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Seizure Types: A Quick Review

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Contact Hours: 8

This online independent study activity is credited for 8 contact hours.

Course Purpose

The purpose of this course is to provide healthcare professionals with a brief overview of the various seizure types, their prevalence amongst age groups, symptoms exhibited, and treatment options.

Overview

A seizure is a neurological disorder characterized by uncontrolled brain activity between the brain cells, also known as neurons. Seizures can cause changes and abnormalities in behavior, emotions, consciousness, and memory. There are different types of seizures, and all differ in terms of causes and symptoms. This course will provide a brief overview of the various seizure types, their prevalence amongst age groups, symptoms exhibited, and treatment options.

Course Objectives

Upon completion of the independent study, the learner will be able to:

  • Identify the classifications of seizures.
  • Identify common causes of seizures in infants, children, and adults.
  • Differentiate the brain lobe origins of focal seizures, and their characteristics.
  • Differentiate between the motor and nonmotor manifestations of generalized seizures, and their characteristics.
  • Review treatment options for the various types of seizures.

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This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.

Disclosures

Fast CE For Less, Inc. and its authors have no disclosures. There is no commercial support.

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Definitions
Absence Seizure (Petit Mal Seizure)A condition that results from an abnormal electrical impulse in the brain. This involves brief and sudden lapse of consciousness.
Atonic SeizureInvolves a sudden decrease in muscle tone, causing a person’s body to go limp, slump or collapse, possibly causing injury. 
Cerebral CortexOne of the parts of the cerebrum. Its main purpose is to promote movement. 
Clonic SeizureRepetitive rhythmic muscle twitching and jerking of part or all the body.
Complex Focal Seizure (Impaired Awareness Seizure)A type of seizure that impairs consciousness.
Computed Tomography (CT)A form of tomography in which a computer controls the motion of the X-ray source and detectors, processes the data, and produces the image.
Corpus CallosotomyA procedure that involves cutting the corpus collosum in the brain, preventing the nerves from sending seizure signals between the two halves of the brain.
Electroencephalogram (EEG)A test that measures electrical activity in the brain using small, metal discs (electrodes) attached to the scalp.
EpilepsyA neurological disorder that causes seizures or unusual sensations and behaviors.
Epilepsy SyndromeA type of epilepsy that is identified by specific seizure types and by the findings on an electroencephalogram.
EpileptogenesisThe gradual process by which a typical brain develops epilepsy.
Focal Seizure (Aura)Sometimes called ‘warnings’ or ‘auras’ because a focal seizure can develop into another type of seizure. 
Generalized SeizuresSudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements, feelings, and consciousness.
HemispherectomyA neurosurgical procedure in which a  half of the upper brain or cerebrum is removed or disconnected.
Invasive Alternative of Electrocorticography (ECoG)Electrodes that are suitable for recording large-scale neural signals and overcoming rigid electrodes’ limitations. 
Laser Interstitial Thermal AblationA minimally invasive surgical procedure that uses a laser to destroy unhealthy brain tissue.
Lennox- Gastaut SyndromeA severe form of epilepsy that affects children and adults.
LesionectomyAn operation to remove a damaged or abnormally functioning area in the brain. 
Multiple Subpial TransectionsSurgical treatment for epilepsy where brain regions cannot be removed safely. 
MyoclonusQuick, involuntary muscle jerk.
Myoclonic SeizuresBrief, shock-like jerks of a muscle or a group of muscles.
ParesthesiasA burning or prickling sensation that is usually felt in the hands, arms, legs, or feet, but can also occur in other parts of the body.
Partial Seizures A seizure that affects only one part of the brain.
Postictal PhaseThe period immediately following a seizure.
Prodrome StageA period during which an individual experiences some symptoms and/or a change in functioning.
PsuedoseizureNonepileptic seizures that are not caused by abnormal electrical activities in the brain but rather physical reactions to mental or psychological stress.
Secondary Generalized SeizuresA seizure that begins in one part of the brain, but then spreads to both sides of the brain.
SeizureA sudden surge of electrical activity in the brain that can affect how a person feels, thinks, or acts.
Tonic SeizureA type of seizure that causes sudden stiffness and rigidity in the limbs and trunk.
Tonic-Clonic Seizure (Grand Mal Seizure)A sudden and intense episode of muscle stiffness and jerking, often accompanied by loss of consciousness and vocalization.
Introduction

A seizure is a neurological disorder characterized by uncontrolled brain activity between the brain cells, also known as neurons.1 Seizures can cause changes and abnormalities in behavior, emotions, consciousness, and memory.1,2 There are different types of seizures, and all differ in terms of causes and symptoms.1 For instance, a seizure can occur once from an acute cause or can be recurring, which is known as epilepsy.1,2 Epilepsy and seizure affect around 50 million people worldwide and are a global health burden.3 The estimated general population with epilepsy, or those needing treatment at any given time is between 4 and 10 per 1000 people.3 People suffering from epilepsy and seizures face premature mortality and poor quality of life.3 It also has substantial economic burdens.3 Moreover, the stigma, discrimination, and myths around seizure and epilepsy can result in discouragement from those affected seeking treatment.3 Thus, continuing education about seizures and their effective treatment is essential to increase awareness and reduce prevalence. This course provides a brief overview of the various seizure types, their prevalence amongst age groups, symptoms exhibited, and treatment options.

Defining Epilepsy

Classification of epilepsy and seizure was constructed last in 1989, and the new classification is important to help researchers and patients find a namable diagnosis and etiology.4 Classification also helps researchers find new and improved treatment options for specific types and conditions.4

Epilepsy is a condition of recurrent unprovoked seizures.2 The estimated lifetime prevalence of epilepsy is 7.60 per 1000 individuals, and approximately 55–65 million individuals are affected worldwide.5 It is common in both children (less than 5 years of age) and adults (over 65 years of age).5 According to the updated definition of epilepsy by the International League Against Epilepsy (ILAE) in 2005, it can be defined as “a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain.”4

To characterize, those with epilepsy may experience:4

  • An epilepsy syndrome
  • One reflex or unprovoked seizure and the probability of having another seizure after two unprovoked seizures (≥60%) over the next 10 years
  • Two reflex or unprovoked seizures 24 hours apart

The probability of additional seizures can also be related to EEG showing epileptiform activity or a potential epileptogenic abnormality on brain imaging.4

The signs and symptoms of epilepsy vary depending on when the brain disturbance first starts and how far it spreads.3 The following are some of the symptoms associated with epilepsy:3

  • Changes in sensations, such as vision, hearing, and taste
  • Disturbances in cognitive functions
  • Disturbances in movement
  • Loss of awareness and consciousness
  • Mood changes
  • Physiological conditions such as depression and anxiety
  • Seizure-related injuries, such as fractures and bruises

Epilepsy is not contagious. However, the underlying cause of the disease is still unknown.3 Researchers believe that epilepsy can be caused by a combination of genetic, metabolic, immune, or structural abnormalities and can include stroke, brain damage, head injury, or brain infection.3

Defining Seizure

A seizure is defined as uncontrolled brain activity when multiple neurons fire signals at the same time, around 5000 times per second, which causes disturbances in normal activities, such as movement, behavior, sensations, and emotions.6 It is also considered a spectrum disorder because of its different types and causes.6 The signs of a seizure depend on the type; for instance, a person may appear to be confused, stare off into th distance, or have repetitive motions.7

Seizures can be provoked or spontaneous.8 Provoked seizures are often caused by alcohol withdrawal or hypoglycemia, whereas spontaneous seizures may be caused by underlying epilepsy.8

Types of Seizures

Seizures are classified into two types; partial/focal and generalized.1,2 Partial seizures are the most common types of seizures in adults, which start in the cerebral cortex and can spread to other areas, causing mild to severe symptoms, depending on the electrical discharge.1,2 In general seizures, electrical discharge occurs simultaneously on both sides of the brain and usually starts during childhood.1,2

The signs and symptoms of each seizure type vary. Thus, accurate diagnosis is important to achieve targeted treatment. The following is the expanded classification of seizure types, applicable to both adults and children.

Focal Seizures

Around 60% of individuals with epilepsy have focal seizures.6 Focal seizures are characterized by highly disruptive brain activity which is localized in one area of the brain and can spread to other areas.9 The site and origin of the seizure are recorded by electroencephalography (EEG) or by the invasive alternative of electrocorticography (ECoG).9 A focal seizure can have different onset mechanisms; for instance, the following two types of onset are generally reported:9

  • A high amplitude slow (HAS) activity characterized by a slower oscillation below the alpha range with a high amplitude at the onset.
  • A low amplitude fast (LAF) activity characterized by oscillations in the beta to gamma range of initially low amplitude that slowly increases as the seizure progresses; and

The onset mechanisms lead to different clinical outcomes; for instance, only a proportion of seizure patients respond to medications, while others benefit from surgical intervention.9 Focal seizures are further classified into the following types: 

Simple (Aware) Focal Seizure

The first step in identifying focal seizure type is to note the first sign or symptom.4 Initially, patients may experience minor symptoms, which can be described as an aura.1 The individual has a premonition that something is about to happen through altered sensations or feelings.1

In focal awareness or simple seizure, the affected individual knows what is happening and notices unusual sensations and movements.1 Moreover, the electrical activity remains focused on one sensory or motor area of the brain.1 After defining the level of awareness, focal seizures may further be classified into motor and non-motor onset mechanisms.4

Complex (Impaired Awareness) Focal Seizure

Complex partial seizures, commonly known as focal impaired awareness seizures, are characterized by the association of seizure activity and unconsciousness. 10 Focal impaired awareness seizures can present with or without an aura.10 An aura can last for a few seconds to a few minutes, where the impairment is typically stronger in the beginning.10 In this type of seizure, the individual may experience minor shaking, chewing, fumbling motions or be dazed or confused regarding their surroundings.1,7 Other symptoms of focal seizures with impaired awareness depend on the part of the brain it is affecting or arising from, such as10

Table 1: Impaired awareness focal seizure origin10

Impaired Awareness Focal Seizure OriginSymptoms and Characteristics
Temporal lobe origin seizureMost common type 40% to 80% of patients experience stereotyped automatisms Gradual recovery after confusion for several minutes occurs postictally. Some patients experience automatic behavior like running, walking about, and non-directed violence. Characterized by slower onset and progression, with pronounced confusion. In children, unresponsiveness and behavioral arrest are common.
Frontal lobe origin seizurePrevalent in 30% of the individuals with impaired focal awareness seizures. Seizures occur multiple times daily, in clusters, lasting for 30 seconds. Most seizures occur at night, during sleep, and have minimal postictal confusion. Motor symptoms include hypermotor thrashing episodes, such as pelvic thrusting and bicycling movements, to asymmetric tonic posturing.
Parietal lobe origin seizureThey are subjective in nature and difficult to diagnose. Positive and negative symptoms, individually or in combination, are common. Paresthesias, visual hallucinations, visual illusions, somatic illusions, and vertiginous features can occur. Patients experience auras, such as epigastric sensations, visual hallucinations, panic attacks, and behavioral arrest.
Occipital lobe origin seizureDifficult to diagnose in young children. Consist of visual auras having features like ictal blindness, rapid and forced blinking, versions of the head and eyes to the opposite side, and oculoclonic activity. If the visual aura is short (less than 5 minutes), it can help differentiate it from migraine aura, which lasts longer.
Insular lobe origin seizureMimics frontal, temporal, and parietal lobe seizures. This type is suspected when motor, sensory, or viscerosensitive symptoms occur, such as: Motor (tonic, hypermotor, or generalized tonic-clonic movements)Viscerosensitive (salivation, vomiting, nausea)Sensory (pain, vibration, tightness, numbness)

Secondary Generalized Seizures

Secondary generalized seizures begin in one part of the brain and then spread to other areas.7 They also involve generalized seizures with tonic-clonic convulsions.11 However, it is difficult to diagnose as the symptoms don’t differentiate from the initial seizure.11 They are prevalent in 16% of children and 9% of adults with seizure disorders.11

Most individuals with complex and simple partial seizures will experience a secondary generalized seizure at some point in their life.11 If they are recurrent, the chances of future seizures increase.11 If they are infrequent, they can be resolved by anti-epileptic medication.11

Generalized Seizures

Generalized seizures can start as focal seizures that spread to both sides of the brain.1 They can also occur in a generalized format, where both hemispheres (potentially asymmetrically) of the brain are simultaneously activated at the onset of the seizure.4 Classification of generalized seizures doesn’t involve “aware” vs. “impaired awareness” comparison because awareness is impaired in most generalized seizures.4 In contrast, they are classified based on their motor and nonmotor manifestations, like focal seizures.12

The following are the common types of generalized seizures:

Absence Seizure

Absence seizures, also known as non-motor or petit mal seizures, most often occur in children aged 4 to 6 and often start as brief staring episodes.1,12 These episodes include typical, atypical, myoclonic, or eyelid myoclonia and are characterized by a sudden cessation of brain activity that results in head nodding and eye fluttering, however, children immediately recover from these episodes.1,12 Genetic makeup is considered to be the main risk factor for childhood absence seizure.13 Use of anticonvulsants, such as phenytoin, vigabatrin, and carbamazepine, can also increase risk.13

  • A myoclonic absence seizure starts with a few irregular jerks followed by an absence seizure.12
  • Atypical absence seizures are like absence seizures but have other symptoms, such as prolonged recovery, slower onset, and more pronounced changes in tone.12
  • Eyelid myoclonia is characterized by jerks of the eyelids and upward deviation of the eyes. Moreover, these seizures are precipitated by light and eye closing.12

Aside from childhood absence seizures, another type, juvenile absence seizures, are also prevalent. In epileptic children, about 10% of seizures are typical absence seizures.13 They are differentiated from complex partial seizures based on their lack of a postictal phase and abrupt ending.13 They can occur singly or co-exist with other seizure types, as mentioned above.13

Typical and atypical absence seizures have different EEG findings and ictal behavior.13 Moreover, typical absence seizures occur in children with normal development and intelligence, whereas atypical seizures occur in children with severe epilepsy and learning disability.13

Myoclonic Seizure

Myoclonic seizures involve brief and sudden jerks and spasms in different muscle groups.1,14 These spasms usually occur in the morning in clusters on both sides of the body, including the arms, neck, or head.1 They do not cause any loss of awareness, and the individual is awake during the seizure.14 They are often accompanied by atonic seizures or can occur individually.14

According to the ILAE classification of epilepsies and epilepsy syndromes, the official definition of myoclonic or juvenile myoclonic epilepsy states:15

Impulsive petite mal seizures appear around puberty and is characterized by seizures with bilateral, single, or repetitive, arrhythmic, irregular myoclonic jerks, predominantly in the arms. No disturbance of consciousness is noticeable. The disorder may be inherited, and sex distribution is equal. The seizures usually occur shortly after awakening and are often precipitated by sleep deprivation.”

Myoclonic seizures usually start in children aged 3 to 12 and can persist for several years.14 Each seizure lasts a few seconds and involves outward arm flinging, knees pulling up, and body bending forward.14

Findings of myoclonic seizures often include:15

  • Age of onset between 10 and 25 years.
  • EEG with normal background and typical ictal generalized high amplitude polyspike and slow waves accompanying myoclonic jerks.
  • Myoclonic jerks occurring within 2 hours of awakening and without loss of consciousness exclusively.
  • Normal intelligence.

Clonic Seizure

Clonic seizures can occur in one area of the brain or on both sides simultaneously.16 They are characterized by sudden jerks and rhythmic movements in different muscle groups, such as arms and legs, followed by muscle relaxation.16 Clonic seizures usually occur in children and are considered a part of tonic-clonic seizures.16

The seizure can last for 1 to 2 minutes, and the person is unaware during the epileptic episode.15 Diagnosis is difficult, and they are often mistaken for myoclonic seizures.16

Tonic Seizure

In a tonic seizure, the muscle tone greatly increases and affects both the upper and lower extremities.17  This type of seizure causes the arms and legs to become tense and stiff.17 The affected individual is completely aware or experiences a minor change in awareness during the episode, which lasts for around 20 seconds.17 Tonic seizures are prevalent in individuals with Lennox-Gastaut syndrome.17

The Lennox-Gastaut syndrome is a severe form of epilepsy that usually occurs in early childhood, before the age of 4.18 Affected individuals of all ages suffer from multiple seizure types, such as atonic, tonic, myoclonic, absence, and tonic-clonic.18 The exact cause is unknown and difficult to diagnose; however, the conditions like central nervous system infection, brain malformations, perinatal asphyxia, and tuberous sclerosis are associated with Lennox-Gastaut syndrome.18

Atonic Seizure

Atonic seizures, also known as drop attacks, are defined as events that cause a person to suddenly drop to the floor.19 These seizures are characteristic of Lennox-Gastaut syndrome but also occur in other seizure types and epilepsy syndromes.19 This classification was first introduced in 2010 and involved bilateral loss of tone and muscle limping.12 The epileptic episodes occur in clusters with flexion at the trunk and flexion or extension of the limbs.12 They are brief and show a distinctive EGG pattern of slow spikes and waves.1 It is usually prevalent in individuals with an intellectual disability or multiple brain injuries.1

Tonic-Clonic Seizure

Formerly known as grand mal seizure, tonic-clonic seizure is defined as a seizure type that begins with muscle stiffening, and later involves rhythmic muscle contractions.21 Generalized tonic-clonic seizures arise within and rapidly involve the brain’s bilateral cortical, subcortical, and brainstem networks.21 It is the most feared seizure type as it is characterized by complete loss of consciousness and involves strong and sustained body muscle spasms, along with tachycardia, respiratory arrest, and metabolic stress.21,22

The most common cause of a tonic-clonic seizure is genetics.21 In addition, these seizures can also be caused by structural, metabolic, infectious, or immune-related pathologies.21 Tonic-clonic seizures often  begin with an abrupt impairment in consciousness without an aura.21 The tonic phase involves body stiffening with or without cyanosis.21 After the tonic phase has ended, symptoms like confusion, agitation, or postictal sleepiness are observed.21 Patients are asked about prior cases of staring spells or early myoclonic jerks after the first episode of generalized tonic-clonic seizures.21

Precursors to Seizure Activity

A seizure can take on different forms and goes through multiple phases, which are generally categorized into the falling 3 types:23

  • Prodrome or aura (beginning phase)
  • Ictal (middle phase)
  • Postictal (end phase)

There is a potential for anyone to experience a seizure.2 Thus, the threshold to having a seizure depends on the influence of external factors, which can vary from person to person.2 Similarly, the seizure phases for individuals vary, and a person may not experience all three stages when having a seizure.23

The prodrome stage, commonly known as aura, is the beginning phase of a seizure. During this phase, a person notices early signs and symptoms that herald the onset of a seizure.23,24 This phase can last anywhere from 30 to 60 minutes and can also persist for several days before seizure onset.24 Prodromal signs and symptoms can help predict the next seizure episode and identify the type.25

A recent metanalysis evaluated prodrome studies to identify the common symptoms and their clinical significance. According to the results, the following are the top prodromal symptoms in patients:25

  • Anxiety
  • Confusion
  • Feeling unwell
  • Headache
  • Irritability
  • Limb-weakness
  • Mood changes
  • Nausea
  • Sleep disturbances
  • Speech changes
  • Tremors

The sudden and often unexpected nature of seizures is a debilitating burden on the affected individual’s life, often leading to depression and anxiety.25 A foretelling of signs can help patients take control of their illness and improve pharmacological and non-pharmacological treatment options.25

Causes of Seizures

Every individual, from infant to adult, has the potential to experience a seizure.2 This potential depends on multiple factors, such as genetics, medication use, electrolyte imbalance, brain inflammation, sleep disturbances, infections, and severe head injury.2 Any of these factors can cause an individual to reach the seizure threshold and trigger an episode.2 Seizure causes are divided into two categories; provoked or unprovoked.2 Provoked seizures, also known as acute symptomatic seizures, can result from the following causes:25

  • Electrolyte disorders
  • Fever
  • Head injury
  • Infectious processes
  • Irregularity with prescribed antiepileptic medications
  • Neoplasm
  • Sepsis
  • Toxins
  • Tumors
  • Vascular anomalies
  • Withdrawal syndromes

Unprovoked seizures are caused in the absence of provocative causes or after seven days when an individual suffers from an acute injury.2 The main reasons are genetic susceptibility or a chronic pathologic process.25 Below, the causes have been further divided based on age.

Infants

Seizures in infants are known as neonatal seizures. They are characterized by sudden, paroxysmal, abnormal alteration of electrographic activity during the neonatal period.26 Often, the affected infant is developmentally immature. The electrographic findings are unique and result in different clinical manifestations that are difficult to identify in relation to other age groups.26

Seizures in infants can occur because of the following underlying causes:26

  • Hypoxic conditions
  • Infections
  • Intracranial hemorrhage
  • Metabolic disturbances
  • Selected enzyme deficiencies
  • Selected vitamin and cofactor deficiencies

Children

The cause of seizures in children more than 6 months of age is unknown.27 A family history of epilepsy can contribute to the cause.27 The most common seizure type in children is febrile seizure, which is caused by fever.27 In addition, the following are some other potential causes of seizures in children:27

  • Affected metabolism of amino acids, fats, and carbohydrates.
  • Blood sugar levels, sodium, vitamin B6, calcium, and magnesium abnormalities.
  • Brain disorders like tumors, bleeding, head injury, brain malformations, stroke, meningitis
  • Sepsis

Adults

In adults, the following are the most common causes of seizures:8

  • Alcohol withdrawal
  • Cerebrovascular disease
  • Neurodegenerative disease
  • Stroke
  • Tumors
Diagnosing Seizures

The diagnosis of a seizure can be detailed and complex. It involves clinical evaluation to determine whether the sudden episode was a seizure or a psuedoseizure.2 For instance, a syncope is often mistaken for a seizure.8 Similarly, other disorders like sleep disorder, transient ischemic attack, psychiatric conditions, dissociative disorders, psychogenic nonepileptic seizures, or panic attacks also act as seizure mimics.8

The following steps should be considered when diagnosing a  seizure:

History

Obtaining a health history is critical for seizure diagnosis and creating the right  treatment regimen.2  The history involves asking patients about their first seizure and any subsequent seizures, along with the duration, sequence, and time interval between seizures.28 The medical and social history, and any alcohol or drug abuse should also be obtained.2 Healthcare professionals should consider the risk factors could contribute to the seizure, such as prior head trauma, alcohol withdrawal, or a known neurological disorder.28

Many patients also experience an aura or signs and symptoms suggesting a seizure onset. However, many patients experience unconsciousness or do not remember experiencing an aura; thus, family members or close witnesses should be questioned about the seizure manifestations.2,28

Questions can also change depending on if the epileptic condition is known or unknown.2 For instance, patients with known epilepsy should be inquired about irregular medication use.2

Physical

The physical assessment includes a general physical exam and a neurologic examination, which can vary for each seizure type.2 For instance, in a generalized tonic-clonic seizure, a healthcare professional may notice the following manifestations:2

  • Blank stare
  • Lack of response to verbal or painful stimulation during the event
  • Rhythmic in-phase motor movements

In unconscious patients with unknown epilepsy, manifestations like bitten tongue, prolonged confusion, and incontinence suggests seizures.28 If a patient has persistent changes in consciousness, status epilepticus should be considered.2 Sometimes, patients may show facial and extremity twitching or repetitive eye movements, and in others there may be no motor movement at all.2  However, these symptoms can also occur in pseudoseizures. How can they be differentiated? There are certain clinical characteristics that you can analyze, such as:28

  • A typical tonic phase is not followed by a clonic phase
  • Intensity varies throughout the episode
  • Muscular activity progression doesn’t correspond to true seizure patterns
  • No postictal confusion occurs
  • Patients resist passive eye-opening
  • Pseudoseizures last longer, up to several minutes or more
  • Temperature and other vital signs remain normal usually

Diagnostic Imaging

Brain imaging and electroencephalography (EEG) are considered the mainstay for diagnosis of seizures.2,8 Brain imaging is recommended when the patient has a history of acute head trauma, being immunocompromised, persistent headaches, fever, malignancy, older age (above 40), anticoagulation use, or focal seizure onset.2 It helps in assessing serious conditions, such as stroke, edema, or hemorrhage, and identifying causes of the seizure.8 Often, multiple brain scan tests are used, such as computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET).6

Magnetic resonance imaging is more sensitive than CT and can help with findings like hippocampal sclerosis and cortical dysplasias (potential causes of seizures and epilepsies).6 Both CT and MRI reveal structural abnormalities in the brain.6 Positron emission tomography scans are used to detect brain regions with lower-than-normal metabolism, which indicates the seizure has spread.6

An EEG is particularly important for diagnosing focal impaired-awareness seizures or absence status epilepticus.28 It detects focal sharp waves or spikes characteristic of focal epilepsy or bilateral (generalized) epileptiform activity characteristic of generalized epilepsy.6,28 Additional lab tests may be conducted for suspected conditions, such as syncope mimicking, central nervous system (CNS) infection.28

Seizure Affects on Growth and Development

Seizures are extremely common in infants and children. In fact, neonatal seizures are a commonly encountered neurologic emergency, with a higher incidence reported in preterm births.26 In the United States, the incidence rate is estimated to be between 80-120 cases per 100,000 neonates yearly.26

Children with seizures and epilepsy may suffer from poor quality of life and other associated comorbid conditions that affect their development.29 Among them, cognitive abnormalities are the most common.29 Research has shown that IQ scores are lower in children with epilepsy, and they are more likely to experience learning difficulties in school than children without epilepsy.29

In infants and children, seizures indicate a serious underlying condition, and many believe that cognitive impairment is the cause of the underlying condition.29 This is true, but not entirely. Several studies have shown that in many cases, cognitive impairment is independent of the underlying condition and is dependent on the early onset of epilepsy, which causes disruption in critical periods of development, leading to poor cognitive outcomes.29

A study used the flurothyl model of recurrent epileptic seizures to show cognitive impairment in rat pups that mimic human neonatal seizures.29 These rats were tested during adolescence and adulthood, and the following cognitive defects were observed:29

  • Deficits of spatial cognition in the water maze
  • Impaired auditory discrimination
  • Non-match to sample task
  • Reduced behavioral flexibility

Aside from seizures, interictal spikes also affect the developing brain and result in transient impairment in the delayed-match-to-sample test.29

Treatment and Management Options

The initial treatment option for seizures is medication or antiepileptic drugs (AEDs).2 There are more than 30 different antiseizure drugs available in the market today, each varying in their benefits and side effects.6 The choice of AED depends on multiple factors, such as seizure type and frequency, lifestyle, age, side effects, and intake of other drugs.6

Medication

Antiepileptic medications can be divided into two general groups:

  • Broad-spectrum antiepileptic drugs: Medications that treat a wide variety of seizure types. Healthcare providers  will usually prescribe these medications first if they are uncertain of the seizure type the patient is experiencing. Some of the broad-spectrum AEDs and the seizure types they treat include:6,8
MedicationSeizure Type
clonazepam (Klonopin)Absence Seizures Lennox-Gastaut Syndrome Myoclonic Seizures  
camotrigine (Lamictal)Focal Aware Onset Seizure Focal Impaired Awareness or Complex Partial Seizures Juvenile Myoclonic Epilepsy Lennox-Gastaut Syndrome Refractory Seizures Secondarily Generalized Seizures or Bilateral Tonic Clonic Seizure Temporal Lobe Epilepsy Tonic-clonic Seizures  
levetiracetam (Keppra)Focal Aware Onset Seizure Focal Impaired Awareness or Complex Partial Seizures Juvenile Myoclonic Epilepsy Myoclonic Seizures Secondarily Generalized Seizures or Bilateral Tonic Clonic Seizure Temporal Lobe Epilepsy Tonic-clonic Seizures  
rufinamide (Banzel)Lennox-Gastaut Syndrome
Topiramate (Topamax)Focal Aware Onset Seizure Focal Impaired Awareness or Complex Partial Seizures Lennox-Gastaut Syndrome Tonic-clonic Seizures  
zonisamide (Zonegran)Focal Aware Onset Seizure Focal Impaired Awareness or Complex Partial Seizures Refractory Seizures Secondarily Generalized Seizures or Bilateral Tonic Clonic Seizure Temporal Lobe Epilepsy  
  • Narrow-spectrum antiepileptic drugs: Healthcare professionals may prescribe these medications to treat focal or partial seizures. Some narrow-spectrum AEDs and the seizure types they treat include:6,8
MedicationSeizure Type
carbamezepine (Tegretol)Focal Aware Onset Seizure Focal Impaired Awareness or Complex Partial Seizures Secondarily Generalized Seizures or Bilateral Tonic Clonic Seizure Temporal Lobe Epilepsy Tonic-clonic Seizures  
gabapentin (Neurontin)Focal Aware Onset Seizure Focal Impaired Awareness or Complex Partial Seizures  
lacosamide (Vimpat)Focal Aware Onset Seizure Focal Impaired Awareness or Complex Partial Seizures Secondarily Generalized Seizures or Bilateral Tonic Clonic Seizure Temporal Lobe Epilepsy  
phenobarbitol (Luminal)Clonic Seizures Focal Aware Onset Seizure Focal Impaired Awareness or Complex Partial Seizures Lennox-Gastaut Syndrome Rasmussen’s Syndrome Refractory Seizures Secondarily Generalized Seizures or Bilateral Tonic Clonic Seizure Temporal Lobe Epilepsy Tonic Seizures Tonic-clonic Seizures  
phenytoin (Dilantin)Focal Aware Onset Seizure Focal Impaired Awareness or Complex Partial Seizures Refractory Seizures Secondarily Generalized Seizures or Bilateral Tonic Clonic Seizure Temporal Lobe Epilepsy Tonic-clonic Seizures  
pregabalin (Lyrica)Focal Aware Onset Seizure
Focal Impaired Awareness or Complex Partial Seizures  
oxcarbazapine (Trileptal)Focal Aware Onset Seizure Focal Impaired Awareness or Complex Partial Seizures Secondarily Generalized Seizures or Bilateral Tonic Clonic Seizure Temporal Lobe Epilepsy Tonic-clonic Seizures  
valporic acid (Depakote)Focal Aware Onset Seizure Focal Impaired Awareness or Complex Partial Seizures Juvenile Myoclonic Epilepsy Lennox-Gastaut Syndrome Myoclonic Seizures Refractory Seizures Secondarily Generalized Seizures or Bilateral Tonic Clonic Seizure Temporal Lobe Epilepsy Tonic-clonic Seizures

After the first seizure episode, the risk and benefits of AEDs should be weighed based on the chance of recurrence of future seizures.8 For instance, if a patient experiences an unprovoked seizure episode, they have a 35% chance of having a recurrent seizure in the next 5 years if their EEG, MRI, and neurological examination is normal.8 The risk of recurrent seizures is higher in the following individuals:8

  • Abnormal EEG
  • Family history of epilepsy
  • Multiple seizures within 24 hours
  • Neurological disorder or developmental delays
  • Prior incidence of stroke or brain injury

Treatment of most seizures with antiepileptic drugs can be controlled with a single drug (monotherapy); otherwise, a combination of drugs are used where monotherapy is ineffective.6 However, special considerations should be made for specific demographics.8 For instance, the use of enzyme-inducing AEDs should be avoided in patients taking multiple medications for other conditions, like HIV or atrial fibrillation.8 Similarly, patients with depression and anxiety should avoid levetiracetam as a first-line AED due to its psychotic side effects.8 Some common side effects of AEDs include:6

  • Minor side effects
    • Depression
    • Dizziness
    • Fatigue
    • Mood changes
    • Weight gain
  • Major side effects
    • Allergic reactions
    • Harmful interactions with other drugs
    • Liver and bone marrow damage
    • Suicidal ideation
      • Patients taking AEDs should be aware of and report any depression or suicidal thoughts to their healthcare provider. Although suicidal ideation may occur, the actual risk for suicide is low.6

Medication Considerations

As a person ages, the effects of AEDs may lessen. However, consuming citrus products can interfere with the breakdown of the drugs, worsening the side effects.

All seizure medicines can cause abnormal blood counts (white cells, red cells and platelets), or abnormal laboratory results for the liver or other internal organs, and as such, blood tests to screen for these problems should be conducted at regular intervals. Blood should be tested when starting an AED to get baseline results, after a few months on the AED, then every few months to yearly thereafter.

Although AEDs are called “antiepileptic,” they do not cure epilepsy. They suppress seizures when prescribed appropriately and taken effectively. Patients should be educated to continue taking AEDs as long as prescribed. If patients remain seizure-free, healthcare professionals may discontinue antiepileptic drug use after 3 to 5 years.6 Discontinuation  of antiepileptic drugs depends on the seizure type and age.6 A study successfully concluded that 68% of adults did not have recurrent seizure episodes when they remained seizure-free for 2 years before stopping their medication.6,8

Monitoring

Because medication is the first line of treatment for seizures, careful monitoring is required to ensure the patient is responding well to the treatment.8 For instance, if the patient experiences multiple adverse effects, they should be switched to another well-tolerated drug, such as:8

  • For focal epilepsy, lamotrigine is considered because it has fewer side effects as compared to carbamazepine or topiramate. But remember that it doesn’t offer rapid protection against seizures.
  • In elders, gabapentin, levetiracetam, and lamotrigine are well-tolerated.

If the first drug is ineffective, a second drug is chosen, and the response rate to the second AED is generally around 13% to 28%.8 If a patient’s condition is not improving after the first and second AED, they likely have drug-resistant epilepsy, and their chances of response to the third or fourth AED also diminish.8 Such individuals are recommended dietary changes, surgery, or neurostimulation.8 

Surgery

Surgery is only considered for persistent focal seizures after a patient has tried two well-tolerated antiepileptic drugs.6,8 Surgery is also considered when the seizure is caused by an unidentified brain lesion.6 In such cases, candidates for surgery are evaluated based on their seizure type, brain lesion involved, and origin site.6 Extensive testing may be conducted, including:8

  • Video-EEG recording – Used to detect typical seizures while the patient is hospitalized and determine the origin site or whether multiple seizures are involved.
  • Magnetic resonance imaging (MRI) – Helps clinicians select and counsel patients for surgery. Patients have a higher chance of postoperative seizure freedom if a lesion on the MRI corresponds with the onset zone.
  • Positron emission tomography (PEYT) – If no lesion is detected on an MRI, a PET scan helps with localized findings and clinical evaluation.
  • Neuropsychology assessment – Important to determine the patient’s presurgical verbal and nonverbal memory functioning.
  • Magnetoencephalogram – Uses magnetic fields generated by interictal discharges to localize dipole sources.
  • Intracranial electrodes – An invasive monitoring option where electrodes are surgically implanted to improve localization and increase the pool of candidates. It helps with cortical mapping and creating a precise map of the function of the cortex area.

Several random controlled trial studies support surgery for epileptic individuals and found patients to have a higher chance of seizure-freedom after surgical interventions when compared to patients who were managed with medication.8  In addition, patients also experienced an improvement in social and employment status.8 Surgical options for seizures include:6,8

  • Lesionectomy – Recommended for focal seizures that involve only one area of the brain and involves removal of that area where the seizure originates. A temporal lobe resection is performed for individuals with medial temporal lobe epilepsy and is the most common lesionectomy. In such cases, one hippocampus is shrunken and scarred and is removed during surgery.
  • Hemispherectomy – A rare procedure and intensive surgery option for children who are not responding well to medication. It involves removing half of the brain’s outer layer or cortex. It is only recommended when other treatments and surgeries have failed. However, children can recover after intense rehabilitation.
  • Corpus Callosotomy – Is recommended in those with generalized seizures that begin in one part of the brain and spread to other areas. It involves severing the neural connections between two hemispheres of the brain. However, seizures do not stop at the origin site and can worsen after surgery. It is useful in preventing drop attacks and other generalized seizures.
  • Laser Interstitial Thermal Ablation – A thermal probe is inserted using MRI guidance to the seizure source, and heat is applied to ablate the tissue. The recovery time and cognitive decline are lower as compared to traditional resection.
  • – this procedure is recommended when seizures originate in a brain area that is difficult or impossible to remove. It involves designing cuts in multiple brain parts to prevent the seizure from spreading. The patient’s normal physical and cognitive abilities remain intact.

Despite the advantages, there are multiple risks associated with surgery.6 Common risk involves cognitive, behavioral, and motor changes; however, the premise is stronger for surgery when AEDs fail.6

Neurostimulation

When the seizure originates in a brain area that is impossible to remove, or when patients are not candidates for surgery because of the seizure type (multifocal or generalized) or in the primary language or motor areas, neurostimulation is recommended.8

A responsive neurostimulation device is used for patients with multifocal and generalized seizures.8 It is a closed-loop system that detects the onset of seizure activity and delivers electrical stimulation pulses using electrodes to prevent the seizure from progressing and spreading.8 After this procedure, around 16% of patients are seizure-free.8

Another method, vagus nerve stimulation, surgically places a subcutaneous stimulator in the chest and a stimulating wire that is attached to the vagus nerve.8 The device sends short bursts of electrical pulses to the brain via the vagus nerve.6 It reduces the severity and frequency of the seizures.8 The patients cannot stop taking medication but can reduce the dosage to lower the frequency of seizures.6

In both procedures, patients experience a neuromodulatory effect and a delayed response recovered over time.8

Diet

Dietary treatment is considered effective for refractory focal and generalized seizures.6,8 Generally, a high-fat, low-carbohydrate (ketogenic diet) reduces seizure activity by 50%. Multiple studies have shown that ketogenic diets improve 50% seizure control in more than 50% of patients, and 10% are seizure-free.6 It also improves cognitive function and mood.8 The ketogenic diet induces a state called ketosis that shifts the body from breaking down carbohydrates to utilizing fats instead.6 Other possible explanations involve the action of decanoic acid, which inhibits the a-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptor, or via DNA methylation.8

A ketogenic diet can be difficult to maintain and cause impaired growth caused by nutritional deficiency, or kidney stones from a buildup of uric acid in the blood.6

Patient Safety Considerations

Infant

  • Parents should be educated about the prognosis and possible neurological impairments of the infant.26
  • Parents should be referred to early rehabilitation centers.26
  • Parents should schedule a routine follow-up with pediatric neurology and strictly adhere to the medication and dosage.26
  • Parents should consider a multi-disciplinary healthcare team to identify any motor and cognitive deficiencies and allow for early neuro-developmental invention.30

Child

  • Avoid water sports and baths without supervision.31
  • Call 911 if there is no response to painful stimuli following a seizure, vomiting during a seizure, repeated seizures without touch or sound response, and seizures in pools or bathtubs.31
  • Children should always have a partner/buddy in physical sports and recreational activities.31
  • Monitor the frequency of seizure episodes and the accompanying side effects of the medications.31
  • Parents should remove harmful objects away from the child during a seizure.31

Adult

  • Avoid the use of alcohol and social drugs.32
  • Call 911 if the seizure lasts more than 5 minutes or occurs shortly after the first episode.32
  • Caregivers should time the seizure duration and frequency.32
  • Have an adequate amount of sleep daily.32
  • Patients should be counseled about working with heavy machinery, operating a motor vehicle, heights, swimming, and bathing in a tub.32
  • Restrict driving after seizure episodes until further evaluation is conducted.32
Nursing Considerations

Antiepileptic medication and surgery are not definitive seizure management options.2  Identifying the underlying disease and causative factors is necessary to improve quality of life.2 Constant care and monitoring are required, along with advanced respiratory and circulatory support.2

Seizures can lead to multiple complications, such as brain injury, tongue, and scalp lacerations. Thus, patients should be educated on the potential risks.2 In addition, an interprofessional team should be assembled to offer optimal care to the patient as their clinical condition can change.2 This team should include specialists, primary healthcare providers, nurses, pharmacists, and mental health specialists.2 An optimized team response is necessary to ensure the best treatment option is selected and the patient regains complete or optimal control of their abilities, whether they have a single uncomplicated event or continued seizures.2

In the interprofessional team, nurses play a critical role in helping providers identify clinically evident seizure activity, ensure patients are safe from adverse effects of antiepileptic agents, and annotate pertinent events.26

The following are the steps a nurse should consider when their patient is having a seizure:

  1. When a seizure occurs, ease the patient on the ground and monitor for signs of respiratory distress.34
  2. If possible, lay the patient on their side or turn the head to the side to promote fluid drainage and prevent aspiration or the tongue blocking the airway.34
  3. Do not put anything in the mouth or attempt to open clenched jaws.34
  4. Protect the patient’s head during the seizure, remove any harmful objects from the surrounding area, and do not attempt to restrain movements.34
  5. Stay with the patient until the seizure ends, and they are fully awake.33
  6. Initiate a ‘seizure watch’ and monitor vital signs/neurological assessment every 15 minutes until the patient is awake.34
  7. After the seizure ends, speak to the patient softly and calmly and explain what happened in detail.33
  8. Initiate Blue Code if the patient’s airway becomes compromised or shows signs of respiratory distress or the patient remains unconscious after the seizure has stopped.34
  9. Keep the family members and surrounding patients calm.33

The following includes the role of nurses in continuing care and managing seizures for different age demographics: 30,34

  • Establish early and ongoing communication with parents and provide family-centered care.
  • Document abnormal movements simultaneously with the recording of cardiorespiratory monitoring.
  • Facilitate follow-up with verbal and written communication and assistance with appointments as required.
  • If stimuli provoke seizures, reduce noise, light, invasive treatment, and care activities.
  • Nurses should maintain a seizure log and make entries of all seizure activity.
  • Instruct parents/caregivers on how to clearly describe seizure activity. For example, explaining the body movement, how long the seizure lasted, consciousness status, etc., instead of naming the seizure type.
  • Educate parents and ensure they are aware that any information about what led up to the seizure, what happened during it, and what happened after will help manage their child’s seizures.
  • Review the basic seizure safety precautions with the caregivers at the start of each shift.
  • The seizure log should document the date and time of seizure onset, the length of the seizure, the body movements involved, the behavioral changes, state of consciousness, state of mouth position, and any treatment or management interventions are taken.
Conclusion

Seizures and epilepsy significantly impact an individual’s quality of life and work productivity.3 It accounts for 0.5% or more of the global burden of disease, which is a time-based measurement that combines years of life lost due to premature mortality and a life spent in less than optimal health.3 Moreover, the economic burden and stigma associated with seizures are hard to overcome.3 Patients need optimal first-line and second-line treatments and management options to regain full or partial control of their abilities and continue their lives confidently.3

Continuing education and awareness among patients and caregivers is necessary to improve health outcomes.2 Developing an interprofessional team is also necessary to ensure the patient receives optimal care according to their changing clinical status.2 All seizures might have different causes. Still, their primary treatment plan is the same.2 Thus, nurses and primary healthcare providers should be well-versed in basic care and AEDs and enable to analyze the risk and benefits in an emergency.2 nurses should be educated in the basic care policy and what to do before, during, and after a seizure.

The number of available antiepileptic drugs has significantly increased in the last 40 years, but there is room for improvement as there are still people with intractable seizures.8 Moreover, surgery and neurostimulation, although effective, are not suitable for all patients because of multifocality, widespread seizure onset legions, and eloquent cortex involvement.8 Thus, research should be increased in dietary therapy and in studying the role of hormones in seizure treatment and management.8 For now, tailored therapy considering the patient’s overall health, age, gender, and comorbidities is the best course of action.8

References
  1. John Hopkins Medicine. Types of Seizures. John Hopkins Medicine. Published 2019. https://www.hopkinsmedicine.org/health/conditions-and-diseases/epilepsy/types-of-seizures
  2. Huff JS, Murr N. Seizure. PubMed. Published September 5, 2022. https://www.ncbi.nlm.nih.gov/books/NBK430765/
  3. Epilepsy. www.who.int. https://www.who.int/news-room/fact-sheets/detail/epilepsy#:~:text=The%20estimated%20proportion%20of%20the
  4. Falco-Walter JJ, Scheffer IE, Fisher RS. The new definition and classification of seizures and epilepsy. Epilepsy Research. 2018;139:73-79. doi:https://doi.org/10.1016/j.eplepsyres.2017.11.015
  5. Hunter SE, Jalazo E, Felton TR, Heinzen EL, Shiloh-Malawsky Y. Epilepsy Genetics: Advancements in the Field and Impact on Clinical Practice. PubMed. Published 2022. Accessed February 24, 2023. https://www.ncbi.nlm.nih.gov/books/NBK580613/#Ch3-sec1
  6. Epilepsy and Seizures | National Institute of Neurological Disorders and Stroke. www.ninds.nih.gov. https://www.ninds.nih.gov/health-information/disorders/epilepsy-and-seizures
  7. CDC. Types of Seizures. Centers for Disease Control and Prevention. Published 2019. https://www.cdc.gov/epilepsy/about/types-of-seizures.htm
  8. Johnson EL. Seizures and Epilepsy. Medical Clinics of North America. 2019;103(2):309-324. doi:https://doi.org/10.1016/j.mcna.2018.10.002
  9. Wang Y, Trevelyan AJ, Valentin A, Alarcon G, Taylor PN, Kaiser M. Mechanisms underlying different onset patterns of focal seizures. Lytton WW, ed. PLOS Computational Biology. 2017;13(5):e1005475. doi:https://doi.org/10.1371/journal.pcbi.1005475
  10. Kumar A, Sharma S. Complex Partial Seizure. PubMed. Published 2022. https://www.ncbi.nlm.nih.gov/books/NBK519030/#:~:text=Complex%20partial%20seizures%20refer%20to
  11. Secondarily Generalized Seizures – Epilepsy Ontario. https://epilepsyontario.org/secondarily-generalized-seizures/
  12. Pack AM. Epilepsy Overview and Revised Classification of Seizures and Epilepsies. CONTINUUM: Lifelong Learning in Neurology. 2019;25(2):306-321. doi:https://doi.org/10.1212/con.0000000000000707
  13. Posner E. Absence seizures in children. BMJ clinical evidence. 2008;2008:0317. Accessed March 3, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907950/#:~:text=Incidence%2F%20Prevalence
  14. Myoclonic Seizures. www.hopkinsmedicine.org. https://www.hopkinsmedicine.org/health/conditions-and-diseases/epilepsy/myoclonic-seizures#:~:text=Myoclonic%20seizures%20are%20characterized%20by
  15. Yacubian EM. Juvenile myoclonic epilepsy: Challenges on its 60th anniversary. Seizure. 2017;44:48-52. doi:https://doi.org/10.1016/j.seizure.2016.09.005
  16. Clonic Seizures. Epilepsy Foundation. https://www.epilepsy.com/what-is-epilepsy/seizure-types/clonic-seizures
  17. Tonic Seizures. Epilepsy Foundation. https://www.epilepsy.com/what-is-epilepsy/seizure-types/tonic-seizures
  18. Lennox-Gastaut Syndrome. National Institute of Neurological Disorders and Stroke. Accessed March 3, 2023. https://www.ninds.nih.gov/health-information/disorders/lennox-gastaut-syndrome#:~:text=What%20is%20Lennox%2DGastaut%20syndrome
  19. National Guideline Alliance (UK). Effectiveness of Antiseizure Therapies in the Treatment of Tonic or Atonic Seizures/Drop Attacks: Epilepsies in Children, Young People and Adults: Evidence Review I. National Institute for Health and Care Excellence (NICE); 2022. Accessed March 3, 2023. https://www.ncbi.nlm.nih.gov/books/NBK581156/
  20. Oguni H. Epilepsy with myoclonic-atonic seizures, also known as Doose syndrome: Modification of the diagnostic criteria. European Journal of Paediatric Neurology. 2022;36:37-50. doi:https://doi.org/10.1016/j.ejpn.2021.11.009
  21. Kodankandath TV, Theodore D, Samanta D. Generalized Tonic-Clonic Seizure. PubMed. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK554496/
  22. Nass RD, Zur B, Elger CE, Holdenrieder S, Surges R. Acute metabolic effects of tonic‐clonic seizures. Epilepsia Open. 2019;4(4):599-608. doi:https://doi.org/10.1002/epi4.12364
  23. Seizure Phases. Epilepsy Foundation. https://epilepsyfoundation.org.au/understanding-epilepsy/seizures/seizure-phases/
  24. Beniczky S, Tatum WO, Blumenfeld H, et al. Seizure semiology: ILAE glossary of terms and their significance. Epileptic Disorders: International Epilepsy Journal with Videotape. 2022;24(3):447-495. doi:https://doi.org/10.1684/epd.2022.1430
  25. Besag FMC, Vasey MJ. Prodrome in epilepsy. Epilepsy & Behavior. 2018;83:219-233. doi:https://doi.org/10.1016/j.yebeh.2018.03.019
  26. Krawiec C, Muzio MR. Neonatal Seizure. PubMed. Published 2020. https://www.ncbi.nlm.nih.gov/books/NBK554535/
  27. Seizures in Children – Children’s Health Issues. MSD Manual Consumer Version. https://www.msdmanuals.com/home/children-s-health-issues/neurologic-disorders-in-children/seizures-in-children
  28. Seizure Disorders – Neurologic Disorders. MSD Manual Professional Edition. Accessed March 8, 2023. https://www.msdmanuals.com/professional/neurologic-disorders/seizure-disorders/seizure-disorders?query=seizure%20in%20adults
  29. Holmes GL. Effect of Seizures on the Developing Brain and Cognition. Seminars in Pediatric Neurology. 2016;23(2):120-126. doi:https://doi.org/10.1016/j.spen.2016.05.001
  30. Health Q. Maternity and Neonatal Clinical Guideline Neonatal Seizures. https://www.health.qld.gov.au/__data/assets/pdf_file/0030/143697/g-seizures.pdf
  31. Seizure Safety Precautions. www.childrenscolorado.org. https://www.childrenscolorado.org/doctors-and-departments/departments/neuroscience-institute/resources-for-families/seizure-safety/
  32. Legg KT, Newton M. Counselling adults who experience a first seizure. Seizure. 2017;49:64-68. doi:https://doi.org/10.1016/j.seizure.2016.09.012
  33. Centers for Disease Control and Prevention. Seizure First Aid. CDC. Published 2019. https://www.cdc.gov/epilepsy/about/first-aid.htm
  34. policyandorders.cw.bc.ca. http://policyandorders.cw.bc.ca/resource-gallery/Documents/BC%20Children
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