Pediatric Seizures

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Pediatric Seizures

• An Overview

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Childhood Seizures

• Evaluation
• Classification
• Diagnosis
• Treatment
• Mimics

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Evaluation

• Frequency 4-6/1,000
• History
• Focal or Generalized
• Duration, State of Consciousness, Triggers
• Aura, Behavior, Posture, Post-ictal State
• Examination
• Vitals, HC, HSM, abnormal Neuro exam
• Skin exam, Retinal exam, hyperventilation

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Classification-Febrile Seizures

• 3-4 of population
• Most common
• Excellent prognosis
• 9 months to 5 years peak 14-18 months
• Strong family history of febrile seizures
• Rapid rising temp, gt38 degrees Celsius
• Generalized Tonic/Clonic lt10 minutes
• If exam is normal, No further Work-up
• Rectal Diazepam for recurrence

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Febrile Seizures (2)

• Work up is necessary if
• More than one febrile seizure in 24 hours
• Seizure last for more than 10 minutes
• Focal seizure characteristics
• Positive physical exam suggestive of infectious,
  structural, neurologic, congenital pathology

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Classification-Partial Seizures

• Simple Partial Seizures
• Maintained Consciousness
• Motor activity Versive Seizures
• Sensory aura
• Autonomic
• No automatisms, No tics (can be suppressed)
• EEG spikes, sharp waves in a unilateral or
  bilateral or multifocal pattern
• Duration 10-20 seconds

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Partial Seizures (2)

• Complex Partial Seizures (impaired LOC)
• Simple partial seizure followed by LOC
• Consciousness impaired at onset of seizure
• Aura 1/3 of patients with PS
• Automatisms ¾ of patients with CPS
• Following LOC into postictal phase, not recalled
• Infant alimentary Child gestural, unplanned

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PS (3) CPS (contd)

• Spreading of discharge throughout brain can lead
  to secondary generalization (tonic-clonic)
• EEG Anterior temporal lobe sharp waves, focal
  spikes or multifocal spikes
• Normal EEG in 20 must use sleep deprived,
  prolonged techniques
• Duration 1-2 minutes
• Needs CT or MRI to rule out structural causes

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PS (4) BPEC

• Benign Partial Epilepsy with Centrotemporal
  Spikes (Rolandic Epilepsy)
• Excellent Prognosis
• Ages 2 14 peak onset at 9 10 years old
• Facial tonic-clonic symptoms
• Normal exam, possible positive FamHx
• One seizure 20 Repeated clusters 25
• Occurs during sleep 75
• EEG repetitive spike in rolandic area, o/w nl.

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Classification Generalized

• Absence
• Simple Cessation of activity with blank facial
  expression, flickering of eyelids
• Usually after age 5, FgtM, hyperventilation
• No aura, no postictal state, duration lt30 seconds
• 3/sec spike, generalized wave discharge
• Complex Associated motor symptoms
• Myoclonic movements of face, fingers, extremities
• May have loss of body tone
• 2-2.5/sec spike and wave discharge

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Generalized (2)

• Generalized Tonic Clonic
• Focal Onset or De Novo
• Aura can suggest origin
• Tonic Contractions
• LOC, eyes roll back, cyanosis, apnea
• Clonic Contractions
• Rhythmic contraction/relaxation, loss of
  sphincter
• Post-ictal 30 minutes to 2 hours
• Truncal ataxia, hyperactive DTRs, Babinskis
• Vomiting, intense bifrontal headache

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Generalized (3) T/C (2)

• Triggers
• Low grade fever
• Fatigue
• Stress
• Drugs Methylphenidate, psychotropics, etc
• Duration Few minutes
• Idiopathic

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Generalized (4)

• Myoclonic Epilepsies of Childhood
• Repetitive seizures
• Brief, symmetrical contractions
• Loss of body tonefalling, slumping forward
• Benign Myoclonus of Infancy
• Myoclonic Epilepsy of Early Childhood
• Complex Myoclonic Epilepsy
• Juvenile Myoclonic Epilepsy

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Generalized (5) MEC (2)

• Infancy
• Neck, trunk, extremities
• Normal EEG, Ends by 2 years, no meds
• Early Childhood
• 6 months 4 years
• Favorable outcome, 50 seizure free
• MR, social problems in the minority
• Positive EEG, possible genetic background
• May have concurrent tonic/clonic or febrile
  seizures

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Generalized (6) MEC (3)

• Complex
• Poor prognosis
• Focal or generalized seizures lt1 year of age
• History hypoxic-ischemic encephalopathy,
  microcephaly
• Positive EEG, less prominent FamHx
• Refractory to meds
• MR, behavioral problems in 75
• Lennox Gastaut syndrome

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Generalized (7) MEC (4)

• Juvenile
• Between ages 12 16
• 5 of all epilepsies
• Initial Morning myoclonic jerks
• Later Morning Generalized Tonic Clonic szs
• Positive EEG 4-6/sec irregular spike
• Enhanced with photic stimulation
• Normal exam, lifelong meds (Valproic Acid)

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Generalized (8)

• Infantile Spasms
• Between 4 8 months
• Flexor, Extensor, or Mixed spasms
• Cryptogenic 10-20, normal work-up
• Good prognosis
• Symptomatic 80-90, underlying pathology
• Prenatal and Perinatal etiologies
• MR 80-90
• Positive EEG hypsarrhythmia pattern

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Diagnosis

• Minimum
• Blood glucose, calcium, mag, lytes, EEG
• EEG techniques 40 of EEGs are normal
• Sleep deprived, prolonged (72 hrs), photic
• CSF
• Infectious etiology suspected
• Radiologic CT or MRI1
• Prolonged or intractable szs, neuro deficit,
  increased ICP
• High risk Predisposing factors, focal sz lt33
  months

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Treatment

• Treat after the first uncomplicated seizure with
  a negative work up80 will NOT have another
  seizure2
• Educate patient and family of possible long term
  use and side effects
• May terminate meds after 2 seizure free years
• Wean over 3-6 months due to possible recurrence
  or status.

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Treatment (2)

• Carbamazepine or Tegretol
• Gen T/C, partial watch leukopenia, LFTs
• Phenytoin or Dilantin
• Gen T/C, partial watch SJS, rashes, lupus-like
• Phenobarbital
• Gen T/C watch behavioral changes
• Sodium Valproate or Valproic Acid
• Gen T/C, absence, myoclonic watch LFTs, Reyes
• ACTH
• Infantile spasms watch glucose, BP, lytes

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Treatment (3)

• Ketogenic Diet
• Increases GABA inhibition of seizure activity
• Recalcitrant seizures
• Complex myoclonic epilepsy
• Fat diet, restriction of CHO and protein
• Surgical Options
• Vagal Nerve Stimulator3
• Ablation therapy
• Intractable seizures

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Mimics

• BPV
• Night Terrors
• Breath Holding Spells
• Simple Syncope
• Cough Syncope
• Shuddering Attacks
• Pseudoseizure
• Benign Paroxysmal Torticollis of Infancy

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Bibliography

• 1Sharma, et. al, Role of Emergent
  Neuroimaging, Pediatrics, Vol 111, January,
  2003.
• 2Shinnar, et. al, Risk of Seizure Recurrence,
  Pediatrics, Vol 98, August, 1996.
• 3Parker, et. al, VNS in Epileptic
  Encephalopathies, Pediatrics, Vol 103, April,
  1999.