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• Posted May 6, 2024

ERs Often Missing Epilepsy in Kids With 'Non-Motor' Seizures

Two-thirds of kids who suffer a subtle type of epileptic seizure go undiagnosed when they seek emergency room treatment, new research shows.

"We do not know how many people are walking around with seizures that they are unaware of, and we are unaware of," said researcher Jacqueline French, a professor of neurology at NYU Grossman School of Medicine. "That number is absolutely unknown, but I suspect it's larger than we would like to think." 

She and her team analyzed data from 83 preteens and teens being treated for epilepsy in 34 hospitals throughout the U.S., Europe and Australia. Seventy percent sought emergency care before being diagnosed with the neurological disorder.

Epilepsy is a chronic disorder in which groups of brain cells send out excessive bursts of electrical signals, triggering seizures. A patient is diagnosed with the condition if they experience two or more seizures with no apparent cause. 

French's team focused on non-motor seizures, a more subtle form of the disease in which kids "zone out"and stare into space or fidget. During these seizures, they may also experience sudden changes in emotions, thoughts or sensations. In contrast, motor seizures cause muscles to move in abrupt, jerking motions. 

These non-motor seizures may occur repeatedly before motor convulsions or other obvious signs of epilepsy develop.

Researchers wanted to understand whether doctors and patients recognize these nonconvulsive episodes for what they are. 

They published their findings May 1 in the journal Neurology.

While four children went to the E.R. for symptoms of a non-motor seizure, the study showed that 44 had a history of them. In comparison, 21 children sought care for their first-ever motor seizure, out of 39 total. 

Stephanie Tischler, a pediatrician in Stony Brook, N.Y., who is affiliated with Good Samaritan Regional Medical Center-Suffern, was not surprised that the subtle seizures go unrecognized. 

"People run to the E.R. or call 911 for a motor seizure because it is so obvious, but parents can often make up a reason for a non-motor seizure," she said. "For instance, if you have a visual or auditory hallucination, they can call it anything from schizophrenia to a migraine." 

The study found that even when treatment was sought, first-time symptoms were unlikely to be properly diagnosed. E.R. physicians correctly identified 33% of nonmotor seizures, compared with 81% of motor seizures, researchers found. 

"The fact that providers in the emergency department were not recognizing that these children had a non-motor seizure before they came in meant that they were not correctly diagnosed for epilepsy,"said lead author Nora Jandhyala, a student at NYU Grossman School of Medicine in New York City. 

Epilepsy is one of the most common brain disorders in children, affecting 470,000 under age 17, according to the U.S. Centers for Disease Control and Prevention. 

If seizures are left untreated, permanent brain damage can occur, as well as memory loss, and in some circumstances, death. 

Researchers pointed out that children with undiagnosed non-motor seizures may experience significant disruption to everyday life, including school and extra curricular activities.

Diagnostic delays also have been linked to preventable injuries and motor vehicle accidents. There is also an emotional toll, as many parents mistakenly attribute the symptoms of a non-motor seizure to behavioral issues. This can lead to periods of therapy and a detrimental impact on mental health. 

Researchers noted that oftentimes, ER personnel weren't asking the right questions. While almost 40% of the teens had a history of non-motor seizures, none were asked about them. 

"When a child comes in with convulsions, part of the review of systems doesn't include asking thorough questions about a non-motor seizure history,"Jandhyala said. 

Researchers proposed some questions that could be asked in an emergency room setting. They focus on five characteristics suggestive of seizures: sudden-onset, short duration, strange or hard-to-describe, stereotyped and symptoms immediately after a seizure. 

Tischler emphasized that these findings will alter her everyday practice.

"Each school form already states any seizure history, but from now on, I will make sure to explicitly ask about any feelings of deja vu, staring episodes, etc.," she said. "If so, I'll be more conscious about referring them to neurology for further testing." 

Jandhaylas noted that this study may underestimate how widespread the problem is, because it did not include small emergency departments with few specialists and it only included kids between 12 and 18 years of age. Many younger children are also diagnosed with epilepsy. Future research is expected to address these limitations. 

Meanwhile, French noted that public awareness is also key to improving the diagnosis of non-motor seizures. Her team is exploring ways to make the public aware of epilepsy symptoms. 

"Just like there was a public awareness campaign for people who are having strokes, there should be a public awareness campaign suggesting that you don't have to shake in order to be having a seizure," she said.

More information

Learn more about the symptoms and causes of epilepsy at the Mayo Clinic.

SOURCES: Stephanie Tischler, MD, pediatrician, Good Samaritan Regional Medical Center-Suffern, N.Y.; Nora Jandhyala, student, NYU Grossman School of Medicine, New York City; Jacqueline French, MD, professor, neurology, NYU Grossman School of Medicine; New York University Langone Health, news release, May 1, 2024; Neurology, May 1, 2024