SEIZURES%20IN%20CHILDREN

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SEIZURES IN CHILDREN

• Rashmi Kumar
• Prof Head, Pediatrics
• King George Medical University
• Lucknow

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• Prevalence
• Definition
• Conditions that mimic seizures
• Pathophysiology
• Etiology
• Age wise etiology
• Classification
• Assessment
• Febrile seizures
• Management

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SEIZURES

• One of the most common life threatening events in
  childhood, more than adults
• Paroxysmal electrical activity in brain --gt
  motor/sensory/autonomic disturbance with /without
  alteration of consciousness
• Convulsion seizure with motor activity 5
• Epilepsy recurrent (2 or more) unprovoked
  seizures beyond newborn period 0.5

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Seizures DDx

• Tremors distal, rhythmic, equal amplitude, no
  loss of
• consciousness
• Jitteriness
• Breath holding spells always after crying,
  sequence of
• events important
• Syncope after prolonged standing/emotional
  upset,
• gradual loss of consciousness, slow pulse,
  pallor, sweating, improves in supine/head
  down position
• Pseudoseizures older girl, never hurts herself,
  bizarre
• movements, normal s Prolactin
• Detailed sequence of events necessary HISTORY,
  HISTORY, HISTORY

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Seizures Pathophysiology

• Sustained partial depolarisation in a group of
  neurons --gt?excitability --gt sudden
  depolarisation in response to stimuli
  --gtconduction to surrounding cells, distant
  synaptically connected cells subcortical
  neurons --gtdissemination --gtloss of consciousness

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SEIZURES - ETIOLOGY

• 1st fit/ recurrent fits
• I Symptomatic
• Infectious/ post infectious (including
  granulomas)
• Anoxic/post anoxic
• Vascular
• Trauma/post traumatic
• Tumour
• Congenital - porencephaly, lissencephaly,
  agenesis of corpus callosum, neurocutaneous
  syndromes
• Degenerative
• Metabolic - hypocalcemia/hypomagnesemia
• hypo/hypernatremia
• hypoglycemia
• pyridoxine deficiency
• Inborn errors
• Drugs/Toxins -aminophylline,antihistamines,steroid
  s,phenothiazines,
• hexachlorophene, strychnine, camphor, INH,
  tetanus, lead,
• shigella/salmonella
• Acute cerebral edema - Hypertension
• Febrile

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• Newborn 1-6 mths
  6m-3 yrs gt3 yrs
• Birth asphyxia/trauma birth asphyxia
  Febrile idiopathic
• IVH cranial
  malformations CNS infections
• Hypocal/hypoglyc inborn errors
  
• IU infections IU infections
  
  Degenerative
• Meningitis
  metabolic
• Tetanus
  
  tumour
• Inborn errors other
• Kernicterus
• Polycythemia
• Narcotic withdrawal

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CLASSIFICATION OF EPILEPTIC SEIZURES ILAE
1981

• I Partial 54
• Simple - motor/sensory/autonomic 7.7
• Complex 35.5
• Partial with secondary generalization 56.4
• II Generalised 40.4
• Tonic clonic 69
• Absence 3
• Myoclonic 20.5
• Tonic 4.1
• Atonic 3.1
• III Unclassifiable 6 (hospital based
  study in Mumbai)
• However, same patient can have more than 1 type
• Many patients show a distinct evolution of disease

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CLASSIFICATION OF EPILEPTIC SYNDROMES ILAE
1989

• I Localisation related
• Symptomatic
• Cryptogenic
• Idiopathic
• II Generalised
• Idiopathic
• Cryptogenic
• West syndrome
• Lennox Gastaut syndrome
• epilepsy with myoclonic astatic seizures
• epilepsy with myoclonic absences
• Symptomatic
• Non specific
• specific
• III Epilepsies undetermined whether focal or
  generalised
• IV Special syndromes

CLASSIFICATION OF EPILEPSY STILL EVOLVING
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EPILEPSY - SPECIAL TYPES

• GTCS v common
• Aura ? tonic spasm ?loss of consciousness ? fall
  ? clonic movements
• Rolling of eyeballs/Frothing at mouth/Distortion
  of face
• Incontinence/ Jerky breathing
• Post ictal sleep

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Absence epilepsy

• 2-4 of childhood idiopathic epilepsy
• Girls 3-7 yrs, normal IQ
• Transient loss of consciousness for few secs
• No loss of tone
• Ppted by hyperventilation
  -
• Treatment Ethosuximide, valproate
• May develop GTCS
• EEG - 3/sec spike wave activity

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EPILEPSY - SPECIAL TYPES

• Infantile spasms Onset in 1st year
• Sudden flexion/extension in series esp on
  awakening
• Upto 100 times /day
• 60 secondary, 30 cryptogenic
• Treatment - ACTH/steroids/ vigabatrin
• Associated with mental regression
• EEG - hypsarrhythmic
• May develop GTCS
• Lennox Gastaut
• 1-8 yrs,
• tonic/atonic/absence type
• EEG - diffuse 2 Hz spike-waves
• Very difficult to control

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EPILEPSY - SPECIAL TYPES

• Psychomotor (Temporal lobe) seizures Complex
  partial seizures with origin in temporal lobe.
• Purposeful but inappropriate acts
  'automatisms'
• Associated with behavioral problems
• Difficult to diagnose or treat.
• Benign epilepsy with centrotemporal spikes
  Partial, idiopathic,
• orofacial/hemifacial, 3-13 yrs, often during
  sleep. Easy to control
• Myoclonic heterogenous, multiple causes
• Juvenile myoclonic myoclonic jerks esp after
  awakening
• EEG - 4-6 Hz polyspike, photosensitivity, GTCS
  may occur
• Good response to Valproate

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FEBRILE SEIZURES

• 2-4 of children
• 3m - 5 yr age
• Assn with fever due to extracranial infection
• Generalised, Short lasting, only one sz per
  illness
• No mental/neurological/EEG abnormality
• Typical vs Atypical (complex)
• Focal
• Prolonged
• gt1 seizure during illness
• 1/3 have at least 1 recurrence
• 1/6 have multiple recurrences
• Risk of epilepsy
• Fh/o epilepsy
• Atypical
• Abnormal neurologic/mental status

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Febrile Seizures Management

• Exclude CNS infection
• Control fever
• Look for treat cause of fever
• Rectal diazepam
• Explain to parents, reassure
• If multiple - intermittent oral diazepam ? ? by
  80
• If high risk for epilepsy ? long term
  phenobarb/valproate.

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Seizures ASSESSMENT

• History
• 1st seizure/ recurrent seizures
• Fever
• Precipitating factors diarrhea/ vomiting/ drug/
  toxin/ metabolic
• Headache/vomiting/visual loss
• Duration
• Age at onset
• No of attacks
• Frequency ?/?, change in seizure type, last
  seizure when?
• Exact description
• Aura
• partial/generalised onset
• Loss of consciousness
• Tonic/clonic phase
• Associated events - bed wetting/fall/tongue
  bite
• Duration
• Post ictal
• Precipitating factors
• Diurnal

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Seizures ASSESSMENT

• Examination
• BP
• Head circumference
• Skin lesions
• Facial features
• Organomegaly
• Fundus
• Meningeal signs
• Neurological deficit
• Development

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Seizures Investigations

• If features of CNS infection - CSF examination
• Glucose, Ca, Mg - low yield
• Skull Xray - calcification/ ? ICT - low yield
• EEG Always diagnostic during a seizure
• Interictal record normal in 40-50 of
  epileptics (spikes/sharp waves spikes slow
  wave complexes)
• ? yield with sleep, sleep deprivation,
  hyperventilation, photic stimulation
• 2-10 normal population may have epileptic
  changes
• EEG indicated in all cases of epilepsy for
• -confirmation of diagnosis syndrome
• -type of seizures - absence vs temporal lobe,
• primary generalised vs secondarily generalised
• -presence of underlying lesion/ idiopathic vs
  symptomatic
• -follow up
• -before withdrawal of AEDs
• -localisation of focus before surgery
• Video EEG

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Seizures Imaging - CT/MRI

• Has revolutionised the management of epilepsy
• Indications focal features on exam, EEG
• Features of ? ICT
• Intractable
• However, now indicated in every case with unknown
  cause
• Not necessary in febrile/absence/BETS/ JME etc.
• Western studies - 30 abnormal (30-50 of focal)
• -only 3 treatable
• Indian studies
• Very high prevalence of granuloma like lesions
  recent onset partial seizures in child/young
  adult
• 40 abn even after 1st seizure
• ? indicated in every case

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MCQ

• The following are features of benign (typical)
  febrile seizures except
• They are short lasting
• They are always generalised
• They only occur within 4 hours of fever onset
• They do not recur in the same febrile illness

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• The typical EEG pattern in absence epilepsy is
• Intermittent spike and slow waves
• Hypsarrythmia
• Burst suppression
• 3 per second spike and waves

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• The following is true about absence epilepsy
• It occurs more commonly in boys
• There is loss of tone
• It is precipitated by hyperventilation
• Imaging is usually abnormal

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• Definition of epilepsy includes
• At least 3 seizures
• EEG is abnormal
• Imaging is abnormal
• Beyond neonatal period

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• The following is true about breath holding
  spells
• It is usually preceded by crying
• Child is always blue
• There is no loss of consciousness
• EEG may show spikes

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• The following is true about infantile spasms
  except
• They occur in clusters
• They may appear like startling
• They usually occur during sleep
• They are also called salaam attacks

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• West syndrome usually has the following features
  except
• Infantile spasms
• Onset in newborn period
• Hypsarrythmia on EEG
• Psychomotor retardation or regression

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• Imaging in seizures is not indicated in
• Generalised tonic clonic seizures
• Absence seizures
• Temporal lobe seizures
• Infantile spasms

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• Prevention of febrile seizures can be achieved
  by
• Intermittent phenobarb
• Long term phenytoin
• Intermittent diazepam
• Long term carbamazepine

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• Emergency dose of IV diazepam for seizure control
  is
• 1 mg/kg
• 0.5 mg/kg
• 0.1 mg/kg
• 0.3 mg/kg

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Seizures - Management

• I Management of acute attack
• Calm down
• Head down lateral position
• Prevent hurt
• If does'nt stop convulsing in 3-5 min,
• Inj Diazepam 0.3 mg/kg slow iv bolus
• Maybe repeated after 20 min
• Effect lasts 0.5-3 hrs
• SE- hypotension, respiratory depression,
  ?secretions
• or
• Rectal diazepam 0.5 mg/kg dose/ nasal midzolam
  0.2 mg/kg/dose

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Domiciliary Mx

• Rectal Diazepam 0.5 mg/kg
• Intranasal midzolam 0.2 mg/kg

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Seizures Status epilepticus

• Prolonged seizure for gt20 min or repeated
  seizures without regaining consciousness
• Persistent seizure activity ? hypoxia,
  hypoglycemia, hyperthermia, cerebral edema
  vasomotor instability
• Life threatening
• Risk of permanent brain damage ? Medical
  emergency

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Mx of Status epilepticus

• ICU, monitoring
• IV dextrose drip
• Oxygen
• IV Inj Diazepam 0.3 mg/kg or Lorazepam 0.1 mg/kg
  (longer action) or Midzolam (lesser respiratory
  depression)
• Inj phenytoin 15-20 mg/kg iv at a
  rate of lt1mk/kg/min
• Inj Phenobarbitone 20 mg/kg iv at a
  rate of 1 mg/kg/min or IV Valproate 20 mg/kg as
  infusion in 50 ml NS over 30 min
• Ventilatory support
  diazepam/midzolam infusion
• 
  
• Thiopental infusion

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LONG TERM MANAGEMENT OF EPILEPSY

• I General advice
• As normal a life style as possible
• No swimming/cycling on road/driving
• Inform teacher
• First aid
• Seizure dairy
• Regularity

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LONG TERM MANAGEMENT OF EPILEPSY

• Drugs
• When to start? If 2 or more seizures within a 12
  month period
• Monotherapy
• Start at lower limit build up gradually till
  toxicity/control
• If no effect at maximum dose, taper off while
  introducing 2nd drug
• 4 first line drugs - Carbamazepine, phenytoin,
  valproate and phenobarbitone
• No drug completely safe
• 70 can be controlled

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First line AEDs

• Carbamazepine
• Ind Partial, tonic clonic
• Dose 10-30 mg/kg/d in 2-3 doses13-18 hrs,
• Adv Relatively safe, improves cognitive fn.
• SE Diplopia,drowsiness, giddiness
  initially.Hepatitis, skin rash, BM depression,
  drug interactions, dystonia, can aggravate minor
  motor seizures

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First line AEDs

• Sodium valproate
• Ind Broad spectrum
• Dose 20-30 mg/kg/d (upto 80) in 2-3 doses
• Half Life 7-10 hrs
• SE Nausea, vomiting, wt gain, hair loss, hepatic
  failure, tremors, ?platelets, ?s ammonia, ?s
  carnitine, no correlation between drug levels
  toxicity, ?levels of other AEDs

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First line AEDs

• Phenobarbitone
• Ind Tonic-clonic, partial, febrile
• Dose 3-6 mg/kg/d as single doses
• level10-15 ?g/ml20-80 hrs
• Adv Cheap, once daily dose
• SE Drowsiness, hyperkinesia, cognitive
  impairment ??, rash, rickets

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First line AEDs

• Diphenylhydantoin
• Ind Tonic-clonic, atonic, partia
• Dose l4-8 mg/kg/d in 2 doses
• level 10-20 ?g/ml
• Half Life Upto 20 hrs
• SE Hirsutism, gum hyperplasia, rickets, ataxia,
  lymphoma like syndrome, Sle like illness,
  megaloblastic anemia, rash, low margin of safety

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• Ethosuximide
• Ind Absence seizures
• Dose 20-25 mg/kg/d in 2 doses
• Half Life 4-30 hrs
• SE Photophobia, ?WBC, nephrosis, blood dyscrasia
• ACTH
• Ind West syndrome
• Dose 20-40 u/d for 4-6 wks
• SE hypercortisolism

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• Nitrazepam
• Ind Myoclonus, atypical absence
• Dose 0.5 mg/kg/d in 2 doses
• SE Sleepiness, salivation,hypotonia, ataxia,
  tolerance
• Clonazepam
• Dose 0.05-0.25 mg/kg/d in 3 doses\
• Drug level monitoring
• EEGs
• When to stop ? 2-3 yrs seizure free

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Newer AEDs

• Clobazam
• Ind Partial, generalised myoclonus (add on
  drug)
• Dose 0.5 mg/kg/d single dose
• SE Drowsiness, tolerance, ? secretions
• Gabapentin
• Ind Secondarily generalised, complex partial
• SE ?liver enzymes, impaired swallowing
  aspiration, somnolence, fatigue, dizziness, wt
  gain
• Lamotrigine
• Ind Generalised, absence, JME, LG syndrome
• SE Synergy with valproate, skin rash, SJ syndrome

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Newer AEDs/ Other modalities

• Topiramate
• Ind Partial, generalised, drop attacks, LG
  syndrome
• SE ?cognitive impairment
• Vigabatrine
• Ind Partial, infantile spasms
• Dose 40-80 mg/kg/d
• SE Drowsiness, agitation, confusion
• Oxcarbazepine
• Derivative of carbamazepine
• Ketogenic diet
• Surgery