Dr Wui-Kwan Wong ( left ) Epilepsy fellow , TY Nelson department of neurology and neurosurgery , The Children ’ s Hospital at Westmead , Sydney , NSW .

Dr Sachin Gupta ( right ) Head of paediatric neurology , TY Nelson department of neurology and neurosurgery , The Children ’ s Hospital at Westmead , Sydney , NSW .

First published online on 7 June 2024

EPILEPSY is a disorder of the brain that

is characterised by an enduring predisposition to generate recurrent unprovoked epileptic seizures .

An epileptic seizure occurs when an individual experiences transient symptoms resulting from abnormal and excessive synchronous neuronal discharges in the brain . 1

Epilepsy is one of the most common neurological disorders , with 3-4 % of people in the developed world diagnosed with the condition during their lifetime . 2

In 2017-2018 , 0.5 % of the Australian population aged 0-18 had epilepsy , with equal numbers of males and females affected . 3

Those under the age of five have the highest incidence ( more than 60 per 100,000 ), and 35 % of children with epilepsy present in the first three years of life . 4

In 2014 , the International League Against Epilepsy defined an individual as having epilepsy if any of the conditions in box 1 were fulfilled . 1

AETIOLOGY

AN aetiology can be identified in up to 80 % of cases of epilepsy in childhood ; these include structural , genetic , metabolic , infectious , immunological or unknown causes ( see box 2 ). 5 An individual ’ s aetiology may fall under more than one category .

Box 1 . Criteria for the diagnosis of epilepsy

Any one of :

• Two or more unprovoked epileptic seizures at least 24 hours apart .

• One unprovoked epileptic seizure and a probability of at least 60 % of having another unprovoked seizure in the next 10 years .

• A diagnosis of an epilepsy syndrome .

Source : Fisher RS et al 2014 1

DIAGNOSIS

THE diagnostic approach requires a detailed history , examination , EEG and , in some cases , neuroimaging .

The initial focus is to differentiate between an epileptic seizure and a seizure mimic ( see later ). Subsequently , the aim is to establish aetiology , comorbidities and an appropriate management plan .

To determine if a paroxysmal event is epileptic , take a detailed history of what occurred before , during and after the event ; obtain this from the patient and an eyewitness .

With smartphones being ubiquitous , a video of the event can be useful . Ask about antenatal and birth history ; associated comorbidities ; and family

history of seizures , epilepsy or developmental delay / intellectual disability .

Important aspects of the physical examination include head circumference ; ocular examination ; and assessment for dysmorphic features , neurocutaneous markers ( facial portwine stain , hypomelanotic macules , shagreen patch — see figure 3 ) or focal neurological deficits .

Determining the type of seizure ( s ) ( see figure 4 ) and the impact is integral in directing further investigations and treatment . 8

Febrile seizures

Febrile seizures — the most common

form of seizures in childhood — affect 2-5 % of children . 9 They occur between the ages of six months and five years in a child with fevers but no evidence of CNS infection or other intracranial causes .

Febrile seizures are classified as simple or complex . Simple febrile seizures are more common , are generalised , are shorter than 15 minutes and only occur once in a 24-hour period .

Approximately one-third of children with a febrile seizure will have another . 9 , 10 An EEG and neuroimaging are not warranted in a neurologically normal child with a simple febrile seizure . Febrile seizures are not a form of epilepsy and do not warrant regular anti-seizure medication ( ASM ).

The prognosis of febrile seizures is generally benign , with a slightly higher risk of epilepsy after a simple febrile seizure ( 1 %) or complex febrile seizure ( 2.5-10 %) compared with the general population ( 0.5 %). 10 Management of febrile seizures includes parental education , as well as investigation and management of the cause of the fever .

INVESTIGATIONS

EEG

PERFORM an EEG if an epileptic seizure

is suspected ( see figure 5 ); however , a normal EEG does not exclude epilepsy .

Only 50 % of individuals with epilepsy demonstrate epileptic discharges in the first EEG , and an abnormal EEG alone is insufficient to diagnose epilepsy as 5-8 % of healthy

11 , 12 children have EEG abnormalities . The EEG may assist in establishing a diagnosis of epilepsy and defining the specific epilepsy syndrome . 13

Recording during sleep increases the EEG yield by 30 %, and sleep deprivation may have additional value if the initial EEG is normal . 12 Prolonged video EEG or ambulatory EEG increases the yield by about 20 % and may be utilised in those posing a diagnostic dilemma after a standard EEG assessment . 12

Neuroimaging

Neuroimaging aims to identify an