Is it reasonable to wean a 6-year-old patient with suspected vasovagal syncope, currently on Keppra (levetiracetam), off the medication and request a follow-up EEG and tilt test?

Weaning Keppra in Suspected Vasovagal Syncope

Yes, it is reasonable to wean Keppra (levetiracetam) in this 6-year-old with suspected vasovagal syncope, as antiepileptic medications are not indicated for syncope and may represent a misdiagnosis. 1

Rationale for Discontinuing Keppra

• Routine EEG is not recommended for syncope evaluation in the absence of specific neurological features suggestive of seizures 1
• Vasovagal syncope can mimic epileptic seizures with brief convulsive movements during loss of consciousness, but these do not require antiepileptic treatment 1, 2
• In pediatric patients with syncope and convulsions on tilt-table testing, 64% exhibited cardiac asystole with pauses >3 seconds, confirming a cardiac rather than epileptic etiology 1
• Many patients are inappropriately treated with antiepileptic drugs when they actually have vasovagal syncope—one study found 27 of 45 patients previously treated with antiepileptic medications did not have epilepsy 3

Role of Follow-Up EEG

• EEG should only be pursued if there are specific neurological features suggesting true seizures (focal neurological findings, prolonged postictal confusion, seizures occurring from sleep, tongue biting, incontinence) 1
• If the clinical history clearly indicates syncope with brief seizure-like activity, EEG is unnecessary and may lead to misdiagnosis 1
• A combined cardiology and neurology evaluation may be warranted only in patients with syncope and seizure-like activity where the diagnosis remains unclear 1

Role of Tilt-Table Testing

• Tilt-table testing can be useful for pediatric patients with suspected vasovagal syncope when the diagnosis is unclear after initial evaluation 1
• The sensitivity of tilt-table testing in children ranges from 20% to 90%, with specificity from 83% to 100% 1
• However, tilt-table testing is not necessary when the initial assessment indicates an uncomplicated faint with typical features (the "3 Ps": posture-related, provoking factors like pain, prodromal symptoms like sweating) 1
• Tilt-table testing is particularly helpful to distinguish convulsive syncope from epilepsy in selected patients 1

Appropriate Management Strategy

Instead of reflexively ordering both tests, follow this algorithm:

1. Review the clinical history carefully for features of uncomplicated vasovagal syncope: episodes during prolonged standing, clear triggers (pain, medical procedures, emotional stress), prodromal symptoms (sweating, feeling warm), and age-appropriate recurrence pattern 1, 4

2. Ensure 12-lead ECG has been performed to exclude cardiac arrhythmias or structural heart disease 1, 4

3. If history is typical for vasovagal syncope with normal ECG:

   • Wean Keppra (no indication for antiepileptic therapy) 1
   • Skip EEG (not indicated) 1
   • Consider skipping tilt-table test if diagnosis is clear 1
   • Focus on education, reassurance, and lifestyle measures 1, 4

4. If diagnosis remains unclear or seizure-like features are prominent:

   • Proceed with tilt-table testing to confirm vasovagal syncope 1
   • Consider EEG only if true epileptic features persist after tilt-table testing 1

First-Line Treatment for Pediatric Vasovagal Syncope

Once vasovagal syncope is confirmed, appropriate management includes:

• Education on symptom awareness and reassurance about the benign nature of the condition 1, 4
• Avoidance of precipitating factors (dehydration, prolonged standing, hot crowded environments) 1
• Increased salt and fluid intake may be reasonable (Class IIb recommendation in pediatrics) 1
• Midodrine is reasonable if lifestyle measures fail (Class IIa recommendation, associated with 78% reduction in recurrence in pediatric RCT) 1

Common Pitfall to Avoid

The most critical error is continuing antiepileptic therapy for what is actually vasovagal syncope. 2, 3 This leads to unnecessary medication exposure, side effects, and failure to address the true diagnosis with appropriate education and lifestyle modifications that form the cornerstone of vasovagal syncope management. 1, 4