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1
Contents
 What is a seizure?
 Seizure types
 Etiology of seizures
 Febrile convulsions
 Epilepsies of childhood
 Epi...
What is a Seizure ?
 Paroxysmal, involuntary & sudden
disturbance of neurological function caused
by an abnormal or exces...
Seizures
Epileptic Non
epileptic
4
Etiology of seizures
 Idiopathic (70-80%) – cause unknown but
presumed genetic
 Secondary
 Cerebral malformations
 Cer...
 Cerebral tumour
 Neurodegenerative disorders
 Neurocutaneous syndromes
 Neurofibromatosis
 Tuberous sclerosis
6
Causes for Non-epileptic seizures
 Febrile seizures
 Metabolic
 Hypoglycaemia
 Hypocalcaemia
 Hypomagnesaemia
 Hypo/...
 Head trauma
 Meningitis/Encephalitis
 Poisons/Toxins
8
9
Definition
 A seizure accompanied by a fever in the
absence of intracranial infection due to
bacterial meningitis or vira...
Incidence
 Affects 3% of children
 Positive family Hx in 10%-20%
 Autosomal dominant inheritance (thus family hx
import...
Diagnostic criteria
 Age
 6 months – 60 months (5yrs)
 Peak 14 – 24 months
 Temperature
 Usually >= 38C with rapidly ...
 Should not last >10min
 Generalized, not focal
 No residual weakness of limb or disability
except a brief period of dr...
 Extra cranial infection may be there. ( URTI,
tonsillitis, otitis media…)
 No Hx of previous afebrile seizure
 No acut...
Classification
SIMPLE COMPLEX
Most common Uncommon
Lasts less than 15min Lasts more than 15min
One fit only in the same
il...
Risk factors for recurrent febrile
seizures
 Younger than 18 months (younger the child, higher
the risk...)
 Shorter dur...
Pathogenesis
 Not well known
 Due to temporary impairment of the
balance between convulsant and
anticonvulsant system of...
 Studies done in children suggest that the
cytokine network is activated and may
have a role in the pathogenesis of febri...
Other suggestions
 Endogenous pyrogens such as IL-1
increase neuronal excitability & cause
seizures
 Hyperthermia induc...
Investigations
 Usually not needed in simple febrile
convulsion
 Complex form may need,
 Blood glucose, serum electroly...
Lumbar puncture is strongly
recommended ,
 Hx of irritability, reduced feeding or lethargy
 Clinical signs of meningitis...
 Prolonged post-ictal altered consciousness
 After a complex convulsion
 After pretreatment with antibiotics
22
In these situations,
 LP must be undertaken to check for,
CSF
sugar
protein
organisms
23
Neuroimaging is considered If,
 Micro/ macrocephaly
 Neurocutaneous syndrome
 Pre-existing neurological defect
 Recurr...
EEG
 Not a guide for treatment
 Does not predict recurrence
 So not usually indicated
25
Management
 Fever
 Find the cause (usually viral illness)
 Must exclude meningitis
○ Infection screen blood culture
uri...
 Treating fever promote comfort.
 Not important in preventing seizures.
 Physical methods
 Fanning
 Tepid sponging (n...
Management at home
 Move danger away
 Left lateral position
 Do not try to stop fitting
 Do not put anything in mouth...
 Loosen clothing
 Wipe secretions from mouth
 No fluids or drugs orally
 Note the time
 Do not panic
29
If seizure lasting >5-10 min,
 Seek medical advice
 Diazepam
 0.5mg/kg rectal
 Midazolam
 0.5mg/kg buccal
30
Prognosis
 Generally excellent
 Risk of further febrile seizures – 30%
 Risk of epilepsy after single febrile seizure –...
Information for parents
 FC are common
 Recurrences likely
 Brain damage
 Later epilepsy
Very rare
32
 No evidence of deaths
 What to do when fitting
 If lasting >10 min & not stopping
 Rectal diazepam
-OR-
 Take to the...
34
Definition
 Chronic neurological disorder
characterized by recurrent unprovoked
seizures, associated with abnormal,
exces...
Pathogenesis
 Sudden, excessive, disorderly
discharging neurons
 Increased GLUTAMATE levels &
decreased GABA levels
36
Classification
 Generalized
 Discharges from both hemispheres
○ Absence
○ Myoclonic
○ Tonic
○ Tonic-clonic
○ Atonic
37
 Focal
 Arise from one or part of one hemisphere
○ Frontal seizures
○ Temporal lobe seizures
○ Occipital seizures
○ Pari...
Generalized seizures
 There is,
 Always LOC
 No warning
 Symmetrical
 B/L synchronous discharge on EEG
39
Absence
Transient LOC
Abrupt onset & termination
Typical(petit mal) or atypical
Often due to hyperventilation
Myocloni...
Focal seizures
 Begin in one hemisphere
 May herald by an aura
 May or may not have change in
consciousness
41
42
Frontal
Motor phenomena
Temporal
Auditory or sensory (smell
or taste) phenomena
Occipital
Positive or negative visual
p...
Diagnosis
 Primarily by detailed Hx
 Child & eye witnesses
 Video if available
 Skin markers of Neurocutaneous syn.
Or...
Investigations
 EEG
 Indicated whenever suspected
 To detect structural abnormalities
 Neuronal hyperexcitability
○ Sh...
 Many children with epilepsy
 Many children never had epilepsy
Normal initial EEG
Abnormal initial EEG
46
Additional techniques
 Sleep deprived record
 24h ambulatory EEG
 Video – telemetry
 Subdural electrodes (prior to sur...
Imaging studies
 Structural scans
 MRI
 CT brain
 Can identify
 Tumours
 Vascular lesions
 Sclerotic areas
48
 Functional scans
 Structural lesions not always possible to see
 Can see areas of abnormal metabolism
 Suggestive of ...
50
West syndrome
 Age of onset 4-6 months
 Violent flexor spasms of head, trunk &
limbs
 Extension of arms
 “salaam spasm...
52
Childhood absence epilepsy
 Age of onset 4-12 y
 Suddenly stop moving & stare
 Lasts only few seconds
 Has no recall
...
54
Benign epilepsy with
centrotemporal spikes (BECTS)
 Age of onset 4-10 y
 Tonic clonic seizures in sleep
 Abnormal feeli...
56
 A seizure lasting >30min or repeated
seizures for 30min without recovery of
consciousness in between
57
Management
Diazepam 0.5mg/kg PR
Lorazepam 0.1mg/kg IV Midazolam 0.5mg/kg buccal
Check blood glucose
If <3mmol/L give IV gl...
Rapid-sequence induction with Thiopental
Mechanical ventilation Transfer to PICU
Phenytoin 18mg/kg IV over 20min or
Phenob...
Summary
60
Febrile
convulsions
Affect 3% of children
Usually tonic-clonic with
rapid rise in fever
Must exclude CNS infect...
61
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Seizure disorders in children

Some basic facts about childhood seizures and epilepsy syndromes.

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Seizure disorders in children

  1. 1. 1
  2. 2. Contents  What is a seizure?  Seizure types  Etiology of seizures  Febrile convulsions  Epilepsies of childhood  Epilepsy syndromes  Status epilepticus 2
  3. 3. What is a Seizure ?  Paroxysmal, involuntary & sudden disturbance of neurological function caused by an abnormal or excessive neuronal discharge.  With or without LOC.  If manifests as motor act – “convulsions” 3
  4. 4. Seizures Epileptic Non epileptic 4
  5. 5. Etiology of seizures  Idiopathic (70-80%) – cause unknown but presumed genetic  Secondary  Cerebral malformations  Cerebral vascular occlusion  Cerebral damage (ex; congenital infections, hypoxic-ischaemic encephalopathy…) Causes for Epileptic seizures 5
  6. 6.  Cerebral tumour  Neurodegenerative disorders  Neurocutaneous syndromes  Neurofibromatosis  Tuberous sclerosis 6
  7. 7. Causes for Non-epileptic seizures  Febrile seizures  Metabolic  Hypoglycaemia  Hypocalcaemia  Hypomagnesaemia  Hypo/hyper natraemia 7
  8. 8.  Head trauma  Meningitis/Encephalitis  Poisons/Toxins 8
  9. 9. 9
  10. 10. Definition  A seizure accompanied by a fever in the absence of intracranial infection due to bacterial meningitis or viral encephalitis. 10
  11. 11. Incidence  Affects 3% of children  Positive family Hx in 10%-20%  Autosomal dominant inheritance (thus family hx important)  Recurrent febrile seizures in 30%-40%  1%-2% of subsequent epilepsy after a simple febrile seizure  4%-12% in complex febrile seizure  Boys > Girls 11
  12. 12. Diagnostic criteria  Age  6 months – 60 months (5yrs)  Peak 14 – 24 months  Temperature  Usually >= 38C with rapidly rising temp., within 24hrs of onset of fever 12
  13. 13.  Should not last >10min  Generalized, not focal  No residual weakness of limb or disability except a brief period of drowsiness  No evidence of CNS infections. (meningitis, encephalitis, abscess….) 13
  14. 14.  Extra cranial infection may be there. ( URTI, tonsillitis, otitis media…)  No Hx of previous afebrile seizure  No acute systemic metabolic abnormality 14
  15. 15. Classification SIMPLE COMPLEX Most common Uncommon Lasts less than 15min Lasts more than 15min One fit only in the same illness Recurring during same illness within 24hrs Generalized tonic-clonic Focal 15
  16. 16. Risk factors for recurrent febrile seizures  Younger than 18 months (younger the child, higher the risk...)  Shorter duration of fever before the seizure  Height of fever (lower the peak, higher the risk…)  Positive family Hx  Complex febrile seizure at onset 16
  17. 17. Pathogenesis  Not well known  Due to temporary impairment of the balance between convulsant and anticonvulsant system of brain 17
  18. 18.  Studies done in children suggest that the cytokine network is activated and may have a role in the pathogenesis of febrile seizures  Threshold level of anticonvulsant system in these genetically predisposed children is lower 18
  19. 19. Other suggestions  Endogenous pyrogens such as IL-1 increase neuronal excitability & cause seizures  Hyperthermia induced alkalosis 19
  20. 20. Investigations  Usually not needed in simple febrile convulsion  Complex form may need,  Blood glucose, serum electrolytes  LP and CSF analysis  Neuro-imaging (CT, MRI)  EEG 20
  21. 21. Lumbar puncture is strongly recommended ,  Hx of irritability, reduced feeding or lethargy  Clinical signs of meningitis/encephalitis  Systemically ill 21
  22. 22.  Prolonged post-ictal altered consciousness  After a complex convulsion  After pretreatment with antibiotics 22
  23. 23. In these situations,  LP must be undertaken to check for, CSF sugar protein organisms 23
  24. 24. Neuroimaging is considered If,  Micro/ macrocephaly  Neurocutaneous syndrome  Pre-existing neurological defect  Recurrent complex febrile seizures 24
  25. 25. EEG  Not a guide for treatment  Does not predict recurrence  So not usually indicated 25
  26. 26. Management  Fever  Find the cause (usually viral illness)  Must exclude meningitis ○ Infection screen blood culture urine culture LP for CSF culture 26
  27. 27.  Treating fever promote comfort.  Not important in preventing seizures.  Physical methods  Fanning  Tepid sponging (now not recommended)  Light clothing  Drugs  PCM  ibuprofen 27
  28. 28. Management at home  Move danger away  Left lateral position  Do not try to stop fitting  Do not put anything in mouth 28
  29. 29.  Loosen clothing  Wipe secretions from mouth  No fluids or drugs orally  Note the time  Do not panic 29
  30. 30. If seizure lasting >5-10 min,  Seek medical advice  Diazepam  0.5mg/kg rectal  Midazolam  0.5mg/kg buccal 30
  31. 31. Prognosis  Generally excellent  Risk of further febrile seizures – 30%  Risk of epilepsy after single febrile seizure – 3%  No increased risk of death 31
  32. 32. Information for parents  FC are common  Recurrences likely  Brain damage  Later epilepsy Very rare 32
  33. 33.  No evidence of deaths  What to do when fitting  If lasting >10 min & not stopping  Rectal diazepam -OR-  Take to the hospital  Information & advice sheets 33
  34. 34. 34
  35. 35. Definition  Chronic neurological disorder characterized by recurrent unprovoked seizures, associated with abnormal, excessive or synchronous neuronal activity in brain 35
  36. 36. Pathogenesis  Sudden, excessive, disorderly discharging neurons  Increased GLUTAMATE levels & decreased GABA levels 36
  37. 37. Classification  Generalized  Discharges from both hemispheres ○ Absence ○ Myoclonic ○ Tonic ○ Tonic-clonic ○ Atonic 37
  38. 38.  Focal  Arise from one or part of one hemisphere ○ Frontal seizures ○ Temporal lobe seizures ○ Occipital seizures ○ Parietal lobe seizures 38
  39. 39. Generalized seizures  There is,  Always LOC  No warning  Symmetrical  B/L synchronous discharge on EEG 39
  40. 40. Absence Transient LOC Abrupt onset & termination Typical(petit mal) or atypical Often due to hyperventilation Myoclonic Brief, repetitive, jerky movements Limbs, neck or trunk Physiologically in hiccoughs Tonic Generalized increased tone Tonic – clonic Rhythmic contractions of muscle groups Become cyanosed Jerking of limbs Tongue biting & incontinence Atonic Combined with myoclonic jerk Followed by transient loss of muscle tone Sudden fall or drop of head 40
  41. 41. Focal seizures  Begin in one hemisphere  May herald by an aura  May or may not have change in consciousness 41
  42. 42. 42
  43. 43. Frontal Motor phenomena Temporal Auditory or sensory (smell or taste) phenomena Occipital Positive or negative visual phenomena Parietal Contra lateral altered sensation 43
  44. 44. Diagnosis  Primarily by detailed Hx  Child & eye witnesses  Video if available  Skin markers of Neurocutaneous syn. Or neurological abnormalities 44
  45. 45. Investigations  EEG  Indicated whenever suspected  To detect structural abnormalities  Neuronal hyperexcitability ○ Sharp waves ○ Spike-wave complexes 45
  46. 46.  Many children with epilepsy  Many children never had epilepsy Normal initial EEG Abnormal initial EEG 46
  47. 47. Additional techniques  Sleep deprived record  24h ambulatory EEG  Video – telemetry  Subdural electrodes (prior to surgery) 47
  48. 48. Imaging studies  Structural scans  MRI  CT brain  Can identify  Tumours  Vascular lesions  Sclerotic areas 48
  49. 49.  Functional scans  Structural lesions not always possible to see  Can see areas of abnormal metabolism  Suggestive of focal seizures  Ex :- PET, SPECT 49
  50. 50. 50
  51. 51. West syndrome  Age of onset 4-6 months  Violent flexor spasms of head, trunk & limbs  Extension of arms  “salaam spasms”  EEG shows hypsarrhythmia 51
  52. 52. 52
  53. 53. Childhood absence epilepsy  Age of onset 4-12 y  Suddenly stop moving & stare  Lasts only few seconds  Has no recall  May look puzzled  Induced by hyperventilation 53
  54. 54. 54
  55. 55. Benign epilepsy with centrotemporal spikes (BECTS)  Age of onset 4-10 y  Tonic clonic seizures in sleep  Abnormal feelings in tongue & face  Focal sharp waves in EEG  Benign so important to recognize 55
  56. 56. 56
  57. 57.  A seizure lasting >30min or repeated seizures for 30min without recovery of consciousness in between 57
  58. 58. Management Diazepam 0.5mg/kg PR Lorazepam 0.1mg/kg IV Midazolam 0.5mg/kg buccal Check blood glucose If <3mmol/L give IV glucose & recheck Airway Breathing Circulation 58
  59. 59. Rapid-sequence induction with Thiopental Mechanical ventilation Transfer to PICU Phenytoin 18mg/kg IV over 20min or Phenobarbital 15mg/kg if on oral phenytoin Paraldehyde 0.4ml/kg PR (If no response in 10min) 59
  60. 60. Summary 60 Febrile convulsions Affect 3% of children Usually tonic-clonic with rapid rise in fever Must exclude CNS infection Family advice about management Does not affect intellect Reassure the parents Epilepsy Affects 1 in 200 children Underlying etiology important If suspected EEG is indicated Need psychological help Parents & teachers need to be aware of the management Avoid injurious situations
  61. 61. 61

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