Children with staring spells who were referred to a
new-onset seizure (NOS) clinic were found to have epileptic seizures about half
the time, according to findings presented here at the Child Neurology Society
annual meeting. The results were based on review of data from a clinic at Emory
University.
Researchers said the diverging findings for these patients
underscore the value of NOS clinics to steer children down the proper path,
particularly for the presenting feature of staring spells, which is so commonly
seen in children.
The study — led by Sookyong Koh, MD, PhD, associate
professor of neurology at Emory, and Anne T. Berg, PhD, research professor of
pediatrics at Northwestern University — is a retrospective review of data from
the clinic for all patients from September 2015 to March 2018 who presented
with staring spells. Electroencephalography (EEG) was performed on all the
patients prior to the patients' visits to the NOS clinic.
The children were an average of 5.2 years old at the time of
onset of their symptoms and an average of 6 years old when they came to the
clinic.
"In addition to a careful history, EEG at the time of
presentation at our NOS clinic visit was critical in making this distinction
between absence seizures vs. focal seizures vs. behavioral staring," Dr.
Koh said.
"We need to take staring spells seriously. EEG on the
same day [as the initial presentation] can expedite care and provide rapid,
accurate diagnoses for both epileptic and non-epileptic spells," she
added. The bottom line is that "we should not be dismissive of staring
spells."
Fifty percent of the children were referred to the NOS
clinic by the emergency department (ED), 48 percent by a primary care
physician, and 2 percent by an urgent care clinic. Of those with epileptic
events, 59 percent were focal seizures and 41 percent were generalized absence
seizures.
Investigators found that children with non-epileptic events
were younger at both their initial onset and when they came to the clinic than
children with epileptic seizures (p=.001 for both).
Children with non-epileptic events were more likely to be
referred by primary care — 61 percent — than children with epileptic seizures,
at 34 percent (p=.003).
"This difference was almost entirely due to children
with focal seizures, 28 of whom (80 percent) were referred from the ED,"
researchers said.
"The NOS clinic can provide rapid, accurate diagnoses
for such spells," Dr. Koh said. "This is important as children with
non-epileptic events should not be given the diagnosis of epilepsy and their
events should not be treated with seizure medications. Similarly, children who
have epileptic seizures require accurate diagnosis, and the treatment depends
on the seizure type."
Francis M. Filloux, MD, professor of pediatric neurology at
the University of Utah, said the main finding dovetailed with his experience at
the NOS clinic.
"The most common presentation in our seizure fast-track
clinic is a new-onset convulsive seizure, the next most common is probably what
they're talking about — the staring spells," he said. "Of those
patients, I'm guessing similarly it might be 50 percent or so have actual
epilepsy."
He added: "It's interesting that their observation is
that if they're referred from the ED there's a higher likelihood of it being a
seizure. That's helpful, but I'm not sure we've had the same experience…. It's
something to think about."
He also wondered about the choice to do an EEG for every
patient that comes to the clinic with staring spells, which is not the practice
at the University of Utah.
"We grappled with that because many of our patients
come from a long distance," he said. "We hate to have them undergo an
unnecessary EEG because honestly there's quite a few of the patients where,
after just taking the history, we know they don't have epilepsy, and so we can
avert the cost of the EEG for them."
He said NOS clinics offer advantages, such as providing a
speedy diagnosis, keeping costs down in part by cutting down on ED visits, and
in easing the anxiety levels of parents eager to get answers.
"Families are just completely stressed out until they
actually meet with a neurologist," Dr. Filloux said. "At least in the
US, the pediatricians are not generally super-comfortable with that evaluation,
so almost all of our pediatricians in our community will refer to us for a
new-onset seizure type situation."
https://journals.lww.com/neurotodayonline/blog/NeurologyTodayConferenceReportersCNSAnnualMeeting/pages/post.aspx?PostID=24
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