Clinical and electroencephalographic follow-up after a first unprovoked seizure

Characteristics and clinical value of early electroencephalography (EEG) after a first unprovoked seizure in children

OBJECTIVE

This study aimed to examine the timing and features of electroencephalography (EEG) as a predictor of seizure recurrence in children with a first unprovoked seizure.

METHODS

We retrospectively evaluated the medical records and EEG recordings of pediatric patients who presented within 24 h of a first unprovoked seizure between January 2018-December 2019 and had at least 1 year of pediatric neurology clinical follow-up.

RESULTS

The study included 108 patients (53.7% males) with a mean age of 98.75±57.75 months. Sixty-eight patients (63%) had an abnormal initial EEG, of which 55 (80.9%) were focal. The semiology of the first unprovoked seizure was focal in 50% of the patients and correlated with initial EEG findings (p<0.001). Forty-three patients had seizure recurrence during the follow-up period of mean 26.86±7.39 months. Recurrence was observed in the first 6 months in 30 patients and occurred twice in 4 patients. An abnormal EEG after the first unprovoked seizure was found to be an independent risk factor for recurrence, with a 2.42-fold higher recurrence risk in patients with focal EEG abnormalities compared to those with a normal EEG (p = 0.044). Analysis of 7 different timing patterns up to 96 h after the first unprovoked seizure showed that EEG timing was not associated with abnormality detection.

DISCUSSION

Our study showed that EEG abnormalities, especially focal abnormalities, after a first unprovoked seizure are a predictor of seizure recurrence. But the rate of detection of EEG abnormalities was not related to the timing of EEG recording, relative to seizure occurrence.

Prognosis of adults and children following a first unprovoked seizure

BACKGROUND

Epilepsy is clinically defined as two or more unprovoked epileptic seizures more than 24 hours apart. Given that, a diagnosis of epilepsy can be associated with significant morbidity and mortality, it is imperative that clinicians (and people with seizures and their relatives) have access to accurate and reliable prognostic estimates, to guide clinical practice on the risks of developing further unprovoked seizures (and by definition, a diagnosis of epilepsy) following single unprovoked epileptic seizure.

OBJECTIVES

1. To provide an accurate estimate of the proportion of individuals going on to have further unprovoked seizures at subsequent time points following a single unprovoked epileptic seizure (or cluster of epileptic seizures within a 24-hour period, or a first episode of status epilepticus), of any seizure type (overall prognosis). 2. To evaluate the mortality rate following a first unprovoked epileptic seizure.

SEARCH METHODS

We searched the following databases on 19 September 2019 and again on 30 March 2021, with no language restrictions. The Cochrane Register of Studies (CRS Web), MEDLINE Ovid (1946 to March 29, 2021), SCOPUS (1823 onwards), ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). CRS Web includes randomized or quasi-randomized, controlled trials from PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP), the Cochrane Central Register of Controlled Trials (CENTRAL), and the Specialized Registers of Cochrane Review Groups including Epilepsy. In MEDLINE (Ovid) the coverage end date always lags a few days behind the search date.

SELECTION CRITERIA

We included studies, both retrospective and prospective, of all age groups (except those in the neonatal period (< 1 month of age)), of people with a single unprovoked seizure, followed up for a minimum of six months, with no upper limit of follow-up, with the study end point being seizure recurrence, death, or loss to follow-up. To be included, studies must have included at least 30 participants. We excluded studies that involved people with seizures that occur as a result of an acute precipitant or provoking factor, or in close temporal proximity to an acute neurological insult, since these are not considered epileptic in aetiology (acute symptomatic seizures). We also excluded people with situational seizures, such as febrile convulsions.

DATA COLLECTION AND ANALYSIS

Two review authors conducted the initial screening of titles and abstracts identified through the electronic searches, and removed non-relevant articles. We obtained the full-text articles of all remaining potentially relevant studies, or those whose relevance could not be determined from the abstract alone and two authors independently assessed for eligibility. All disagreements were resolved through discussion with no need to defer to a third review author. We extracted data from included studies using a data extraction form based on the checklist for critical appraisal and data extraction for systematicreviews of prediction modelling studies (CHARMS). Two review authors then appraised the included studies, using a standardised approach based on the quality in prognostic studies (QUIPS) tool, which was adapted for overall prognosis (seizure recurrence). We conducted a meta-analysis using Review Manager 2014, with a random-effects generic inverse variance meta-analysis model, which accounted for any between-study heterogeneity in the prognostic effect. We then summarised the meta-analysis by the pooled estimate (the average prognostic factor effect), its 95% confidence interval (CI), the estimates of I² and Tau² (heterogeneity), and a 95% prediction interval for the prognostic effect in a single population at three various time points, 6 months, 12 months and 24 months. Subgroup analysis was performed according to the ages of the cohorts included; studies involving all ages, studies that recruited adult only and those that were purely paediatric.

MAIN RESULTS

Fifty-eight studies (involving 54 cohorts), with a total of 12,160 participants (median 147, range 31 to 1443), met the inclusion criteria for the review. Of the 58 studies, 26 studies were paediatric studies, 16 were adult and the remaining 16 studies were a combination of paediatric and adult populations. Most included studies had a cohort study design with two case-control studies and one nested case-control study. Thirty-two studies (29 cohorts) reported a prospective longitudinal design whilst 15 studies had a retrospective design whilst the remaining studies were randomised controlled trials. Nine of the studies included presented mortality data following a first unprovoked seizure. For a mortality study to be included, a proportional mortality ratio (PMR) or a standardised mortality ratio (SMR) had to be given at a specific time point following a first unprovoked seizure. To be included in the meta-analysis a study had to present clear seizure recurrence data at 6 months, 12 months or 24 months. Forty-six studies were included in the meta-analysis, of which 23 were paediatric, 13 were adult, and 10 were a combination of paediatric and adult populations. A meta-analysis was performed at three time points; six months, one year and two years for all ages combined, paediatric and adult studies, respectively. We found an estimated overall seizure recurrence of all included studies at six months of 27% (95% CI 24% to 31%), 36% (95% CI 33% to 40%) at one year and 43% (95% CI 37% to 44%) at two years, with slightly lower estimates for adult subgroup analysis and slightly higher estimates for paediatric subgroup analysis. It was not possible to provide a summary estimate of the risk of seizure recurrence beyond these time points as most of the included studies were of short follow-up and too few studies presented recurrence rates at a single time point beyond two years. The evidence presented was found to be of moderate certainty.

AUTHORS' CONCLUSIONS

Despite the limitations of the data (moderate-certainty of evidence), mainly relating to clinical and methodological heterogeneity we have provided summary estimates for the likely risk of seizure recurrence at six months, one year and two years for both children and adults. This provides information that is likely to be useful for the clinician counselling patients (or their parents) on the probable risk of further seizures in the short-term whilst acknowledging the paucity of long-term recurrence data, particularly beyond 10 years.

Impact of the Occurrence While Sleeping of First Unprovoked Seizure on Seizure Recurrence: A Systematic Review

BACKGROUND AND PURPOSE

The impact of the occurrence while sleeping of first unprovoked seizure (FUS) on seizure recurrence in people with FUS is currently unclear. This uncertainty makes it challenging for physicians to determine whether to apply antiseizure medications (ASMs) to people with FUS while sleeping (FUS-S). This study aimed to determine the impact of the occurrence while sleeping of FUS.

METHODS

We searched the MEDLINE, Embase, Cochrane Library, Web of Science, and Scopus electronic databases. Among retrieved studies, we selected those that provided information on the number of people with FUS, and relapsed people among these in each instance of FUS-S and FUS when waking (FUS-W). We used a random-effects model for meta-analyses.

RESULTS

Of the 3,582 identified studies, 13 were eligible for systematic review. Seven of these 13 studies were deemed adequate for inclusion in a meta-analysis since they provided information at the time point of 2 years follow-up after FUS. The seven studies were of high quality regarding their risk of bias. When combining these 7 studies, the total sample comprised 1,659 people, of which 626 had FUS-S and 1,033 had FUS-W. The relative risk of seizure recurrence between FUS-S and FUS-W was 1.627. The seizure recurrence rates (SRRs) were 59.8% and 36.5% in the FUS-S and FUS-W groups, respectively.

CONCLUSIONS

We verified that the SRR was higher among people with FUS-S than FUS-W. After 2 years of follow-up, the SRR in people with FUS-S was about 60%. It is preferable to initiate an ASM for people with FUS-S.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42021266191.

Risk factors affecting seizure recurrence in childhood epilepsy during short-term follow-up

PURPOSE

The aim of this study is to examine the factors affecting seizure recurrence in pediatric patients diagnosed with epilepsy.

METHODS

Three hundred patients presenting to the pediatric neurology clinic between 2015 and 2018 and diagnosed with epilepsy and treated with single antiseizure drug were included in the study. Medical histories and clinical and laboratory findings were retrieved retrospectively from the hospital data system. The combined and adjusted effects of risk factors on seizure recurrence were evaluated using multivariate binary logistic regression analysis.

RESULTS

Boys had a higher rate of seizure recurrence than girls. Seizure recurrence was also higher in patients with abnormal neurological examinations at the time of diagnosis compared to those with normal neurological examinations. Seizure recurrence was significantly higher in patients with global growth retardation. Epilepsy patients with abnormal MRI findings also had a higher rate of seizure recurrence than patients with normal neuroimaging findings. In addition, seizure recurrence was significantly higher in epilepsy patients with comorbidities such as cerebral palsy and autism spectrum disorders compared to patients without comorbidities. No significant association was observed between seizure recurrence and the first drug, perinatal asphyxia history, localization of epileptiform discharges on EEG, family history of epilepsy, family history of febrile seizures, history of stay in the neonatal intensive care unit during the perinatal period, or preterm delivery.

CONCLUSION

Abnormal neurological examination, abnormal neuroimaging and accompanying comorbidities, and global growth retardation at the time of diagnosis are important factors affecting seizure recurrence in pediatric patients with epilepsy.

Risk of seizure recurrence after a first unprovoked seizure in childhood

OBJECTIVE

The aim of this study was to assess the risk of recurrence after a first unprovoked seizure in childhood and to explore the correlation between the first and second seizures in recurrent patients.

METHODS

In a prospective study, we included 467 children aged 1 month to 16 years, who were attended to between November 1, 2008 and October 31, 2016 following a first seizure. Children who had been started on treatment with antiepileptic drugs were excluded. Recurrence rates were calculated using Kaplan-Meier survival analyses. Univariate and multivariate analyses for recurrence risk were performed using the Cox proportional hazards model. The kappa coefficient of correlation for categorical data was calculated.

RESULTS

Recurrences occurred in 280 children (60.0%), of which 75 (26.8%) occurred in the first month, 184 (65.7%) within 6 months, and 256 (91.4%) within 2 years. None of the patients had new neurologic sequelae after their first or second seizure. The estimates of seizure recurrence risk were 39.5%, 48.1%, 55.1%, 60.8%, 61.8% and 61.8% at 0.5, 1, 2, 5, 8, and 10 years after the first seizure, respectively. Multivariate analysis showed that abnormal electroencephalogram and neuroimaging findings significantly increased the risk of recurrence. First and second seizures were significantly associated with state of arousal, status epilepticus, and multiple seizures in recurrent patients.

CONCLUSION

Over half of untreated children had recurrence after a first unprovoked seizure, but prognosis was good overall.

Acute Seizures-Work-Up and Management in Children

Seizures are common in the pediatric population; however, most children do not go on to develop epilepsy later in life. Selecting appropriate diagnostic modalities to determine an accurate diagnosis and appropriate treatment as well as with counseling families regarding the etiology and prognosis of seizures, is essential. This article will review updated definitions of seizures, including provoked versus unprovoked, as well as the International League Against Epilepsy operational definition of epilepsy. A variety of specific acute symptomatic seizures requiring special consideration are discussed, along with neonatal seizures and seizure mimics, which are common in pediatric populations.

Recurrence of First Afebrile Unprovoked Seizure and Parental Consanguinity: A Hospital-Based Study

PURPOSE

The aim of the current study was to determine the incidence, clinical characteristics, and risk factors associated with the recurrence of first unprovoked seizure in children.

METHODS

A retrospective, observational study was conducted at King Abdullah University Hospital in Jordan. Children aged from 1 month to 16 years old who attended the hospital between January 2013 to December 2017 were evaluated on the basis of medical records, from the first visit and for a 1-year follow-up period.

RESULTS

During the study period, a total of 290 cases with first unprovoked seizure were included. The incidence of first unprovoked seizure was 441 cases per 100 000 patient visits to the pediatric clinic. More than half of the cases developed a second attack (55.3%). Children with parental consanguinity were almost 3 times more likely to develop a second attack of seizure compared to those without parental consanguinity (odds ratio [OR] = 2.785, 95% confidence interval [CI] = 1.216-6.378, P = .015) and patients who had a history of focal type of seizure were almost twice as likely to develop seizure recurrence (OR = 1.798, 95% CI = 1.013-3.193, P = .045).

CONCLUSIONS

The current results showed a high incidence of first unprovoked seizure among children in Jordan. Parental consanguinity and focal seizure were associated with the increased risk of recurrent attack. This finding highlights the need for public education regarding the outcomes of parental consanguinity to improve the patient's quality of life.

Risk factors for seizure recurrence in a pediatric observation unit

BACKGROUND

Most patients present with seizures to pediatric emergency department (PED) are observed for extended periods for the risk of possible acute recurrence.

OBJECTIVE

The aim of this study is to determine the risk factors of acute recurrence within first 24 h.

METHODS

Patients who presented to PED with seizure during past 24 h were enrolled. Demographic features, number and duration of seizures, diagnostic studies, physical examination findings, presence and time of seizure recurrence in PED were noted.

RESULTS

187 patients were eligible for the study. 46% had recurrence of seizures in 24 h, 90,8% of recurrence within the first 6 h. Univariate analysis showed that younger patients, epileptic patients who were on multiple antiepileptic drugs (AEDs), who had multiple seizures during the past 24 h, who had abnormal neurological examination or neuroimaging findings had increased risk of seizure recurrence. Multivariate analysis showed that number of seizures during the past 24 h and previous use of AEDs was significantly associated with increased risk of recurrence.

CONCLUSION

Risk factors for acute recurrence should be evaluated for each patient. Patients without risk factors and no seizures during the first 6 h should not be observed for extended periods in PED.

Evaluation of Seizure Frequency Distribution in Epileptic Patients with Normal and Abnormal Electroencephalogram in Al-Zahra Hospital of Isfahan

BACKGROUND

Epilepsy is a chronic neurological disorder characterized by seizure recurrence in patients. Electroencephalogram (EEG) has a diagnostic and prognostic role in the management of patients. Studies have shown a significant relation between seizure recurrence and abnormal EEG in newly diagnosed epileptic patients, and people with first episode of unprovoked seizure. The aim of this study is to evaluate seizure frequency in chronic epileptic patients on drug therapy based on normal or abnormal EEG.

MATERIALS AND METHODS

This prospective cohort study examined seizure recurrence in 59 epileptic patients (50.8% generalized, 49.2% focal) with normal and abnormal EEG. Data were recorded in patient medical file, and patients were followed by telephone call or visiting by neurologist.

RESULTS

In this study, 59 patients with a mean age of 29.58 ± 10.37 years were assessed that 42.4% of them were males and 57.6% were females. Seizure frequency in patient with specific abnormal EEG was significantly more than other patients (specific abnormal: 78.9%, nonspecific abnormal: 45.5%, and normal: 31%, P = 0.005). Seizure recurrence in patients on polytherapy was significantly higher than others (polytherapy: 76.9% and monotherapy: 27.3%, P < 0.001). In patient with abnormal imaging seizure, frequency was more than other patients which was nearly significant (P = 0.054).

CONCLUSION

Abnormal EEG and number of anticonvulsant drugs have a role in seizure recurrence in epileptic patients.

Early Recurrence of First Unprovoked Seizures in Children

OBJECTIVES

The risk of early seizure recurrences after first unprovoked seizures in children is largely unknown. We aimed to determine the rate of seizure recurrence within 14 days of first unprovoked seizures in children and identify associated risk factors. Secondarily, we aimed to determine the risk of recurrence at 48 hours and 4 months.

METHODS

We conducted a secondary analysis of a multicenter cohort study of children 29 days to 18 years with first unprovoked seizures. Emergency department (ED) clinicians completed standardized histories and physical examinations. The primary outcome, recurrent seizure at 14 days, and the secondary outcomes, recurrence at 48 hours and 4 months, were assessed by telephone follow-up and medical record review. For each recurrence time point, we excluded those patients for whom no seizure had recurred but chronic antiepileptic drugs had been initiated.

RESULTS

A total of 475 patients were enrolled in the parent study. Of evaluable patients for this secondary analysis, 26 of 392 (6.6%, 95% confidence interval [CI] = 4.4%-9.6%) had recurrences within 48 hours of the incident seizures, 58 of 366 (15.8%, 95% CI = 12.3%-20.0%) had recurrences within 14 days, and 107 of 340 (31.5%, 95% CI = 26.6%-36.7%) had recurrences within 4 months. On logistic regression analysis, age younger than 3 years was independently associated with a higher risk of 14-day recurrence (adjusted odds ratio [OR] = 2.1, 95% CI = 1.2-3.7; p = 0.01). Having had more than one seizure within the 24 hours prior to ED presentation was independently associated with a higher risk of seizure recurrence at 48 hours (adjusted OR = 4.3, 95% CI = 1.9-9.8; p < 0.001).

CONCLUSIONS

Risk of seizure recurrence 14 days after first unprovoked seizures in children is substantial, with younger children at higher risk. Prompt completion of an electroencephalogram and evaluation by a neurologist is appropriate for these children.

Risk of recurrence after a first unprovoked seizure in children

OBJECTIVES

This study aimed to evaluate the first episode of unprovoked epileptic seizure in children and assess recurrence risk factors.

METHODS

This was a retrospective observational study, based on the analysis of medical records of patients admitted between 2003 and 2014, with first epileptic seizure, at the pediatric service of a secondary hospital. The data were analyzed using the SPSS 20.0 program.

RESULTS

Of the 103 patients, 52.4% were boys. The median age at the first seizure was 59 (1-211) months. About 93% of children were submitted to an electroencephalogram at the first episode and 47% underwent neuroimaging assessment. Treatment with an antiepileptic drug was started in 46% of patients. The recurrence rate was 38% and of these, 80% had the second seizure within six months after the first event. Of the assessed risk factors, there was a statistically significant association between seizure during sleep and recurrence (p=0.004), and between remote symptomatic etiology seizure and occurrence of new seizure (p=0.02). The presence of electroencephalogram abnormalities was also associated with the occurrence of new seizures (p=0.021). No association was found between age, duration of the seizure, and family history of epilepsy with increased risk of recurrence.

CONCLUSIONS

Most children with a first unprovoked epileptic seizure had no recurrences. The risk of recurrence was higher in patients with seizure occurring during sleep or remote symptomatic ones and those with abnormal electroencephalogram results.

Risk factors following first spontaneous epileptic seizure in children below 3 years of age

AIM OF THE STUDY

To assess the recurrence rate after the first spontaneous epileptic seizure in pediatric patients, and determine the related risk factors.

MATERIALS AND METHODS

Data from 190 infants (aged between one month and three years) admitted after first spontaneous epileptic seizure to Soochow University Affiliated Children's Hospital between April 2009 and April 2011 were retrospectively analyzed; patients were followed up until April 2014. The recurrence rate and risk factors of recurrence were analyzed based on central nervous system imaging data (computed tomography or magnetic resonance imaging), electroencephalogram (EEG) and developmental quotient assessment.

RESULTS

Of the 190 infants, 11 cases (5.79%) were lost to follow-up. The cumulative recurrence rate of spontaneous epileptic seizure after five years was 52%. A total of 82% recurrence cases occurred within the first year. Age > 24 months (odds ratio (OR) = 0.498༌95% confidence interval (CI): 0.285-0.869) was an independent protective factor, while symptomatic seizure (OR = 1.624, 95% CI: 1.020-2.587), seizure during sleep (OR = 2.779, 95% CI: 1.757-4.397) and epileptic discharge in EEG (OR=3.269, 95% CI: 2.049-5.217) were independent risk factors.

CONCLUSION

Recurrence rate is high in infants after the first spontaneous epileptic seizure, and recurrence is more likely to occur within one year.

Seizure Recurrence in Developmentally and Neurologically Normal Children With a Newly Diagnosed Unprovoked Seizure

This study aims to assess recurrence risk in developmentally and neurologically normal children with a newly diagnosed unprovoked seizure. The medical record was retrospectively reviewed in 393 children who had a newly diagnosed, unprovoked seizure. A total of 152 children met inclusion criteria. The relationship between seizure recurrence and variables was examined. Seventy cases had recurrent seizures. Total 113 cases had follow-up data and 70 cases of these (63.7%) experienced recurrent seizures. EEG was abnormal in 65 (44.8%): focal epileptiform abnormality in 34 cases (23.4%) and generalized epileptiform abnormality in 23 cases (15.9%). Brain MRI revealed any structural abnormality in 14 of 86 cases (16.3%). Neither EEG abnormality nor brain MRI abnormality was statistically significantly associated with increased seizure recurrence in this cohort. Further study is required to confirm the EEG and brain MRI findings in otherwise normal children with a newly diagnosed unprovoked seizure.

Risk factors for seizure recurrence in children after first unprovoked seizure

BACKGROUND

The question of whether to treat a patient after a first unprovoked seizure is controversial. This prospective study assessed the time to recurrence and risk factors for seizure recurrence after a first unprovoked seizure in children.

METHODS

Participants were recruited between 1 July 1997, and 30 June 2009. Eligible candidates were children between 1 month and 15 years old who presented with their first unprovoked afebrile seizure. After enrollment, recurrence of seizures was investigated. All participants were followed for at least 2 years. Log-rank test was used for bivariate analysis to check associations, and hazard ratios were used to analyze variables and clinical outcome (recurrence) during follow-up.

RESULTS

Of 73 subjects, 42 (57.5%) experienced recurrence. The overall product-limit estimate of recurrence was 61.9% at 6 months, 85.7% at 1 year, and 95.2% at 2 years after seizure onset, respectively. Incidence of recurrence with partial and generalized seizures was 69.0% and 31.0%, respectively. Children with partial seizures had recurrence significantly more often than those with generalized seizures (P < 0.001). Recurrent seizures occurred after normal findings on electroencephalogram (EEG) in 21.4%, after generalized spike-and-wave complexes in 16.7%, and after focal epileptic discharge in 61.9%. Children with focal epileptic discharge had recurrence significantly more often than children with normal EEG findings (P < 0.001).

CONCLUSION

The time to seizure recurrence after first unprovoked seizure may be within 1 year, and particularly within 6 months; and partial seizure and abnormal EEG with focal epileptic discharge may be risk factors for seizure recurrence.

In search of epilepsy biomarkers in the immature brain: goals, challenges and strategies

Epilepsy and seizures are very common in the early years of life and are often associated with significant morbidity and mortality. Identification of biomarkers for the early detection of epileptogenicity, epileptogenesis, comorbidities, disease progression and treatment implementation will be very important in implementing more effective therapies. This article summarizes the current needs in the search for new early life epilepsy-related biomarkers and discusses the candidate biomarkers that are under investigation, as well as the challenges associated with the identification and validation of these biomarkers.

Prognostic significance of interictal epileptiform discharges in newly diagnosed seizure disorders

EEGs performed for new-onset seizures show epileptiform discharge in approximately 18% to 56% of children and 12% to 50% of adults. An EEG after sleep deprivation improves detection of epileptiform abnormalities, showing discharge in 13% to 35% of patients whose standard EEG findings were normal. Some studies have also shown a higher yield with EEG performed within 24 hours after the seizure. The EEG is a useful diagnostic study in this clinical setting for a number of reasons. First, specific EEG abnormalities help characterize the seizure type and epilepsy syndrome, which allows more informed decisions regarding therapy and more accurate prediction of seizure control and ultimate remission. Second, in certain cases, the EEG may detect more subtle seizures, including absence, myoclonic, or partial seizures. Third, specific EEG patterns may alert the clinician to the presence of a focal cerebral lesion. Fourth, most studies have shown that an epileptiform discharge is predictive of seizure recurrence, particularly in patients with idiopathic epilepsy. In the presence of epileptiform discharge, the recurrence risk is approximately double what would be predicted after a normal EEG. The predictive value of nonepileptiform abnormalities is not clearly established.

Feasibility and clinical utility of early electroencephalogram (EEG) in children with first seizure

The feasibility and clinical utility of early electroencephalogram (within 48 hours) was studied in 127 children (age, 1 month-17 years) referred for a "first seizure." The electroencephalogram was considered late after 48 hours. Electroencephalogram abnormalities were classified as nonepileptiform or epileptiform. Children were classified as having an "epileptic" or "nonepileptic" event. An early electroencephalogram was obtained in 23 (18%). Late referral (n = 36), weekend event (n = 23), difficulty contacting families (n = 11), parental schedules (n = 9), and laboratory scheduling (n = 11) resulted in late electroencephalograms. All 94 children with an epileptic event had an electroencephalogram, 19 (20%) within 48 hours. Results were abnormal in 9 (47%) early (7 epileptiform, 2 nonepileptiform) and 35 (44%) late (30 epileptiform, 5 nonepileptiform). Increased abnormalities were not seen with early electroencephalography (P = .50). Early electroencephalograms may not be feasible in the pediatric population and did not show a higher yield of abnormalities.

Evidence-based versus reported epilepsy management practices

Evidence-based medicine practices are widely touted in medicine, although their adoption by busy practitioners is problematic and cumbersome. In this study, we examined published evidence underpinning 2 relevant clinical management questions in pediatric epilepsy: when to initiate an antiepileptic drug and when to prescribe the ketogenic diet. We surveyed practicing child neurologists who were attending their national meeting to determine whether their current practices aligned with the evidence. Clinical studies were evaluated using the Oxford Scale, which was adopted by the American Academy of Neurology. In addition, using a novel rating approach, we examined the impact on overall recommendations by scoring results from studies refuting a given practice. The data show that child neurologists' attitudes firmly adhere to evidence-based practice on when to initiate treatment with an antiepileptic drug, but not on when to prescribe the ketogenic diet. It seems clear that important differences in attitudes of practitioners toward different management strategies for epilepsy cannot be explained only by differences in the evidence. Safety and efficacy data suggest that the ketogenic diet should be more widely adopted as a management strategy in pediatric epilepsy.