Focused Neurological Examination for Absence Seizures in an 8-Year-Old Male
A focused neurological examination for an 8-year-old male with absence seizures should prioritize assessment of attention, consciousness, and cognitive function while ruling out other neurological abnormalities that might suggest symptomatic rather than primary generalized epilepsy.
Key Components of the Examination
1. Observation and Attention Testing
- Observe for brief episodes of staring, unresponsiveness, or behavioral arrest (typical absence seizures)
- Test attention with continuous tasks:
- Counting exercises (have child count continuously)
- Finger tapping tasks (have child tap in rhythm)
- Reading aloud (for school-aged children)
- These tasks may provoke absence seizures during the examination
2. Provocation Techniques
- Hyperventilation (3-5 minutes of deep breathing)
- Most effective provocation technique for absence seizures
- Have child blow on a pinwheel or paper for 3 minutes
- Observe for sudden behavioral arrest, staring, or brief loss of consciousness
- Photic stimulation (if available)
- Flashing light at various frequencies may trigger absence seizures
3. Cognitive Assessment
- Brief assessment of:
- Attention span and concentration
- Memory (short-term recall)
- Language skills
- School performance history (often affected in children with frequent absence seizures)
4. General Neurological Examination
- Mental status: Orientation, alertness between episodes
- Cranial nerves: Complete examination (particularly eye movements)
- Motor system:
- Strength and tone (normal in typical absence seizures)
- Coordination (finger-to-nose, rapid alternating movements)
- Sensory system: Brief screening
- Reflexes: Deep tendon reflexes (should be symmetrical)
- Cerebellar function: Gait assessment
5. Developmental Assessment
- Brief developmental history
- Milestone achievement
- School performance
- Behavioral concerns
Documentation and Findings
Document the following specific information:
- Frequency and duration of absence episodes
- Triggers (if any identified)
- Associated symptoms (automatisms, eye blinking, mild clonic movements)
- Level of awareness during episodes
- Post-ictal state (typically minimal to none in absence seizures)
Important Considerations
- MRI is rarely indicated in neurologically normal children with typical absence seizures due to their genetic underpinnings 1
- Primary generalized epilepsies like childhood absence epilepsy typically have normal neurological examinations 1
- Only 2% of patients with primary generalized epilepsy have abnormal imaging findings 1
- EEG remains the gold standard diagnostic test (not part of the physical exam)
- Ethosuximide suppresses the paroxysmal three cycle per second spike and wave activity associated with lapses of consciousness in absence seizures 2
Red Flags Requiring Further Investigation
- Focal neurological findings (suggests symptomatic rather than primary absence)
- Developmental regression or delay
- Abnormal head circumference
- Dysmorphic features
- Neurocutaneous stigmata (suggests symptomatic epilepsy)
- Seizures resistant to first-line therapy (may indicate glucose transporter type 1 deficiency, especially if onset before age 4) 3
The focused neurological examination should be thorough but efficient, with particular emphasis on attention testing and hyperventilation to potentially capture an absence episode during the clinical encounter.