Shinshu Med J, 72⑴：39～47, 2024

Demographic and Clinical Characeristics of Seizures in Children at
Emergency Room Visits : A Single-Center Study
Masaru Nasuno, Tatsuya Kinoshita＊, Yusuke Moritani
Sachiko Nagaharu and Koichi Hirabayashi
Department of Pediatrics, Ina Central Hospital

Aim : This study aimed to evaluate the demographic and clinical characteristics of children who present to theemergency room with seizures and determine the etiology to appropriately treat these patients.
Methods : This hospital-based retrospective cohort study was conducted using data retrieved from the medical
records of 1600 seizure cases treated at the Emergency and Pediatric Departments of Ina Central Hospital fromJanuary 2010 to December 2019.
Results : Of the 1600 cases, 1248 (78 ％) were associated with fever and 1228 (98.3 ％) were diagnosed with febrile
seizures. Epilepsy was the most frequent cause of seizures without fever (75 ％). A total of 222 patients (17.3 ％)visited multiple times (maximum seven times). Complex febrile seizures increased the chances of being diagnosed
with epilepsy later. Six cases (0.3 ％ of all visits) were diagnosed with acute encephalitis/encephalopathy ;however, there were no cases of meningitis. Body temperature at the visit was significantly lower, whereas age
and previous occurrence of seizures were significantly higher in the epilepsy group with fever than in the febrile
seizure group. In contrast, the recurrent seizure frequency during the same episode was significantly higher in
the acute encephalitis/encephalopathy group than in the epilepsy group without fever.
Conclusion : Clinical characteristics and backgrounds such as age, body temperature, seizure history and recurrent
episodes can be the important factors to predict the cause of seisures to ensure appropriate treatment of pediatricpatients experiencing seizures in an emergency outpatient department. Shinshu Med J 72 : 39―47, 2024
(Received for publication October 5, 2023 ; accepted in revised form November 28, 2023)
Key words : encephalitis, epilepsy, fever, meningitis, seizures

including children, many of whom are evaluated for

Ⅰ Introduction

seizures annually.

Childhood seizures are common and frightening dis-

FS is a common neurological disorder occurring inorders that occur in approximately 4 ％-10 ％ of chil-

2 ％-5 ％ and 7 ％-11 ％ of children (aged 6-60 months)

dren, accounting for 1 ％ of all emergency depart-in the United States and Western Europe2）-5） andment visits1）. Several neurological disorders, including

Japan6）7）, respectively5）. It is also reported as the mostfebrile seizure (FS), epilepsy, acute encephalitis/en-

common disorder in children in out-of-hospital andcephalopathy, traumatic head injury, and gastro-

emergency department settings, with an incidence of1）enteritis, may cause pediatric seizures . Our hospital

38.5 ％-68.6 ％8）-10）. Although almost pediatric seizure

locating in the Kami-Ina area, Nagano, Japan has anpatients have good neurological and developmental

emergency department that treats patients of all ages

prognoses, serious diseases which need prompt diag-＊

Corresponding author : Tatsuya Kinoshita
Department of Pediatrics, Ina Central Hospital,1313-1, Koshirokubo, Ina, Nagano 396-8555, Japan
E-mail : ta-kino@inahp.jp

No. 1, 2024

nosis and intensive care, such as central nervous system infections, including acute meningitis and encephalitis/encephalopathy, should be identified. On
the other hand, no study has reported analyzing pe39

Nasuno・Kinoshita・Moritani et al.

diatric seizures using a large number of cases forzures occurring ＞24 h apart and 2) one unprovoked

years. Therefore, clarification of the clinical differenc-

seizure and probability of further seizures similar toes for each seizure by statistical analysis of a large

the general recurrence risk11）. We defined acute en-number of patients is important especially in out-of-

cephalitis/encephalopathy as a condition with acutehospital and emergency department settings.

onset of impaired consciousness lasting more than 24

Because our hospital is the only center providing

h. Benign convulsion with mild gastroenteritis (CwG)

emergency medical care 24 h a day, 365 days a year

is a clinical condition characterized by seizures oc-

in the Kami-Ina area which has approximately 25,000

curring in otherwise healthy children, usually with-children (＜15 years old), most pediatric patients fromout high fever and with mild acute gastroenteritis12）.

this area are brought here by ambulance or theirCwG was diagnosed when a patient met these criteria :guardians. Here, we report the prevalence of various

1) seizure associated with gastroenteritis without

seizure etiologies in children who visited the emer-

clinical signs of dehydration or electrolyte derange-

gency and pediatric departments at Ina Central Hos-

ment and 2) body temperature ＜38 ℃ before andpital during past 10 years.

after seizures. Breath-holding spells are episodes

Ⅱ Methods
This retrospective hospital-based cohort study included all pediatric seizure patients aged ＜15 years
treated at the Emergency and the Pediatric Depart-

where infants excessively cry for up to 1 min while
holding their breath to the point of losing consciousness, with a seizure occurring immediately after13）.
Ⅲ

Statistical Analysis

ments of Ina Central Hospital in Ina, Japan (January

Patient and disease characteristics in all cohorts

2010-December 2019). The study was approved by thewere summarized using descriptive statistics. Com-institutional ethics committee of Ina Central Hospital.

parisons of demographic and clinical data between

We collected demographic and clinical data andthe groups were performed using Fisher’s exact test

history from the electronic medical records of Ina

for categorical variables. Student’s t or Mann-Whitney

Central Hospital. Each seizure diagnosis was based

U tests were used to assess the significance of differ-on the discharge diagnosis or retrospectively identi-

ences for continuous variables. Statistical analysis

fied by reviewing case histories and reported clinicalwas performed using EZR14）, a modified version of R

findings. Status epilepticus was defined as a single

commander designed to add frequently used statisti-

seizure lasting over 30 min or repeated seizures with-

cal functions in biostatistics. All reported p-values

out full consciousness recovery between ictal eventswere 2-sided and considered significant if ＜0.05.

11）

in more than 30 min . FS was defined as a seizure
accompanied by fever (temperature ≥ 38 ℃) without

Ⅳ Results

a central nervous system infection occurring in infants

Table 1 shows the entire cohort’s demographic andand children aged 6-60 months5）. In this study, evenclinical characteristics. Our hospital received 1600

if they were ＞60 months old and fit the definition of

seizure cases (890 males [55.6 ％ ] and 710 females

FS, except for age, they were defined as FS patients.

[44.4 ％], 1285 patient visits) within the cohort period.

Simple FS lasts for ＜15 min, is initially generalized,

The median patient age was 28 months (0-179 months).

and occurs once during 24 h. In contrast, complex FS

Overall, 80 ％ of patients were aged ＜5 years ; thelasts ≥ 15 min, has focal features at any time, andlargest number being patients aged 1 year (Fig. 1). A

recurs within 24 h. “Fever” was also considered re-seizure history was found in 580 (36 ％) patients. Al-

gardless of body temperature at admission if the bodythough 841 (52.6 ％) patients used ambulances, only

temperature before the seizure was ≥ 38 ℃. Epilepsy

64 (4 ％) had persistent seizures at the time of arrival.

was defined as a neurological disease with any of the

Fever was associated with seizures in 1248 patients

following conditions : 1) at least two unprovoked sei-

(78 ％ ) ; the remaining 352 (22 ％ ) were non-febrile.

40

Shinshu Med J

l. 72

Clinical characteristics of emergency room seizures in children
Table 1

Clinical characteristics of subject

Parameters

N＝1600Median age at seizure, months (range)
Sex
Male
FemalePast history of seizure
FS
OthersUse of ambulance
Seizure at admission
Fever
Median duration of seizure, min (range)
Status epilepticus
Recurrent seizure during same episode
Emergency use of anticonvulsantsi.v. diazepam
i.v. midazolam
Suppository diazepam
OthersUse of suppository diazepam after seizure
OutcomeNot hospitalized
Hospitalized in our hospital
Transferred to advanced hospitals with pediatric intensive care unit

28 (0-179)
890 (55.6)
710 (44.4)
580 (36.0)
369 (23.4)
201 (12.6)
841 (52.6)
64 (4.0)1248 (78.0)
2 (1-120)
50 (3.2)
191 (11.9)
103 (6.4)
46 (2.9)
14 (0.9)38 (2.4)
5 (0.3)1241 (77.6)
1297 (81.1)
280 (17.5)
23 (1.4)

Data presented are number (％) unless otherwise indicated.
i.v., intravenous

Fig. 1 Age distribution of children with seizures
The number of seizure patients in 1-year age groups. Peaks of age at seizure onset are seen at 1 year in the fever andno fever groups. The number of seizure patients in the with fever group decreases with age, and there are few patients
aged over 8 years. There are an almost even number of seizure patients from age 2 to 14 years in the no fever group.
No. 1, 2024

41

Nasuno・Kinoshita・Moritani et al.
Table 2
Final diagnosis
Febrile seizure
SimpleComplex
Epilepsy
CwG
Breath-holding spell
Acute encephalitis/encephalopathy
Brain tumor
Cerebrovascular disorder
Others†Final diagnosis of subjects
Total (N＝1600)

Fever (N＝1248)

Without fever (N＝352)

n (％)

n (％)

n (％)

1228 (76.8)
1042 (65.1)
186 (11.6)
282 (17.6)
41 (2.6)
20 (1.2)
6 (0.4)3 (0.2)1 (0.1)1228 (98.4)
1042 (83.5)
186 (14.9)
18 (1.4)00
2 (0.2)000264 (75.0)
41 (11.6)
20 (5.7)
4 (1.1)3 (0.9)1 (0.3)19 (1.2)

019 (5.4)†Others include hypoglycemia, hypocalcemia, after head injury, after suffocation, and neurally-mediated syncope.
CwG, benign convulsions with mild gastroenteritis.

The median seizure duration was 2 min, and 50 pa-

with acute encephalitis/encephalopathy, no meningi-

tients (3.2 ％) were treated as status epilepticus. Ad-

tis case was detected. Fig. 2 shows the number ofditionally, 191 (11.9 ％) patients experienced repeatedpatients according to the visit frequency across all

seizures during the same episode. Although only 106

patients and FS and/or other diagnoses ratio for each

(6.4 ％) patients were administered with acute anti-

number of visits. In 1600 cases, 1063 patients visited

convulsant drugs to control seizures, suppository

once owing to seizures. However, 222 patients visiteddiazepam was used after seizures in 1241 (77.6 ％ )multiple times (maximum seven). Although FS oc-

patients to prevent subsequent seizures. After emer-

curred majorly in patients who only visited once, thegency management at the emergency or pediatricincidence of epilepsy among seizures increased indepartment, 1297 (81.7 ％) patients were not hospital-patients who visited multiple times, especially in

ized, 280 (17.5 ％) were hospitalized in our hospital,

those who visited ≥ 3 times. Table 4 shows the de-and 23 (1.4 ％) were transferred to advanced hospi-

mographic and clinical characteristics of FS intals with pediatric intensive care units.

patients grouped according to whether they had de-Table 2 shows the final diagnoses of the patients.

veloped epilepsy until at least 5 years of age ; the tar-

FS was the most common cause (76.8 ％), followed by

get was patients born before December 31, 2014 (n＝epilepsy (17.6 ％) and benign CwG (2.6 ％). FS account-926). Complex FS incidence was significantly higher

ed for 98.4 ％ of cases with fever, whereas epilepsy

in the group where FS later developed into epilepsy

accounted for 75 ％ of cases without fever. Among

than in the group where FS did not develop into epi-

the 1228 cases with FS, 186 (15.1 ％) showed complex

lepsy (p＝0.031), whereas sex, age, body temperature,

FS patterns. Six cases (0.3 ％) were diagnosed withseizure duration, and seizure recurrence during theacute encephalitis/encephalopathy (Table 3) ; of these,same episode were not significantly different be-

only two cases diagnosed as mildly encephalitic/en-

tween the two groups.

cephalopathic with reversible splenial lesion (MERS)

Table 5 shows a comparison of the clinical data ofpresented with fever, and no cases presented withpatients with FS and epilepsy with fever at visit. The

status epilepticus. However, five of the six patients

median body temperature was significantly higher inshowed repeated seizures, and all experienced im-

the FS group (39.4 ℃ vs. 38.75 ℃, p＜0.001). In con-paired consciousness. Furthermore, magnetic reso-

trast, the median seizure age and the presence ofnance imaging (MRI) showed significant findings inpast histry of seisures were significantly higher

three cases, leading to diagnoses. In contrast to casesin the epilepsy group (25.0 months vs. 103.5 months,

42

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Clinical characteristics of emergency room seizures in children
Table 3

Detail of clinical data in 6 patients with encephalitis/encephalopathy

Durationof first
seizure(minutes)

Loss of
NumberCSF
consciousnessoffindings on
at admission :seizuresadmission
GCS

Brain MRI
results

Final
diagnosis

Past history

notexamined

splenic lesion†

MERS

FS

E4V4M6

normalsplenic lesion†

MERS

None

3

E4V4M5notexaminedbright tree
appearance inwhite matter

AESD

FS

1

1

E4V4M5normalnormalunclassified
acuteencephalopathy encephalopathy

－

1

3

E4V4M6

WBC 32/μL

normalnon-herpetic
lymbicencephalitis

None

－

1

6

E4V4M6notexamined

normalnon-herpetic
lymbicencephalitis

FS

No.

Age

Sex Fever

1

1y11m

M

＋

1

13

E4V4M6

2

3y8m

M

＋

1

10

3

3y11m

M

－

2

4

5y6m

F

－

5

12y1m

F

6

12y10m M†high-signal-intensity on DWI in the midline of the splenium of the corpus callosumy, years ; m, months ; GCS, Glasgow Coma Scale ; CSF, cerebral spinal fluid ; MRI, magnetic resonance imaging ;F, female ; M, male ; WBC, white blood cells ; DWI, diffusion-weighted images ; MERS, mild encephalitis/encephalopathy
with a reversible splenial lesion ; AESD, acute encephalopathy with biphasic seizures and late reduced diffusion.

Fig. 2 Distribution of the number of visits and each diagnosis
The number of visits ranges from 1 to 7 times ; 1063 of 1285 patients visited our emergency room only once. In the image,① indicates the group of febrile seizure diagnoses only, ② indicates the group of diagnoses of febrile seizure and epilepsy,③ indicates the group of epilepsy diagnoses only, and ④ indicates the group of other diagnostic combinations.

No. 1, 2024

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Nasuno・Kinoshita・Moritani et al.
Table 4

Clinical characteristics of patients with FS according to whether they exhibited or not epilepsy
FS only

FS later developed(N＝902)

epilepsy(N＝26)

Sex(male/female)
Body temperature at visit (℃), mean ± SD
Age at seizure (months), mean ± SD
Duration of seizure, minutes†

529/373
39.34 ± 0.87
34.78 ± 21.99

13/13
39.26 ± 0.74
28.85 ± 15.85

2.0 [1, 4]

2.5 [1, 5]

0.385

Recurrence of seizures during same episode‡79 (8.8)
109 (12.1)

2 (7.7)7 (26.9)

1.000
0.031

Complex FS‡

p-value
0.422
0.670
0.172

† median [25 ％, 75 ％], ‡ number (％), SD, standard deviation.

Table 5Comparison between FS and epilepsy with fever at visit
Febrile seizure(N＝1228)

Epilepsy(N＝18)

p-value

39.37 ± 0.85
31.63 ± 20.25

38.81 ± 0.57
96.72 ± 41.99

0.005＜0.001380 (30.9)

17 (94.4)＜0.001

2 [1, 5]

3 [1, 5]0.200

Recurrence of seizures during same episode‡124 (10.1)

3 (16.7)

0.418

Use of anticonvulsants‡

30 (2.4)

2 (11.1)

0.076

Body temperature at visit (℃), mean ± SD
Age at seizure (months), mean ± SD
Past history of seizures‡
Duration of seizure, minutes†† median [25 ％, 75 ％], ‡ number (％), SD, standard deviation.

Table 6Comparison between epilepsy and acute encephalitis/encephalopathy without fever at visit

Age at seizure (months), mean ± SD
Past history of seizure‡
Duration of seizure, minutes†
Recurrence seizures during same episode‡Use of anticonvulsants‡

Epilepsy(N＝264)

Acuteencephalitis/encephlopathy
(N＝4)

p

86.60 ± 50.76

103.00 ± 54.38

0.522

154 (58.3)

3 (75.0)

0.644

3 [1, 5.5]
36 (13.6)

1 [1, 1.5]
3 (75.0)

0.138
0.010

30 (11.4)

1 (25.0)

0.390† median [25 ％, 75 ％], ‡ number, (％), SD, standard deviation.

p＜0.001 ; 94,4 ％ vs. 30.9 ％, p＜0.001, respectevely).

seizure duration, and anticonvulsant use did not

However, the differences in the median seizure dura-

reach statistical significance.

tion and proportion of cases with seizure recurrence
during the same episode between the two groups

Ⅴ

Discussion

were not statistically significant. Table 6 presents a

We analyzed the characteristics of 1600 pediatriccomparison of the clinical data of patients with epi-

seizure cases admitted to the emergency and pediat-

lepsy and acute encephalitis/encephalopathy without

ric departments. To the best of our knowledge, nofever at visit. The recurrent seizure frequency during

study has analyzed pediatric seizures using such a

the same episode was higher in the acute encephali-large number of cases over the past 10 years.

tis/encephalopathy group than in the epilepsy group

Overall, 1285 patients, representing 5.4 ％ of the(75 ％ vs. 13.6 ％, p＝0.010). The median seizure age,

population aged ＜15 years in our medical block44

Shinshu Med J

Vol. 72

Clinical characteristics of emergency room seizures in children(Kami-Ina area, Nagano Prefecture), visited our hos-fever, suggesting that acute encephalitis/encephalop-

pital owing to seizures in 10 years, although this mightathy cannot be ruled out even if fever is not followed

be a little higher because of some patients who wereby seizures. Although long-lasting seizures were nottreated by family physicians. Similar to previous re-present in these six cases, seizures occurred ≥ thrice

ports, FS was the most frequent cause of seizures inin five cases, and all patients showed mildly impaired

patients admitted to the emergency and pediatricconsciousness. Nishiyama et al.21） reported that 9.1 ％departments, accounting for a higher proportionof 120 status epilepticus cases had acute encephali-of all seizures (76.8 ％ ) in our study than in othertis/encephalopathy, and in Japan, status epilepticus

9）studies. Studies conducted by Berksoy et al. , Abbasi
10）8）

is considered a risk factor associated with developing

et al. , and Ojha et al. reported 38.5 ％, 46.8 ％, andacute encephalitis/encephalopathy. Our results indi-

68.6 ％ of children with FS in Turkey, Pakistan, andcate that seizure recurrence, in addition to seizure

Nepal, respectively. The high FS rate in our study

duration, is also an important factor in patients withmay be because FS incidence is higher in East Asia,

impaired consciousness for predicting acute encepha-especially in Japan, than in European countries2）-7）.

litis/encephalopathy and is an important factor for

Consistent with previous findings that simple FS ac-

deciding whether to perform additional neurological

5）
15）
16）

counts for 80 ％-85 ％ of FS, approximately 85 ％tests, such as MRI and electroencephalography. We

of FS were simple FS in our study. Furthermore,

further analyzed several statistical differences toour data indicated that complex FS is associated withclarify the factors essential for distinguishing epilep-

the risk of developing epilepsy later, consistent withsies from FS in cases with fever and found signifi-

17）
18）

previous findings. Additionally, epilepsy was thecant differences in body temperature, age, and history,

most frequent cause of seizures in cases without

whereas seizure duration and recurrence showed no9）

fever, which was according to previous findings .

significance. These findings indicate that patients with

However, our data showed that 17.3 ％ of patients

relatively low fever, older age, and past seizures are

visited multiple times who showed a higher chancemore likely to be diagnosed with epilepsy than FS. In

of being diagnosed with epilepsy. These data are im-contrast, in cases without fever, seizure recurrence

portant for treating patients with a seizure history.

during the same episode was more significant for dis-

Notably, although FS accounted for 98.4 ％ of cases

tinguishing acute encephalitis/encephalopathy fromwith fever, no case was diagnosed as meningitis. The

epilepsy compared with age and history. These find-wide use of Haemophilus influenzae type b (Hib) andings have never been reported previously and will

pneumococcal conjugate vaccines since 2010 might

greatly help in treating pediatric seizure patients.

have reduced the overall incidence of bacterial men19）

Our study has some limitations, mainly due to its

ingitis in Japan . We encountered ≥ 10 meningitis

retrospective nature in a single institution. First, be-cases, including several with acute purulent meningi-

cause most of the included children were lost to follow-

tis, during the cohort period, although seizure did not

up after their seizure episodes, their long-term prog-

accompany any on admission. The American Acade-nosis was not fully evaluated. Epilepsy might develop

my of Pediatrics does not recommend performing

in more children with seizures than reported here.

routine evaluation with neuroimaging, electroenceph-

Second, as not all patients underwent neuroimaging,

20）

alography, and electrolyte serum tests for simple FS .

electroencephalography, or lumbar punctures, someOur data indicate that seizures are not necessarily

patients with clinically diagnosed FS might have had

essential symptoms directly leading to meningitis

a mild central nervous system infection.

diagnosis by themselves when treating outpatient

Taken together, our study showed that under-

children with fever. However, six cases diagnosed as

standing the patient demographics and assessing

acute encephalitis/encephalopathy were detectedpatient backgrounds and clinical characteristics willamong all our patients, wherein only two cases had

help us to predict the cause of seizures for providing

No. 1, 2024

45

Nasuno・Kinoshita・Moritani et al.

more appropriate treatment and avoiding unneces-Acknowledgmentssary examinations.
Ⅵ

We sincerely thank Yuji Inaba, MD, PhD (a director

Conclusionof the Division of Neuropediatrics in Nagano children’s

We evaluated seizures in a sizable number of chil-

Hospital, Azumino, Japan) for checking this manuscript

dren, revealing a higher rate of FS in cases withand providing us with various valuable comments

fever and epilepsy as the major cause of seizures inand suggestions.
The authors would like to thank Enago (www.enago.

cases without fever. We also revealed several new
findings. First, patients with complex FS or visitedjp) for the English language review.

multiple times have a higher chance of being diagnosed with eplepsy. In adission, in the case of pa-

Approval of the research protocol : This study wastients with fever, relatively low fever, older age, andapproved by the institutional ethics committee of Ina

past seizures are more likely to be diagnosed with

Central Hospital (No. 20-21) on October 21, 2020, andeplilepsy than FS. Furthermore, in the case without

was performed according to the ethical guidelines offever, seizure recurrence during the same episodethe Declaration of Helsinki.

was more significant in acute encephalitis/encepha-

Informed consent : The institutional ethics committee

lopathy as compared with eplilepsy.

of Ina Central Hospital waived informed consent because we collected and analyzed demographic andclinical data in an anonymized manner
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（2023. 10. 5 received ; 2023. 11. 28 accepted）

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