), brain trauma(2.8%), cerebrovascular disease(1.8%) and CNS tumor(0.9%). At six months of follow-up, the incidence of a first unprovoked seizure was 28.4% for children with acute symptomatic seizure, 67.6% for those with encephalopathic cause, 44% for those with structural cause, and O% for those with metabolic cause. At six months of follow-up, the risk of a first unprovoked seizure was significantly greater for those with acute symptornatic seizure with SE(100%) than without SE(22%). CONCLUSION: The leading causes of acute syrnptomatic seizures were acute gastroenteritis. Age-specific incidence was highest in the group aged 0-12 rnonths. The incidence of subsequent un-provoked seizure was highest in the group of encephalopathy. The risk for subsequent un-provoked seizure was greater for those with SE than for those without SE and for those with abnormal EEG and abnormal findings of neuroimage.