Abstracts

This abstract is a recipient of the Grass Young Investigator Award.
This abstract has been invited to present during the Pediatric Epilepsy Highlights platform session.

Rationale: Many children with undiagnosed focal epilepsy seek evaluation in emergency departments (EDs). Accurate history taking is essential in the prompt diagnosis and treatment of these children, particularly as delays to diagnosis of epilepsy have been reported in this group. In this study we investigated ED recognition of different seizure semiologies in children and the effect this may have on the management and treatment of pediatric focal epilepsy.

Methods: This was a retrospective analysis of the enrollment data from the Human Epilepsy Project, an international multi-institutional study that collected data from 34 sites in the U.S., Canada, Europe, and Australia between 2012 and 2017. Participants enrolled were 11 years or older, typically developing, and within 4 months of diagnosis of focal epilepsy. We used participant medical records to select participants who were evaluated in the ED and reviewed diagnoses and treatments received.

Results: A total of 444 participants were analyzed. Of these, 83 enrolled at age ≤ 18 years. Fifty-eight children (70%) presented to the ED prior to diagnosis. The majority of ED presentations were for motor seizures (n=52; 90%). However, many had a history of prior non-motor seizures (n=20; 38%, Figure 1). Children with only non-motor onset seizure semiology at time of diagnosis were less likely to present to the ED (26 of 44; 59% vs. 32 of 39; 82%, p = 0.02). Furthermore, children presenting to the ED with non-motor seizures were significantly less likely to have their presenting seizure correctly identified than those presenting with motor seizures (33% vs. 81%, p = 0.008, Figure 2A). Strikingly, the history of prior non-motor seizures was not elicited in the ED in any of the children. As a result, children with a history of prior non-motor seizures (and therefore meeting the definition of epilepsy) were equally as unlikely to have treatment initiated as those with no prior history presenting with first lifetime-motor seizure (18% vs. 14%). We also noted no difference in recognition of motor seizures (82% vs. 81%), referral to neurologists (71% vs. 38%), or admission from the ED (24% vs. 38%) (Figure 2B). This lack of recognition of non-motor seizure history is more pronounced than that observed in adults presenting with first-lifetime motor seizure and history of prior non-motor seizures (0% vs. 23%, p = 0.057).  Similarly, these children were also less likely to initiate epilepsy treatment in the ED when compared to their adult counterparts (18% vs. 43%, p=0.05).

Conclusions: Our study supports growing evidence that non-motor seizures often go undiagnosed, with many individuals coming to attention only after conversion to motor seizures. Unfortunately, this treatment gap is exacerbated in the pediatric population, with many non-motor seizures going unrecognized by medical providers.  Our study highlights a critical need for physicians to inquire about the symptoms of non-motor seizures, even when the presenting seizure is motor in nature. Future interventions should focus on large-scale interventions aimed at improving recognition and treatment of non-motor seizures in pediatric ED settings.

Funding: Not applicable