A seizure is a discrete event with various manifestations while epilepsy (seizure disorder) is defined as a condition with recurrent seizures.1–4 The well-known Mayo Clinic study looking at the incidence of epilepsy in their area from 1935 to 1967 reported an incidence of newly identified epilepsy as 36 to 48/100,000/y in the 10 to 19 year age cohort.5 Various studies note that epilepsy affects approximately 1% to 2% of the general population and approximately 25% of those with epilepsy are younger than 18 years.3,5–7 The prevalence is 3 to 5/1000 adolescents while research notes the annual incidence of a seizure disorder is 24.7/100,000 10- to 14-year-old and 18.6/100,000 15- to 19-year-old. Thus, there are many children and youth with epilepsy who may be involved in sports.
Epilepsy may develop de novo in childhood at any time; thus, in adolescence, it may be a carryover from childhood or begin anytime in the adolescent years. Table 10-1 identifies various causes for epilepsy, but most cases are idiopathic in children and also in adolescents beginning younger than 16 years. As youths get older than 16 years of age, the possibility of a space-occupying lesion increases. Evaluation can also identify seizures because of head trauma, drug abuse, cerebrovascular accidents, central nervous system infections, pseudoseizures, cancer or adverse effects of cancer treatment, syncopal complications, sleep deprivation, hyponatremia, and others (Table 10-1).3,8 Juvenile myoclonic epilepsy and juvenile absence epilepsy are examples of epilepsy that begin in the adolescent years.9,10
Differential Diagnosis | Possible Precipitating Factors Idiopathic Seizures | Laboratory Evaluation* |
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A careful history and physical examination along with selected laboratory testing is necessary to identify the underlying cause of the new-onset seizure activity (Table 10-1).3,4 It is important to pay close attention to preseizure and periseizure events, overall development, family history of epilepsy, and history of injuries (including sports-related trauma, such as concussions). Fortunately, the injury sustained by most children and adolescents is not severe enough to lead to traumatic brain injury (TBI) or seizures. A careful description of the seizure and events surrounding it is useful in classifying the type of epilepsy that has developed.
If there is a history of fainting and vision reduction, syncope may be the cause of the unconsciousness and a concomitant reduction in blood pressure leading to the appearance of a pale facies. Pay close attention to the aura, that may have developed, eye or limb movements, duration of loss of consciousness (including reactions to pain or voice), and the presence or absence of incontinence. A thorough review of associated medical and psychologic factors is important in identifying a diagnosis of pseudoseizures, either as the only diagnosis or as concomitant with idiopathic epilepsy.
The physical examination includes blood pressure assessment, both standing and lying measurements to look for orthostatic hypotension. A thorough neurologic evaluation is important including auscultation for bruits (neck, orbits, and skull) while a dermatologic assessment may reveal clues for neurocutaneous syndromes. Body or extremity asymmetry may point to a chronic neurologic abnormality.
Chorea |
Dystonia following phenothiazine ingestion |
Gilles de la Tourette’s syndrome |
Hyperventilation |
Hysteria (pseudoseizure) |
Migraine headaches |
Narcolepsy |
Nightmares |
Night terrors |
Oculogyric crisis |
Tardive dyskinesia |
Vasomotor syncope |
Vertigo |
Table 10-1 lists diagnostic tests used to evaluate children and adolescents with seizure activity. Seizure types include partial seizures (simple partial, complex partial, or partial types that become secondarily generalized), generalized seizures (absence [including atypical types], myoclonic [versus myoclonic jerks], clonic, tonic, tonic-clonic, and atonic [astatic]), and unclassified types.3,11–14
The 16-channel electroencephalogram (EEG) is an adjunctive or confirmatory test in epilepsy diagnosis and is normal in some cases of epilepsy, as for example, in complex partial seizures or in some children with epilepsy as they enter puberty. It is the patient who is treated and not the EEG. The EEG, when performed, should be done with the child or adolescent awake and, if possible, asleep or sleep deprived, and during photic as well as hyperventilatory stimuli. Characteristic EEGs are noted in various seizure types, such as infantile spasms, absence seizures, or Lennox-Gastaut syndrome.3,4,9,10
Important imaging techniques include ultrasound, computed tomography (CT scan), and magnetic resonance imaging (MRI). The MRI is preferred over the CT scan to assess the spinal cord, brain stem, temporal lobe, and posterior fossa. Also, the MRI is preferred over the CT scan for assessing youth with seizures of probable focal onset. Brain mapping is an experimental and technically challenging diagnostic procedure that is of minimal proven value in epilepsy assessment. Also experimental are single-photon-emission computed tomography (SPECT)—blood flow and positron-emission tomography (PET)—glucose metabolism with EEG correlation.
There has long been concern that participation in sports would be detrimental to children and adolescent athletes.6 At one time, those with epilepsy were prevented from participation in many sports and many are less physically active than their nonepileptic peers.13 However, research has noted the beneficial aspects of exercise and sports in all athletes, including those with a chronic illness such as epilepsy.13,14 Reports of seizures worsening with exercise are rare and cases of sudden death during exercise are even rarer.7,15 There is no evidence that the stress of sports participation, increased breathing or hyperventilation associated with aerobic exercise, or injury resulting from sports (including contact or collision sports) will worsen the seizure pattern in an individual with epilepsy.6,13,14,16 Although concern about allowing children or adolescents with epilepsy to take part in swimming often arises, there is minimal support for concern for those in good control who are well-supervised, including using a peer to always be available (“buddy system”).1,13,14
The athlete should be in good seizure control and an adequate supervision is always important, especially in situations where a seizure could result in major injury, such as high diving, gymnastics with parallel bars, rope climbing, scuba diving, skydiving, and motor racing.7,13,16 Those not in good control need individual assessment to see which sports may be acceptable, depending on the type of seizure the athlete has and the specific sport being played.16 An individual with epilepsy is prohibited from becoming a pilot.14
Some experts have expressed concern when a seizure will injure not only the athlete, but also those who depend on him or her, such as in scuba diving, rope or mountain climbing, and others.13,14 Careful supervision is always necessary, but especially if the athlete is swimming, water skiing, horse riding, hang-gliding, parachuting, and involved in other high-risk activities.1,7,13 Those with mental retardation and developmental disabilities need careful supervision. Thorough discussion is important for the athlete and parents regarding theoretical risks.6 However, these risks should not be exaggerated. For example, a seizure-related drowning by one with epilepsy is more likely when alone taking a bath than being involved in a supervised swim meet.1,17
An impact seizure describes seizurelike activity that occurs within seconds following head trauma. It alone does not increase any risk for development of epilepsy. Head trauma, even repetitive trauma, from contact or collision sports has not been shown to induce epilepsy in one without this diagnosis, or to worsen by itself seizure patterns in someone with diagnosed but well controlled epilepsy.6,14 Thus, antiseizure medication is not necessary for someone with an impact seizure unless there is further evidence of idiopathic epilepsy.
Early posttraumatic epilepsy (PTE) is a disorder that may develop within 7 days of head trauma and results from acute, overt damage to the central nervous system. Later PTE develops over 7 days from head injury that causes CNS damage. PTE risk factors are noted in Table 10-3. PTE is acutely and chronically controlled with antiseizure medications. However, there is no link between head trauma in contact or collision sports and PTE except in unusual, anecedotal situations. Adequate sports equipment, including protection of the head and neck, is always recommended for any athlete involved in sports with increased risks for head or neck injury. If head trauma does seem to provoke seizures, avoidance of contact sports is then warranted.6 See the discussion of sports and concussions.