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Neurology Today Conference Reporter: CNS Annual Meeting

Tuesday, October 23, 2018

Staring Spells Are Epileptic Seizures Half the Time, Clinic Review Finds

BY THOMAS R. COLLINS

CHICAGO—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."

Drs. Koh and Filloux reported no disclosures.

LINK UP FOR RELATED INFORMATION:

Chelse AB, Kelley K, Hageman JR, Koh S. Initial evaluation and management of a first seizure in children. Pediatric Ann 2013:42(12):e253-e257.