eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Critical Care

Status Epilepticus: Differential Diagnoses & Workup

Author: Marcio Sotero de Menezes, MD, Associate Professor, Department of Neurology, Division of Pediatric Neurology, Children's Hospital of Seattle, University of Washington
Coauthor(s): Ednea Simon, MD, Acting Assistant Professor, Department of Neurology, University of Washington
Contributor Information and Disclosures

Updated: Jul 13, 2009

Differential Diagnoses

Somatoform Disorder: Conversion
Somatoform Disorder: Somatization
Syncope

Other Problems to Be Considered

Psychogenic seizures

Occasionally, psychogenic seizures can be confused with generalized tonic-clonic status epilepticus (GTCSE). Patients with nonepileptic seizures can reproduce an outward clinical seizure pattern as a manifestation of an unresolved psychological conflict (psychogenic seizure), or the seizure may be a malingering manifestation, providing the patient with a clear secondary gain.

However, pediatric patients rarely fake a seizure. Symptoms of true psychogenic seizures resemble conversion symptoms. Symptoms are often similar to those of generalized tonic-clonic status epilepticus; however, many times, a few details make the physician aware of the nonepileptic nature of the event (eg, no loss of consciousness in the presence of bilateral movements, asynchronous movements, pelvic thrusting, inconsistency of movement patterns). Nonetheless, no loss of consciousness in the presence of bilateral movements, pelvic thrusting, and asynchronous and thrashing movements can be part of frontal lobe seizures, which may lead to status epilepticus in some cases. Only careful observation of the patient (eg, video) with simultaneous EEG allows the physician to differentiate between sustained nonepileptic seizures and generalized tonic-clonic status epilepticus.

Workup

Laboratory Studies


Treatment algorithms for convulsive status epilep...

Treatment algorithms for convulsive status epilepticus.

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Treatment algorithms for convulsive status epilep...

Treatment algorithms for convulsive status epilepticus.


The following studies are indicated in patients with status epilepticus (SE):

  • Stabilization phase: While attending to the ABCs and inserting an intravenous (IV) line, obtain CBC count and laboratory studies for anticonvulsant medication, electrolyte, BUN/creatinine, calcium, and magnesium levels.
    • Serum glucose measurement should be performed by a fast assay (eg, Dextrostix); this measurement is particularly important because hypoglycemia may be a contributing factor or cause of seizures in adults or children.
    • Although routine laboratory studies are not always useful in assessing patients with brief seizures who present to the emergency department (ED), children with generalized tonic-clonic status epilepticus (GTCSE) require a more aggressive workup. Other necessary tests may include urine/serum toxicology, especially in teenagers with unexplained seizures. If school-aged children who have cats (particularly kittens) at home present with unexplained mental status changes and prolonged seizures, evaluate for catscratch fever based on elevated indirect fluorescent antibody titers to B henselae. A lumbar puncture is commonly indicated in children with generalized tonic-clonic status epilepticus, especially those with unexplained fever or mental status changes preceding or following the seizure episode.
  • Continued evaluation: Continue evaluation after seizures are controlled.
    • Basic tests recommended by the Epilepsy Foundation Working Group on Status Epilepticus include liver function tests (LFTs), toxicology screen, and brain imaging.5
    • After a status epilepticus episode, perform a lumbar puncture for individuals with fever or other evidence of CNS infection. Remember that febrile convulsive status may be associated with CNS infection without typical meningeal signs. Brain imaging should be part of the workup for status epilepticus prior to lumbar puncture for patients with acute neurologic changes as evidenced by increased intracranial pressure.

Imaging Studies

  • Imaging studies are indicated in patients with generalized tonic-clonic status epilepticus once they are stabilized. In many centers, head CT scanning is available on an emergency basis. If CT scanning is unavailable and the patient is stable and has no signs of increased intracranial pressure, CT scanning can be temporarily deferred.
  • Perform an imaging study for all patients who have histories of neurologic (including mental status) changes and for patients who have actual deficits on the neurologic examination that persist after cessation of seizures.
  • Brain imaging should be part of the workup for status epilepticus prior to lumbar puncture for patients with acute neurologic changes as evidenced by increased intracranial pressure.
  • Children with complex partial seizures preceding or leading to the episode of generalized tonic-clonic status epilepticus should undergo brain MRI. In many centers, CT scanning is performed in the ED because MRI services are often unavailable after hours. If not immediately available, MRI should be performed in the following days.
  • Brain imaging may be unnecessary for patients who have already had MRI performed as part of workup for epilepsy or when the cause or precipitant for their episode of status epilepticus is obvious (eg, low anticonvulsant levels, acute infection).
  • On follow up many patients with documented a priori normal MRI findings may develop increased T2, diffusion and fluid attenuated inverted recovery (FLAIR) signal. This is especially true in cases of prolonged partial seizures leading to secondary generalized tonic-clonic status epilepticus. Most of these changes are either due to transient vasogenic or cytotoxic edema.

Other Tests

  • Every patient who presents with status epilepticus requires EEG; however, treatment should not be delayed to wait for EEG results. When a seizure persists longer than 30-60 minutes, making immediate arrangements for an EEG is advisable.
  • The EEG helps in differentiating the convulsive status from pseudoseizure (nonepileptic or psychogenic seizure). Nonconvulsive status epilepticus (NCSE) may need to be differentiated from postictal state–related depression and unresponsiveness from metabolic (renal and hepatic) as well as anoxic encephalopathies. Especially when treatment with anticonvulsant medication does not improve the patient’s alertness.
  • Patients who ultimately require continuous infusion with a barbiturate or benzodiazepine (see Medical Care) should undergo continuous EEG monitoring.
  • During a prolonged seizure, EEG manifestations follow a sequence of partial (focal) EEG seizures, leading to discrete generalized tonic-clonic seizures that eventually become fused (ie, continuous EEG seizure). Rhythmic lateralized or generalized discharges later appear to slow in frequency and may appear similar to periodic lateralizing epileptiform discharges (PLEDs). A patient who arrives at the ED may be at any of these EEG stages; historical information concerning seizure progression usually correlates somewhat with stage. Patients at the later stages of EEG with generalized tonic-clonic status epilepticus may be more difficult to treat.
  • Patients who cannot be aroused following a seizure should have an EEG performed to rule out subclinical status epilepticus. An EEG can confirm the seizure pattern and help indicate the most appropriate long-term treatment, if necessary. For example, a toddler with a history of one unprovoked seizure presents with a generalized tonic-clinic convulsion that lasts 45 minutes; after the event, her EEG findings reveal frequent unilateral spikes. In this situation, the physician would probably recommend treatment with a medication effective against partial seizures (eg, carbamazepine, phenytoin) when the child leaves the hospital.

More on Status Epilepticus

Overview: Status Epilepticus
Differential Diagnoses & Workup: Status Epilepticus
Treatment & Medication: Status Epilepticus
Follow-up: Status Epilepticus
Multimedia: Status Epilepticus
References
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Further Reading

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Keywords

status epilepticus, prolonged seizures, SE, generalized tonic-clonic status epilepticus, generalized tonic-clonic SE, GTCSE, nonconvulsive status epilepticus, nonconvulsive SE, NCSE, epilepsia partialis continua, complex partial and absence status epilepticus, simple partial status epilepticus, complex partial status epilepticus, epilepsy, seizures, violent seizures, hypoglycemia, head trauma, progressive encephalopathy, CNS lipid storage diseases, mitochondrial disorder, cerebral insult, electrolyte disturbance, zombie, hyperthermia, hypotension, periodic lateralizing epileptiform discharges, PLEDs, catscratch fever, meningitis, otitis media, pneumonia, lymphadenopathy, carbamazepine, tiagabine, treatment, diagnosis

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Contributor Information and Disclosures

Author

Marcio Sotero de Menezes, MD, Associate Professor, Department of Neurology, Division of Pediatric Neurology, Children's Hospital of Seattle, University of Washington
Marcio Sotero de Menezes, MD is a member of the following medical societies: American Academy of Neurology and American Epilepsy Society
Disclosure: Nothing to disclose.

Coauthor(s)

Ednea Simon, MD, Acting Assistant Professor, Department of Neurology, University of Washington
Ednea Simon, MD is a member of the following medical societies: American Academy of Neurology, American Epilepsy Society, and Child Neurology Society
Disclosure: Nothing to disclose.

Medical Editor

G Patricia Cantwell, MD, Associate Clinical Professor, Department of Pediatrics, University of Miami; Director of Pediatric Critical Care Medicine, Miller School of Medicine, Jackson Children's Hospital
G Patricia Cantwell, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Barry J Evans, MD, Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center
Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

 
 
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