Prolonged seizures can cause brain injury, but epidemiological studies have not provided evidence that prolonged first seizures in otherwise healthy persons increase the risk of subsequent seizures.7 Furthermore, the number of seizures that occur before treatment is initiated is not necessarily associated with a greater likelihood of medical intractability. 8 Seizure frequency and whether the seizures are generalized or partial have stronger predictive power. Therefore, little advantage is gained by treating first-time seizures, whether they are provoked by an identified acute insult or they occur out of the blue. The rationale for treating children with recurrent seizures is that treatment will ameliorate seizure recurrence.
DIAGNOSTIC SUSPICION
Most often, seizure history related by the patient's parents and the physical findings will lead the physician to suspect epilepsy. For example,a history of febrile seizures (particularly if prolonged) is a well-recognized risk factor for the development of temporal lobe epilepsy caused by mesial temporal sclerosis.9,10 An additional helpful clue from the history is a past brain injury from trauma or infection. It is generally understood that relatively remote trauma of a minor degree confers very little risk, but prolonged loss of consciousness or a penetrating head injury are significant risk factors for seizure episodes. 11,12 A family history is important, because epilepsy in first-degree relatives is another risk factor.
Physical examination findings that indicate an abnormality of brain function provide further evidence of an increased likelihood of seizures. They also help classify epilepsy as either symptomatic or idiopathic. For example, mental retardation, cerebral palsy, or the presence of neurocutaneous lesions is noteworthy. Cerebral imaging studies may demonstrate a structural brain abnormality.
Certain circumstances can erroneously heighten suspicion of seizures by the patient, parent, and physician. Benign or at least nonepileptic behaviors may be mistakenly identified as seizures or described in rather dramatic terms. Table 1 provides a brief overview of nonepileptic events that mimic specific seizure types that occur particularly in children.
Parents of children who have health challenges that may include previous seizures may be very sensitive to any perceived abnormality in the child's health. Benign events, such as hypnic jerks, may prove very frightening to the parents of a child who recently suffered a febrile seizure. A child with autism may have stereotyped movements that convince a concerned parent that the child is having seizures. Munchausen syndrome and Munchausen syndrome by proxy also may present as seizures.13,14 When the history suggests seizure, a careful differential diagnosis is important.
