Staring spells in children: Descriptive features distinguishing epileptic and nonepileptic events

doi:10.1016/S0022-3476(98)70108-8

The Journal of Pediatrics

Volume 133, Issue 5, November 1998, Pages 660-663

https://doi.org/10.1016/S0022-3476(98)70108-8 Get rights and content

Abstract

Objective: To identify questions sensitive and specific for staring spells of epileptic (absence seizures [AS]) or nonepileptic etiology to increase the yield of history taking. Study design: A questionnaire was completed by parents of 40 children who presented with staring spells. Results from 17 children with AS and 23 with nonepileptic staring (NES) were compared. Results: Features with moderate sensitivity (43% to 56%) but high specificity (87% to 88%) for NES included preserved responsiveness to touch, lack of interruption of playing, and initial identification by a teacher or health professional. These features were more frequent in NES than in AS (P = .013, .016, .030). Body rocking occurred only in NES, but sensitivity was low (13%). Features with high specificity (91% to 100%) for AS included limb twitches, upward eye movements, and urinary incontinence; but sensitivities were low (13% to 35%). Conclusion: In children with normal interictal electroencephalography findings and without neurologic disease, staring spells are most likely nonepileptic when parents report preserved responsiveness to touch, body rocking, or initial identification by a teacher or health professional without limb twitches, upward eye movements, interruption of play, or urinary incontinence. In these cases a diagnosis of NES may be confidently applied, with confirmation based on long-term follow-up. (J Pediatr 1998;133:660-3)

Section snippets

Patients and Methods

We compiled a questionnaire with 25 questions based on observations from the literature*and our personal clinical experience. Questions explored features such as arrest of activity, unresponsiveness, eye blinking, upward eye rolling, myoclonic twitches, body stiffening, dropping of the head or jaw, complex movements or automatism, and body rocking. Questions also addressed age of onset, duration, and frequency of the staring spells; presence or

Results

The staring spells of the patients in both groups were characterized by a dazed or vacant facial expression with sudden onset and abrupt cessation. The stares lasted for several seconds, were associated with reduced interaction and responsiveness, and were not preceded by a warning or aura. No differences between children with AS and those with NES were detected by questions exploring these features.

For children with NES compared with those with AS, there were no significant differences in age

Discussion

We found that in children with normal interictal EEG findings and without other seizure types or neurologic abnormalities (except mild cognitive delay or learning problems), staring spells were highly likely to be nonepileptic when parents reported preserved responsiveness to touch, no interruption of playing by the stares, or initial identification of the stares by a teacher or health professional rather than by a relative. Body rocking occurred only in NES, but sensitivity was low. On the

References (22)

P Kotagal et al.
Psychomotor seizures of temporal lobe onset: analysis of symptom clusters and sequences
Epilepsy Res
(1995)
P Desai et al.
Nonepileptic events in normal and neurologically handicapped children: a video study
Pediatr Neurol
(1992)
MS Duchowny et al.
Video EEG diagnosis of repetitive behavior in early childhood and its relationship to seizures
Pediatr Neurol
(1988)
L Carmant et al.
Differential diagnosis of staring spells in children: a video-EEG study
Pediatr Neurol
(1996)
SF Berkovic
Generalized absence seizures
PL Pearl et al.
Absence seizures
RO. Carpenter
School failure
RJ. Porter
The absence epilepsies
Epilepsia
(1993)
AM Bye et al.
Complex partial seizures in young children
Epilepsia
(1994)
V Salanova et al.
Frontal lobe seizures: electroclinical syndromes
Epilepsia
(1995)

SS Ho et al.

Parietal lobe epilepsy: clinical features and seizure localization by ictal SPECT

Neurology

(1994)

Cited by (43)

Paroxysmal Disorders
2018, Nelson Pediatric Symptom-Based Diagnosis
Utility of long-term video-EEG monitoring for children with staring
2017, Epilepsy and Behavior
Citation Excerpt :
Other studies have shown that other factors are important. These include the presence of an aura, frequency of the staring spells, preserved responsiveness to touch, lack of interruption of play, body movement, eye movements, and urinary incontinence [5,6]. Other differences in our study compared to these are likely to be due to different patient populations and clinical practices in different centers and perhaps different decades.
Staring spells are a common reason for referral to overnight epilepsy monitoring unit (EMU) evaluation. However, inpatient EMU admissions are expensive and time consuming. This study determined what percentage of those referred for staring had a confirmed epileptic seizure on long-term video-EEG monitoring (LTM) and developed a scoring system to help prioritize which patients should undergo this procedure.
We performed a four-year retrospective chart review of all children at a tertiary pediatric hospital who received LTM (long-term monitoring) for the purposes of characterizing staring. The two goals were to: a) assess how often an LTM admission captured a staring spell that was diagnosed as a seizure and b) determine if any baseline factors predicted this particular positive result. We coded several characteristics of the most recent prior routine EEG if available. We also coded parental reports of the duration, frequency, and breakability of the events as well as post-ictal mental status and the presence/absence of automatisms. Finally, we coded previous neurological and psychiatric diagnoses and medications, as well as family history of epilepsy.
Of the 276 admissions, only 29 (11%) captured a staring spell and diagnosed it as seizure. Several baseline variables predicted the likelihood of this positive result. Based on this information, we created a scoring system as follows: − 3 points if the previous EEG was normal, − 1 point if the child took a medication for a psychiatric condition, + 1 point if the child took an anti-epileptic drug for epilepsy, and + 1 point if the spells lasted less than 1 min. If the total score was zero or less, staring spells diagnosed as seizures rarely occurred (less than 5% of the studies).
Our scoring system shows how consideration of prior EEG findings, medication history, and staring spell duration can help prioritize patients for LTM admission to evaluate if staring spells are epileptic seizures.
Paroxysmal Disorders
2017, Nelson Pediatric Symptom-Based Diagnosis
Epilepsy, Diagnosis of
2014, Encyclopedia of the Neurological Sciences
Epilepsy implies an enduring tendency to have seizures. Pragmatically, the diagnosis of epilepsy may be made when there have been two or more unprovoked seizures. Seizures may be provoked by many acute brain disturbances (e.g., fever or immediately after head trauma) and provoked seizures are more common than unprovoked seizures that typically come ‘out of the blue.’ There are a variety of seizure types that may be confused with other disorders. In particular, the following symptoms may be seizures or have other causes – loss of consciousness, staring spells, short or long episodes of confusion, body jerks, paroxysmal events during sleep, decreased speech, and decreased social interactions. The history of these events is the only way to make the diagnosis of epilepsy, and medical investigations are typically not definitive.
Modes of onset of epilepsy and differential diagnosis
2013, Handbook of Clinical Neurology
Citation Excerpt :
Habitual staring is a universal experience but sorting out absence seizures from simple “tuning out” may occasionally be challenging. A study from Cleveland explored the likelihood that a child assessed for staring spells would have absence seizures (Rosenow et al., 1998). There were 40 children, 17 of whom were eventually diagnosed as having absence seizures and 23 had “nonepileptic staring.”
Epilepsy has protean manifestations and may be diagnosed when two unprovoked seizures have occurred. This determination is nearly always based on the available history because most seizures have stopped long before patients arrive at medical care. Great care must be taken, even by experts, to correctly interpret the history and there is strong evidence that incorrect diagnoses are frequent. An abnormal EEG cannot rule epilepsy in or out unless an actual seizure is recorded. When the diagnosis of epilepsy is based only on two seizures, the seizures are usually generalized tonic–clonic. Less “severe” seizure types usually occur multiple times before prompting a medical visit. Some patients present with what seems to be a first generalized tonic–clonic seizure but have a history of less severe attacks that have not brought them to medical attention – epilepsy can then be diagnosed. Others present with staring spells, episodes of confusion, body jerks, spasms, drops, loss of speech and social interactions and/or cognitive function, paroxysmal events during sleep, and febrile seizures. This chapter examines and considers the differential diagnoses for each of these modes of presentation. The consequences of a missed alternate diagnosis, such as cardiac arrhythmia, may be profound.
Psychogenic nonepileptic seizures
2013, Handbook of Clinical Neurology
Citation Excerpt :
As noticed earlier, PNES presenting as unresponsiveness are possibly more frequent in school age children (Patel et al., 2007). Rosenow et al. (1998) noticed that a preserved responsiveness to touch, lack of interruption of playing, and initial identification by teacher or health professionals instead of parents had a high specificity (though moderate sensitivity) for inattention or day dreaming in patients with normal interictal EEG. Limb twitches, upward eye movements, and urinary incontinence had a high specificity but low sensitivity for epileptic absences.
Psychogenic nonepileptic seizures (PNES) are clinical events resembling epileptic seizures but lacking abnormal cortical electrical discharges. They are involuntary manifestations of a psychological distress. PNES are less frequent in the pediatric population than in adults, they represent from 3.5 to 9% of patients admitted for prolonged video-EEG (PV-EEG). Diagnosis is rarely made on history only and PV-EEG is mandatory to obtain a definitive diagnosis. Children as young as 5 years can present with PNES. They are more frequent in girls except in school age children where boys are identically or more represented than girls. PNES can either present with subtle signs, even unresponsiveness, or prominent motor activity. Major differential diagnosis is absences, day dreaming, and complex partial seizures including hyperkinetic frontal seizures. PNES are usually rapidly registered during PV-EEG and provocative methods have not been thoroughly studied in children. Major risk factors are psychological stressors, such as school or family problems. Psychiatric conditions are less frequent than in adults though they should be looked for. Prognosis is better than in adults, and most children become PNES-free. There are no guidelines for treatment, however stressors should be addressed. In general, it should be clearly explained that PNES are not epileptic seizures.

View all citing articles on Scopus

^☆: From the Department of Neurology, The Cleveland Clinic Foundation, Cleveland, Ohio. Drs Rosenow and Hamer are now at the Neurologische Universitätsklinik, Marburg, Germany.

^☆☆: Reprint requests: Elaine Wyllie, MD, Department of Neurology, S51, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195.

^★: 0022-3476/98/$5.00 + 0 9/21/94315

View full text

Staring spells in children: Descriptive features distinguishing epileptic and nonepileptic events☆,☆☆,★

Abstract

Section snippets

Patients and Methods

Results

Discussion

Epilepsy Res

Pediatr Neurol

Pediatr Neurol

Pediatr Neurol

Generalized absence seizures

Absence seizures

School failure

The absence epilepsies

Epilepsia

Complex partial seizures in young children

Epilepsia

Frontal lobe seizures: electroclinical syndromes

Epilepsia

Parietal lobe epilepsy: clinical features and seizure localization by ictal SPECT

Neurology