Question of the Week # 355

355)  A 6 year old boy is brought to your office with history of staring spells. He has had three such episodes in the past one month. His mother reports that during the episode he states blankly in to space for about two to three minutes. He does not respond to verbal commands during such episodes. The episodes are usually, followed by a period during which he is either confused or drowsy for about 30 minutes. On two such occasions, he reported unpleasant taste sensation prior to the staring spells. On examination, he appears comfortable and healthy. There are no physical abnormalities. Basic laboratory investigations including thyroid stimulating hormone are normal. Which of the following is the most appropriate diagnosis?

A) Attention Deficit Hyperactivity Disorder

B) Absence Seizures

C) Complex Partial Seizures

D) Simple Partial Seizures

E) Generalized Seizures

14 Responses

  1. B) absence seizures

  2. b

  3. The answer is B. Absence seizures

  4. B.Absent seizures

  5. B) Absence Seizures

  6. absence seizure

  7. b

  8. absence seizures

  9. Answer C.

    The differential diagnosis of Staring spells in children include Absence Seizures, Complex partial seizures and Non Epileptic Staring spells ( Day-Dreaming, Inattention spells)

    The patient has complex partial seizures as evidenced by loss of consciousness during the episode and preceded by aura and followed by post-ictal state. Symptoms of Complex partial seizures vary massively among the patients. When starting spells are the only manifestation of complex partial seizures, it is important not to get confused with Absence Seizures. Absence seizures are a type of generalized seizures – hence, they are not preceded by Aura and there is no post-ictal state. Also, Absence seizures are very brief lasting only for few seconds (15 to 30 seconds) unlike complex partial seizures that may last everal minutes . These features will help differentiate a “True” absence seizure from a complex partial seizure.

    Feature Absence ( petit-mal) Complex-Partial
    Duration 15 to 30 seconds Minutes ( up to 3 minutes)
    Aura Absent Present
    Post Ictal State Absent Present
    Consciousness Impaired Impaired

    Option A is incorrect. ADHD may be associated with staring spells of inattentiveness ( Pseudo-absences or Non-epileptic staring spells) which can be disrupted by tactile stimuli such as tickling or touching. Hand waving or vocal stimulation (calling his name) may not disrupt such spells but verbal or tactile stimuli certainly will. Even normal kids may have such non-epileptic staring spells which are referred to as Day-dreaming. These spells occur during periods of inactivity/ boredom and never occur during physical activity such as playing. There is no true loss of consciousness and there is no post-ictal type state.

    Option B is incorrect. See explanation above under Option A

    Option D is incorrect. Consciousness is preserved in Simple partial seizures and the patient is aware of the surroundings. These are called “AURA”. The patient did have an aura preceding these complex partial seizures.

    Option E is incorrect. A generalized seizure involves the whole cerebral cortex and is not preceded by Aura. An absence seizure is a type of generalized seizure. Generalized seizures can be differentiated in to tonic-clonic or absence types. A generalized tonic-clonic seizure is followed by post-ictal state but Absence seizure is not.

  10. How to answer this question?
    Let us start with very basic concept – Are Absence seizures focal or generalized? What features differentiate a partial seizure from generalized seizure? You are required to know these basic concepts so you can answer not just this question but many others in this topic.

    There are two broad types of seizures : generalized versus partial. Generalized seizures include Tonic-Clonic seizures and Absence seizures. Generalized means seizure involves the entire cortex when it starts unike partial seizure where only a portion of cortex is involved. When only a portion of cortex is involved the rest of the cortex is watching it – so, such partial seizure patients experience a subjective sensation or feeling or symptoms referred to as “Aura” . If the seizure involves the whole cortex, nothing left unaffected to watch and realize that aura feeling – so, True generalized seizures never have an Aura. Hence a reliable history of Aura differentiates Generalaized seizures from Partial seizures. Now, go back and look at the question again. Does this patient have Aura?

    Yes – he has unpleasant taste sensations prior to the attack. So, your classification should move to the word “PARTIAL” . Once you define it as Partial – IS IT SIMPLE OR COMPLEX? Simple means consciousness and awareness are preserved. Complex means the consciousness is lost.

    Now, Final answer :
    An aura represents a simple partial seizure, and a good history of aura confirms the seizure as partial and not generalized. The differential diagnosis of Staring Spells in children include a) Absence seizures b) Complex partial seizures c) Non epileptic staring spells. Absence seizures do not have aura ( like all generalized seizures) and do not have post ictal confusion. They last only for 15 to 30 seconds. A staring spell that is preceded by Aura and followed by post ictal state is a complex partial seizure and this one often lasts for few minutes. Simply put, presence of aura and post ictal state distinguish staring spells in complex partial seizures from True Absence seizures.

    • Thank u very much for clarifying this concept!! Much appreciated!!

    • Very helpful explanation! Thank you very much! But how can I get full Q-bank

  11. Thanks a million for the explanation 🙂
    In the beginning i answered B !
    but u made it very clear in a simple manner
    🙂 thannks again 🙂

  12. gud q

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