Do Children Need to be Treated After Their First Tonic-Clonic Seizure?

ABSTRACT & COMMENTARY

Synopsis: More than 20 children with newly diagnosed unprovoked tonic-clonic seizures were followed for up to two years. Many of these children had a "decelerating disease process" and became seizure-free without anticonvulsant therapy.

Source: Van Donselaar CA, et al. Clinical course of untreated tonic-clonic seizures in childhood. Prospective hospital based study. BMJ 1997;314:401-404.

Two hundred four children aged 1 month to 16 years were seen in four hospitals in the Netherlands because of recent onset, unprovoked tonic-clonic seizures. They were followed until anticonvulsant therapy was started (78), until the occurrence of four untreated seizures (45), or for two years without treatment.

A "decelerating pattern" was frequently seen, although in 110 children the disease process could not be characterized because of initiation of therapy after one or more seizures. A decelerating pattern was found in 83 of 85 children who became seizure-free (42%) without therapy. Although untreated epilepsy is often considered to be a progressive disorder with decreasing intervals between seizures, a large proportion of children have a decelerating disease process. The fear that tonic-clonic seizures commonly evoke into a progressive disease should not be used as an argument in favor of early drug treatment in children with epilepsy.

COMMENT BY RICHARD S.K. YOUNG, MD, FAAP

This is a hospital-based study of 204 children with tonic clonic seizures. Van Donselaar and colleagues studied whether the pattern of subsequent seizure was "accelerated" or "decelerated." Although this is an important clinical issue, this paper unfortunately does not provide definitive results.

Van Donselarr and associate neurologists at four hospitals in the Netherlands begin with the premise that "untreated epilepsy may be thought of as a progressive disorder." This is a "straw man" argument, as I do not believe many neurologists would agree with this description. Indeed, most studies show that seizure disorders in children are often self-limited.1

Van Donselaar et al studied all children aged 1 month to 16 years presenting with a first unprovoked tonic/clinic-like seizure. This is mixing apples and oranges. The prognosis of seizures in children younger than 2 years differs markedly from that of children older than 2 years. In addition, Van Donselaar et al lumped together both focal onset and generalized seizures. Again, prognosis is substantially different in these two groups.

Unfortunately, the likelihood of seizure recurrence after a single, nonfebrile seizure remains uncertain. A number of studies have examined this question, but methodological problems preclude a clear answer. Non-random treatment with anticonvulsants (as occurred in the study) greatly confounds the outcome. In addition, patients presenting with their "first" seizure may have had prior seizures of which they may have been unaware. (Dr. Young is a pediatric neurologist and Chief of Pediatrics at the Hospital of St. Raphael, New Haven, CT.)

Reference

1. Hart RG, Easton JD. Seizure recurrence after a first, unprovoked seizure. Arch Neurol 1986;43:1289-1290.