What is the appropriate management for an adolescent child presenting with symptoms mimicking seizures?

From the Guidelines

The appropriate management for an adolescent child presenting with symptoms mimicking seizures begins with a comprehensive evaluation to distinguish between epileptic seizures and non-epileptic events such as psychogenic non-epileptic seizures (PNES). Initial assessment should include a detailed history, physical examination, and diagnostic testing including electroencephalogram (EEG), preferably with video monitoring, and brain imaging such as MRI, as recommended by the American College of Radiology Appropriateness Criteria for seizures in children 1.

Key Considerations

• If epileptic seizures are confirmed, first-line antiepileptic medications like levetiracetam or lamotrigine may be prescribed, with dosing adjusted based on patient response and tolerability.
• For PNES, cognitive behavioral therapy is the treatment of choice, typically involving 12-16 weekly sessions, combined with appropriate psychiatric care for any underlying conditions.
• Family involvement is crucial regardless of diagnosis, as is coordination between neurology, psychiatry, and primary care.
• Regular follow-up every 3-6 months is essential to monitor treatment response and adjust management as needed.

Diagnostic Approach

• A comprehensive evaluation should consider various causes of seizure-like symptoms, including stroke, which, although rare in children, can present with similar symptoms 1.
• Imaging plays a critical role in the assessment of children with possible stroke, especially in those presenting with acute onset of stroke symptoms.

Treatment Principles

• Early and accurate diagnosis is critical, as misdiagnosis can lead to inappropriate medication use and delayed effective treatment.
• Treatment should be tailored to the individual patient's needs, taking into account the underlying cause of the seizure-like symptoms and any comorbid conditions.
• Electroconvulsive therapy (ECT) may be considered in certain cases, such as severe, treatment-resistant mood disorders, but its use in adolescents should be approached with caution and careful consideration of potential risks and benefits 1.

From the FDA Drug Label

1.2 Myoclonic Seizures in Patients with Juvenile Myoclonic Epilepsy Levetiracetam is indicated as adjunctive therapy in the treatment of myoclonic seizures in adults and adolescents 12 years of age and older with juvenile myoclonic epilepsy. 2.2 Dosing for Partial Onset Seizures Pediatric Patients 4 Years to < 16 Years: Initiate treatment with a daily dose of 20 mg/kg in 2 divided doses (10 mg/kg twice daily). Increase the daily dose every 2 weeks by increments of 20 mg/kg to the recommended daily dose of 60 mg/kg (30 mg/kg twice daily)

For an adolescent child presenting with symptoms mimicking seizures, management should involve a thorough evaluation to determine the underlying cause of the symptoms. If the symptoms are determined to be due to seizures, the child may be a candidate for treatment with levetiracetam, which is indicated for use as adjunctive therapy in the treatment of myoclonic seizures in adolescents 12 years of age and older with juvenile myoclonic epilepsy. The recommended dosing for adolescents with partial onset seizures is 20 mg/kg per day in 2 divided doses, with increases every 2 weeks by increments of 20 mg/kg to a maximum recommended daily dose of 60 mg/kg per day 2. It is essential to follow the dosing guidelines and monitor the child's response to treatment and adjust as necessary. Key considerations include:

• Accurate diagnosis of the underlying condition
• Careful dosing and titration of levetiracetam
• Monitoring for potential side effects and adjusting treatment as needed It is crucial to consult the FDA drug label for the most up-to-date information and to consult with a healthcare professional for personalized guidance 2.

From the Research

Diagnostic Approach

To manage an adolescent child presenting with symptoms mimicking seizures, it is essential to distinguish between seizure mimics and actual seizures. According to 3, this can be achieved by clarifying the event duration, frequency, semiology, and any precipitating factors. The study highlights that seizure mimics are often consistently triggered by an event, location, or emotion and may resolve with distraction or tactile stimulation.

Key Characteristics of Seizures

Suspicion should be raised for seizures when events occur out of deep sleep, there is a loss of consciousness with the event, movements are not suppressible, and there is a period of fatigue after the event (minutes to hours) 3. A past medical history of developmental delay, developmental regression, or neurologic injury also increases the patient's risk for seizures.

Treatment Options

For actual seizures, various treatment options are available. According to 4, initial treatment of convulsive status epilepticus is usually with an intravenous benzodiazepine, phenobarbital, or phenytoin. For myoclonic seizures, valproate is commonly the first choice, alone or in combination with some benzodiazepines or levetiracetam 5. For absence seizures, ethosuximide, valproate, and lamotrigine are currently used, with ethosuximide representing the optimal initial empirical monotherapy for children and adolescents with absence seizures 6.

Seizure Mimics

Several conditions can mimic seizures, including syncope, psychogenic nonepileptic seizures, stroke or transient ischemic attack, sleep disorders, movement disorders, and migraines 7. A focused history, physical examination, and additional studies can assist in differentiating seizures from mimics.

Management

For patients with an apparent seizure, resuscitation and management are precedent while identifying any provoking factors and treatment of those factors 4, 7. Acute treatment of breakthrough seizures and clusters of seizures at home with rectal benzodiazepines may prevent progression to status epilepticus in some children and adolescents and reduce the need for visits to emergency facilities 4.

• Key points to consider in management:
  • Distinguish between seizure mimics and actual seizures
  • Identify precipitating factors and treat them
  • Use appropriate treatment options for actual seizures
  • Consider the use of benzodiazepines for acute treatment of breakthrough seizures
  • Monitor for potential side effects of treatment, such as intolerable adverse events 6