Recurrent seizure

Question 1

You are seeing a 10 year old girl in general outpatient clinic. She was recently discharged from hospital after having a potential seizure event at school on a background of epilepsy since 3 years of age. Previously the seizure was well controlled on medication. The medication was stopped 12 months ago after being seizure free for > 2 years.

Answer 1

Impression
Concerned about recurrence of seizures given previous history of epilepsy and recently ceasing medication.

Ddx to consider
- primary epilepsy; consider different seizure syndromes. And consider type of seizure (focal, generalised, absence)
- secondary causes of seizure;
   o infective: meningitis, encephalitis
   o SOL
   o electrolytes
   o trauma
   o medications
- syncopal episode (cardiac, neurogenic, BP)

Goals

• thoroughly assess to determine likely underlying aetiology of presentation
• Likely epilepsy management with referral to paeds neuro/gen paeds for likely restarting of anti-epileptic medications.

Question 2

Seizure recurrence - History

Answer 2

History

• sx: ask about pre, during (semiology), and after ‘episode’. any video of the event? likely require collateral history. Any pre-ceding aura, incontinent, sore muscles post? generalised shaking during? or abscence seizure.
• Risks: Recent stressors? sleeplessness, stress, etc.
• History of previous epileptic seizures, similar? impact on quality of life?
• medication utilised previously? any investigations (EEG, etc)

Question 3

Seizure recurrence - Examination

Answer 3

Examination

• General appearance + vital signs
• Neurological exam: focal neuro for DDx, Brudzinski’s/Kernig’s sign
• Paeds assessment (height, weight, BMI, growth charting)

Question 4

Seizure recurrence - Investigations

Answer 4

Investigations

• Bedside: Video EEG (gold standard)
• Bloods: UEC, LFT, CRP/ESR, FBC,
• MRI Brain

Question 5

Seizure recurrence - Management

Answer 5

Management
- Ensure no ongoing seizure activity
- Referral to paeds neurology, likely consider definitive treatment with anti-epileptic medication (would likely utilise medication which was previously used to Good effect;
o Focal: carbemazepine
o Generalised: Sodium valproate
o Others: lamotrigine, keppra,
o Epilepsy management plan: take home buccal midaz with parent education if regular status

Supportive

• seizure risk prevention: avoid over-fatigue, stress, don’t suddenly cease meds.
• lifestyle changes
• keep seizure diary
• ensure observed whilst swimming