Seizure: European Journal of Epilepsy 114 (2024) 96–97

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Seizure: European Journal of Epilepsy

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Letter to the Editor

More about nonconvulsive status epilepticus in children

A R T I C L E I N F O

Keywords
Children
Electroencephalogram
Epilepsy
Epileptiform discharges
Nonconvulsive status epilepticus
Seizure

Dear Sir, epilepsy (long-lasting predisposition to generate recurrent sei­

zures) is met [1,6].
We read with great interest the article by María José Jiménez-Vil­
legas and appreciate the author’s updated narrative review about the
According to the operational epilepsy definition adopted by the In­
first unprovoked seizure (US) in children and adults [1]. However, we
ternational League Against Epilepsy (ILAE) in 2014, epilepsy diagnosis
would like to add some concerns about nonconvulsive status epilepticus
can be established after one US if the recurrence risk is high (≥60 %),
(NCSE) in children.
such that it approaches the risk of recurrence associated with a second
Recently, we have recommended to perform an electroencephalo­
clinical US (e.g., a case of a child with a first US of structural etiology and
gram (EEG) after the first US, including the onset as status epilepticus
epileptiform discharges detected in the EEG) [8]. In fact, the risk of a
(SE), to establish the recurrence risk and the diagnosis of epileptic
second clinical US in children with epileptiform discharges is up to 66 %
syndrome, start antiseizure medication, and avoid misdiagnosis of epi­
[1].
lepsy, especially in prolonged psychogenic non-epileptic seizures
The highest probability of finding epileptiform discharges occurs in
(PNES) [2]. Indeed, pediatric patients (8–14 years) with PNES can be
the first 16 h after the onset of the event. In one study, 52.1 % of EEGs
misdiagnosed as SE in up to 3 % of boys and 7 % of girls [3].
performed within the first 16 h after seizure onset showed an epilepti­
Regarding this matter, it is important to point out the following:
form EEG pattern compared to 20.2 % performed after (p < 0.001) [9].
In the ILAE guidelines on the management of pediatric seizures after
1.- SE is a common pediatric neurological emergency that requires
failing to rule out abnormal paroxysmal events recorded on video by
rapid evaluation and management. Treatment and prognosis
caregivers, they recommend performing a routine EEG. If the result is
depend mainly on the duration, type, and cause of SE. Early
abnormal, manage based on the identified alterations (e.g., hypsar­
treatment is one of the most effective factors to control SE and
rhythmia in infantile spasms syndrome) (expert opinion, level U of ev­
reduce morbidity and mortality [4]. NCSE is common in pediatric
idence); but they do not specify that it must be performed in the first 16
inpatient settings (including Intensive Care Unit). Incidence is up
h after seizure onset [10].
to 46 % of critically ill children, and in those with suspected
In a recent study of 87 patients (mean age 43 years) treated in the
NCSE, it was confirmed in 14 % by EEG [5].
Emergency Department (ED) for seizures and suspected NCSE, interictal
2.- EEG is an essential diagnostic tool to evaluate epileptic disorders.
epileptiform discharges (IEDs) were observed in 38.4 % of patients with
Epileptiform discharges have been shown to predict recurrent
the first US and in 33.3 % of known epileptic patients; 36.4 % of possible
USs (a clinical definition of epilepsy) [6]. American Academy of
NCSE were confirmed by EEG. EEG with IEDs meant starting or modi­
Neurology pediatric guidelines recommend obtaining an EEG
fying antiseizure medication in 59.8 % of patients, highlighting the EEG
after a single US [7] since epileptiform discharges detected in the
usefulness in the management of seizures in the ED, both in severe acute
EEG can be useful in identifying epileptogenic foci, structural
situations (NCSE) and in epilepsy diagnosis [11].
abnormalities, and EEG patterns associated with specific epileptic
In summary, EEG is a very valuable test in the diagnosis and treat­
syndromes. The EEG predictive value is which has the most
ment of epilepsy in the ED, being irreplaceable, safe, and cost-effective
relevant role in a single US assessment [6]. The recurrence risk of
in the NCSE management. And both to initiate and optimize antiseizure
pediatric seizures is higher during the first two years (14–65 %)
treatment in case of epilepsy decompensation since it allows early
after US [1]. The risk increases to 60–90 % after the second US, at
therapeutic decisions to be made (especially if performed within the first
which time it is considered that the traditional definition of
16 h after seizure) [1,6-9]. Finally, we recommend performing an EEG
after the first US, both in adult and pediatric patients. It is essential to

https://doi.org/10.1016/j.seizure.2023.12.006
Received 7 December 2023; Received in revised form 9 December 2023; Accepted 12 December 2023
Available online 12 December 2023
1059-1311/© 2023 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

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Letter to the Editor
conduct further real clinical practice studies for this purpose.
Declaration of Competing Interest
The authors do not have a financial interest or relationship to
disclose regarding this letter to the Editor.
References
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voked seizure in children and adults: a narrative review. Seizure 2021;90:28–33.
[2] León-Ruiz M, Benito-León J, Castañeda-Cabrero C. The electroencephalogram: a
complementary test that should not be forgotten to perform before a first seizure.
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28, 2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
Seizure: European Journal of Epilepsy 114 (2024) 96–97
[9] Llauradó A, Santamarina E, Fonseca E, Olivé M, Requena M, Sueiras M, et al. How
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Moisés León-Ruiza,*, Julián Benito-Leónb,c,d,e, Carlos Castañeda-
Cabreroa
a
Section of Clinical Neurophysiology, Department of Neurology, La Paz
University Hospital, Paseo de la Castellana, 261, Madrid 28046, Spain
b
Department of Neurology, 12 de Octubre University Hospital, Madrid,
Spain
c
Research Institute (i+12), 12 de Octubre University Hospital, Madrid,
Spain
d
Department of Medicine, Faculty of Medicine, Complutense University of
Madrid, Madrid, Spain
e
Centro de Investigación Biomédica en Red Sobre Enfermedades
Neurodegenerativas (CIBERNED), Madrid, Spain
*
Corresponding author.
E-mail address: pistolpete271285@hotmail.com (M. León-Ruiz).