Epilepsy in children 2021
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This document discusses epilepsy in children, including types, clinical presentation, investigations, management, and complications. It provides an overview of seizure types and classifications, the etiology and syndromes of epilepsy in children, how epilepsy presents clinically and is evaluated, and guidelines for treatment and counseling to control seizures and prevent complications. Key aspects covered include acute seizure management, anti-epileptic medications, status epilepticus, and the potential neurological and developmental impacts of uncontrolled epilepsy.
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Epilepsy in children 2021
- 1. Epilepsy in Children Types, Clinical Presentation, Investigations, Management Prof. Imran Iqbal Fellowship in Pediatric Neurology (Australia) Prof of Paediatrics (2003-2018) Prof of Pediatrics Emeritus, CHICH Prof of Pediatrics, CIMS Multan, Pakistan
- 2. (God Almighty speaking to Prophet Muhammad (PBUH) The Rahman (The All-Merciful Allah) has taught the Qur‘an. He has created man. He has taught him (how) to express himself. The sun and moon are moving according to His (God) fixed plan The Holy Quran; surah Al-Rahman 55:1-4 In the name of Our Creator Allah, the most Gracious, the most Merciful
- 3. CNS
- 4. Brain
- 5. Our perceptions and Movements
- 7. CNS disease – Clinical Presentation • Seizures / Convulsions / Fits • Impaired Conscious level • Developmental delay • Intellectual handicap • Neurological Paralysis / Paresis (motor weakness ) • Neuromuscular disorders / Hypotonia • Movement disorders • Headache • Regression of acquired milestones • Behaviour problems
- 8. Seizures / Convulsions / Epilepsy Definition, Clinical Presentation, Etiology
- 9. Seizures Definition and Clinical Presentation • Seizure is a paroxysmal involuntary disturbance of brain function that may manifest as – • impaired conscious level, • abnormal motor activity, • behavioral abnormalities, • sensory disturbances • autonomic dysfunction
- 10. Convulsions Definition and Clinical Presentation • Convulsion is a generalized seizure with increased tone and tonic - clonic movements of the body
- 11. GTCS – (Generalized Tonic - Clonic Seizures) Clinical Presentation • Duration – seconds to hours • Loss of consciousness • Froth at mouth • Tonic stiffening of muscles • Clonic jerky movements of face / limbs • Enuresis • Sleep
- 12. Seizures in Children Etiology - Acute Symptomatic Seizures • Febrile Seizures (age 6 months to 5 years) • CNS infections (Meningitis / Encephalitis / Cerebral malaria) • Intracranial hemorrhage • Hypoglycemia / Electrolyte imbalance (Na,Ca,Mg) • Drugs / Chemical Poisoning / Encephalopathy • Trauma • Hypoxia • PNES (Psychological Non-epileptic Seizures) • Tetanus (spasms not seizures)
- 13. Seizures in Children Recurrent Seizures – Epilepsy • Epilepsy is a disorder of the brain characterized by an enduring predisposition to generate seizures • Epilepsy is seen in 5 per 1000 children • Epilepsy presents as recurrent seizures unrelated to fever or an acute cerebral insult
- 14. Epilepsy in Children Etiology Epilepsy in children has a genetic basis Epilepsy in children may be secondary to: Hypoxic-ischemic injury to Brain Cerebral Malformations Degenerative / Metabolic Brain diseases Epilepsy in children may be associated with: Cerebral palsy Intellectual disability / Mental handicap
- 15. Seizures in Children ILAE Classification 2017 International League Against Epilepsy
- 16. Classification of Seizures in Children ILAE Classification – 1981 • Partial Seizures (part of body affected) - Simple Partial Seizures (consciousness retained) - Complex Partial Seizures (consciousness lost) • Generalized Seizures (all of the body affected) - Generalized Tonic-clonic Seizures (grand mal epilepsy) - Myoclonic Seizures - Absence Seizures (petit mal epilepsy) • Unclassifiable seizures
- 17. Seizures in Children Focal vs Generalized Seizure Focal Onset Seizure Generalized Onset Seizure
- 18. Seizures in Children ILAE Classification – 2017 • Focal (Onset) Seizures: - Motor --- Aware --- Impaired Awareness - Non-motor • Generalized (Onset) Seizures: - Motor --- tonic-clonic (GTCS) --- myoclonic - Non-motor (Absence seizures) • Unknown Onset Seizures:
- 19. Seizures in Children ILAE Classification – 2017
- 20. Epilepsy in Children ILAE Classification 2017 International League Against Epilepsy
- 21. Unknown Immune Infectious Structural Etiology Metabolic Genetic Co-morbidities Epilepsy types Focal Generalized Combined Generalized & Focal Unknown Focal Epilepsy Syndromes Seizure types Generalized onset Unknown onset Focal onset
- 22. Seizure types ILAE Classification – 2017 • Focal (Onset) Seizures: - Motor --- Aware --- Impaired Awareness - Non-motor • Generalized (Onset) Seizures: - Motor --- tonic-clonic (GTCS) --- myoclonic - Non-motor (Absence seizures) • Unknown Onset Seizures:
- 23. Epilepsy types ILAE Classification – 2017 • Focal Epilepsy: --- Focal / Multifocal Seizures --- Focal EEG changes • Generalized Epilepsy : --- Generalized seizures, bilateral involvement --- Generalized EEG changes • Combined Generalized and Focal Epilepsy: --- Both Generalized and Focal seizures and EEG changes • Unknown Epilepsy type:
- 24. Epilepsy Syndromes ILAE Classification – 2017 • Epilepsy Syndrome refers to a combination of clinical features, seizure types, EEG findings, and imaging results that tend to occur together • Different Epilepsy Syndromes have typical age of onset, seizure types, EEG findings, co-morbidities, prognosis and management guidelines • Examples: --- CAE (Childhood Absence Epilepsy), --- JME (Juvenile Myoclonic Epilepsy) --- West syndrome (Infantile / Epileptic spasms)
- 25. Epilepsy in Children ILAE Classification 2017 • Seizure types – Focal (Onset), Generalized (Onset) • Epilepsy types – Focal, Generalized, Combined, Unknown • Epilepsy Syndromes – Infantile onset, Childhood onset, Adult onset • Etiology – Genetic, Structural, Infectious, Metabolic • Co-morbidities - Cerebral palsy, Intellectual disability, autism spectrum disorder
- 26. Unknown Immune Infectious Structural Etiology Metabolic Genetic Co-morbidities Epilepsy types Focal Generalized Combined Generalized & Focal Unknown Focal Epilepsy Syndromes Seizure types Generalized onset Unknown onset Focal onset
- 27. Epilepsy in Children Clinical Evaluation, Differential Diagnosis, Investigations
- 28. Epilepsy in Children Clinical Evaluation • History: • Seizures – Onset, Frequency, Duration, Progression • Seizure – Description, Video evaluation, Type • Present illness – any other symptoms • Birth History – hypoxia • Development history – milestones • Family History – epilepsy • Physical Examination: • General Physical Examination – all systems of body • Neurological Examination – Development, HMF, CN, Motor, Sensory, Skull and spine
- 29. Epilepsy in Children Differential Diagnosis • Breath – Holding Spells • PNES (Psychological Non-epileptic Seizures, Pseudoseizures) • Parasomnias (sleep disorders) • Tics • Movement disorders • Gratification disorder • Syncope (recurrent, cardiac or vascular causes)
- 30. Epilepsy in Children Diagnosis • Two unprovoked seizures occurring 24 hours apart • One unprovoked seizure and a probability of further seizures (based on) -- Neurological abnormalities -- EEG changes • Diagnosis of an Epilepsy syndrome
- 31. Epilepsy in Children Investigations • EEG – electroencephalography --- diagnosis of epilepsy --- classification of epilepsy --- diagnosis of epilepsy syndrome • Neuroimaging – CT / MRI Brain • Other investigations as needed • Genetic abnormalities (Whole genome sequencing)
- 32. EEG – Electroencephalography • EEG (electroencephalograph) is the record of electrical activity generated by the brain • EEG is obtained using electrodes placed on the scalp with a conductive gel • EEG is recorded on computer and printed on paper
- 33. EEG – Electroencephalography - Typical Findings Focal Epilepsy Generalized Epilepsy Absence Epilepsy Normal EEG
- 35. Epilepsy in Children Acute Complications of Seizures • Hypoxia and Hypercapnia • Hypoglycemia • Hyperpyrexia • Aspiration pneumonia • Shock • Raised ICP (Intracranial Pressure) • Physical injuries • Hypoxic-Ischemic Brain Injury • Status epilepticus
- 36. Epilepsy in Children Long term Complications • Behavior problems • Delayed development (due to uncontrolled frequent seizures) • Epileptic encephalopathy (cognitive impairment) seen in specific severe epilepsies
- 38. Epilepsy in Children Management • Counselling of parents • What precautions to take • What to do when a seizure occurs • Anti-epileptic drugs • How to start and When to stop treatment
- 39. Epilepsy in Children Counselling of Parents • Child has an increased tendency to develop seizures which can occur at any time without any warning • Keep the child under observation and do not leave him / her unattended • Activities like swimming, climbing should be avoided • Lack of sleep, lack of food, tiredness flashing lights (TV, mobiles) can precipitate seizures • It is important that anti-epileptic medications are taken regularly and any dose is not missed • If a seizure occurs, give first aid and take to nearby hospital
- 40. Seizures in Children Acute Management for Seizures
- 41. Seizures in Children Acute Management for Seizures > 5 minutes • General Management: • Airway – Breathing – Circulation • Oxygen by mask / nasal prongs • Monitoring – GCS, Vitals, SaO2, • Seizure Management: • Rectal diazepam (at home) • IV diazepam or IV midazolam (benzodiazepines) • IV Leviteracetam (if needed)
- 42. Epilepsy in Children Anti – Epileptic Medications • Anti – Epileptic Medications are generally started after two unprovoked seizures • Anti – Epileptic Medications are chosen according to the type of epilepsy and epilepsy syndrome • Anti – Epileptic Medications are started at low dose with gradual increase in dose • If one medicine does not control the seizures, another suitable medicine can be added • Anti – Epileptic Treatment is given for at least two years and may be stopped gradually after two years if chances of further seizures are low
- 43. Epilepsy in Children Choice of Anti – Epileptic Medications • Seizures / Epilepsy in infants – Phenobarbitone, Leviteracetam • Focal Seizures / Epilepsy – Carbamazepine (Oxcarbazine), Sodium Valproate, Leviteracetam • Generalized tonic-clonic Seizures / Epilepsy – Sodium Valproate, Leviteracetam, Carbamazepine, Clonazepam • Generalized Non-motor Epilepsy (Childhood Absence Epilepsy) – Sodium Valproate
- 44. Status Epilepticus Definition, Complications, Management
- 45. Status Epilepticus • Status Epilepticus is defined as continuous or recurrent seizure activity without regaining of consciousness lasting for more than 5 minutes • Status Epilepticus can lead to neurological damage in brain • Multiple Complications can rapidly develop • Control of Seizures is a Medical Emergency • Management needs to be quick and comprehensive
- 46. Status Epilepticus Complications • Raised Intracranial Pressure • Hypoxia • Hypercapnia • Hypoglycemia • Hypoxic-Ischemic Brain Injury • Hyperpyrexia • Shock • Aspiration pneumonia • Physical injuries
- 47. Status Epilepticus Initial Management • Airway – Breathing – Circulation • Oxygen by mask / nasal prongs • Monitoring – GCS, Vitals, SaO2, • IV dextrose if Hypoglycemia • Control of seizures
- 48. Status Epilepticus Control of Seizures • Initial Treatment: • IV diazepam or IV midazolam (benzodiazepines) • repeat diazepam or midazolam dose upto 3 times • Seizures not controlled: • IV Leviteracetam dose by infusion • IV Phenytoin dose by infusion • IV Phenobarbitone dose by infusion • IV Sodium Valproate dose by infusion • Seizures not controlled: • IV Midazolam continuous infusion
- 49. Prof Imran Iqbal Fellowship Pediatric Neurology-1991 Royal Children Hospital, Melbourne, Australia