What is the standard workup for a first-time seizure (sz) in a child?

From the Guidelines

The standard workup for a first-time seizure in a child should include a thorough history, physical examination, and selected diagnostic tests, with MRI being the primary imaging modality due to its higher sensitivity in detecting brain abnormalities compared to CT, as evident from studies such as Aprahamian et al 1. The workup should begin with a detailed history of the seizure event, including eyewitness accounts, duration, associated symptoms, and any potential triggers like fever, illness, or trauma. Ask about developmental history, family history of seizures or neurological disorders, and any recent medications or toxin exposures. Perform a complete physical and neurological examination, looking for focal deficits, signs of increased intracranial pressure, neurocutaneous stigmata, or developmental abnormalities. Some key points to consider in the workup include:

• Laboratory tests should include basic metabolic panel, glucose, calcium, magnesium, complete blood count, and toxicology screening if indicated.
• An electroencephalogram (EEG) should be performed within 24-48 hours of the seizure, as early testing increases the yield of detecting epileptiform abnormalities.
• Neuroimaging with MRI is recommended for children with focal seizures, focal neurological deficits, developmental delay, or concerning physical exam findings, due to its superiority in identifying peri-ictal cortical abnormalities and detecting abnormalities not identified by CT, as seen in studies by Jan et al and Singh et al 1.
• CT scan may be used in emergency situations if there is concern for acute intracranial pathology.
• Lumbar puncture should be considered in febrile infants, immunocompromised children, or if meningitis/encephalitis is suspected.
• Antiepileptic medication is typically not started after a single unprovoked seizure unless there are significant risk factors for recurrence such as abnormal EEG, structural brain abnormality, or focal neurological deficits. This comprehensive approach helps identify the cause of the seizure and guides appropriate management and follow-up, prioritizing the child's morbidity, mortality, and quality of life as the primary outcomes, as recommended by the American College of Radiology 1.

From the Research

Standard Workup for a First-Time Seizure in a Child

The standard workup for a first-time seizure in a child involves several steps, including:

• Taking a history to determine whether the event was a seizure and whether it was provoked or unprovoked 2
• Performing a neurologic examination to determine the cause of the seizure 2
• Determining the type of seizure, such as simple febrile, complex febrile, or unprovoked 2, 3
• Ordering diagnostic tests, such as:
  • Electroencephalogram (EEG) for children with a first unprovoked seizure 2
  • Neuroimaging with magnetic resonance imaging (MRI) for children with new-onset seizures, particularly focal seizures or status epilepticus 2, 4
  • Laboratory tests to determine the cause of the fever in cases of febrile seizures 3

Special Considerations

• Children with simple febrile seizures typically do not require additional evaluation 2, 3
• Children with complex febrile seizures or unprovoked seizures may require further evaluation, including EEG and neuroimaging 2, 3, 5
• The use of antiepileptics is not indicated for children with febrile seizures, except in cases where the risk of recurrence is high 3
• Parents should be educated on the excellent prognosis of children with febrile seizures and provided with practical guidance on home management of seizures 3

Diagnostic Criteria

• The diagnosis of epilepsy can be made after a first unprovoked seizure if the clinical presentation and supporting diagnostic studies suggest a greater than 60% chance of a second seizure 5
• The revised diagnostic criteria for epilepsy allow for the diagnosis to be made after a single seizure in select patients with distinct epilepsy syndromes 5