Download seizures in children - King George`s Medical University

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
SEIZURES
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One of the most common life threatening events in
childhood, more than adults
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Paroxysmal electrical activity in brain -->
motor/sensory/autonomic disturbance with
/without alteration of consciousness
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Convulsion – seizure with motor activity
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Epilepsy – recurrent (2 or more) unprovoked
seizures beyond newborn period 0.5%
5%
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
Seizures: Pathophysiology:
Sustained partial depolarisation in a group of
neurons -->excitability --> sudden
depolarisation in response to stimuli ->conduction to surrounding cells, distant
synaptically connected cells & subcortical
neurons -->dissemination -->loss of
consciousness
SEIZURES - ETIOLOGY
1st fit/ recurrent fits
I Symptomatic
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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,steroids,phenothiazines,
hexachlorophene, strychnine, camphor, INH, tetanus, lead,
shigella/salmonella
Acute cerebral edema - Hypertension
Febrile
II Idiopathic
Newborn
Birth asphyxia/trauma
IVH
Hypocal/hypoglyc
IU infections
Meningitis
Tetanus
1-6 mths
6m-3 yrs
birth asphyxia Febrile
cranial malformations
inborn errors
IU infections
Degenerative
>3 yrs
idiopathic
CNS infections
metabolic
tumour
Inborn errors
other
Kernicterus
Polycythemia
Narcotic withdrawal
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
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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
CLASSIFICATION OF EPILEPTIC
SYNDROMES : ILAE 1989
I Localisation related
• Symptomatic
• Cryptogenic
• Idiopathic
II Generalised
• Idiopathic
• Cryptogenic
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CLASSIFICATION
OF EPILEPSY
STILL EVOLVING
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
EPILEPSY - SPECIAL TYPES:
GTCS: v common
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Aura  tonic spasm loss of consciousness  fall  clonic
movements
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Rolling of eyeballs/Frothing at mouth/Distortion of face
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Incontinence/ Jerky breathing
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Post ictal sleep
Absence epilepsy
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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
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Treatment – Ethosuximide, valproate
May develop GTCS
EEG - 3/sec spike & wave activity
EPILEPSY - SPECIAL TYPES:
Infantile spasms: Onset in 1st year
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Sudden flexion/extension in series esp on awakening
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Upto 100 times /day
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60% secondary, 30% cryptogenic
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Treatment - ACTH/steroids/ vigabatrin
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Associated with mental regression
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EEG - hypsarrhythmic
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May develop GTCS
Lennox Gastaut:
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1-8 yrs,
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tonic/atonic/absence type
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EEG - diffuse 2 Hz spike-waves
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Very difficult to control
EPILEPSY - SPECIAL TYPES:
Psychomotor (Temporal lobe) seizures: Complex partial seizures
with origin in temporal lobe.
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Purposeful but inappropriate acts 'automatisms'
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Associated with behavioral problems
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Difficult to diagnose or treat.
Benign epilepsy with centrotemporal spikes: Partial, idiopathic,
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orofacial/hemifacial, 3-13 yrs, often during sleep. Easy to
control
Myoclonic: heterogenous, multiple causes
Juvenile myoclonic: myoclonic jerks esp after awakening
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EEG - 4-6 Hz polyspike, photosensitivity, GTCS may occur
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Good response to Valproate
FEBRILE SEIZURES:
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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
>1 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
Febrile Seizures: Management
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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.
Seizures: ASSESSMENT
History:
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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
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Aura
partial/generalised onset
Loss of consciousness
Tonic/clonic phase
Associated events - bed wetting/fall/tongue bite
Duration
Post ictal
Precipitating factors
Diurnal
Family history
Antecedant events - trauma/CNS infection/asphyxia
Personality change/intellectual deterioration
Failure to thrive
Developmental milestones
Treatment
Seizures: ASSESSMENT
Examination:
• BP
• Head circumference
• Skin lesions
• Facial features
• Organomegaly
• Fundus
• Meningeal signs
• Neurological deficit
• Development
Seizures: Investigations
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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
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
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
The typical EEG pattern in absence epilepsy
is:
• Intermittent spike and slow waves
• Hypsarrythmia
• Burst suppression
• 3 per second spike and waves
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
Definition of epilepsy includes:
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At least 3 seizures
EEG is abnormal
Imaging is abnormal
Beyond neonatal period
The following is true about breath holding
spells:
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It is usually preceded by crying
Child is always blue
There is no loss of consciousness
EEG may show spikes
The following is true about infantile spasms
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They occur in clusters
They may appear like ‘startling’
They usually occur during sleep
They are also called ‘salaam attacks’
West syndrome usually has the following
features except:
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Infantile spasms
Onset in newborn period
Hypsarrythmia on EEG
Psychomotor retardation or regression
Imaging in seizures is not indicated in:
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Generalised tonic clonic seizures
Absence seizures
Temporal lobe seizures
Infantile spasms
Prevention of febrile seizures can be
achieved by:
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Intermittent phenobarb
Long term phenytoin
Intermittent diazepam
Long term carbamazepine
Emergency dose of IV diazepam for seizure
control is:
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1 mg/kg
0.5 mg/kg
0.1 mg/kg
0.3 mg/kg
Seizures - Management
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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
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• Rectal diazepam 0.5 mg/kg dose/ nasal midzolam 0.2
mg/kg/dose
Domiciliary Mx
• Rectal Diazepam 0.5 mg/kg
• Intranasal midzolam 0.2 mg/kg
Seizures: Status epilepticus:
• Prolonged seizure for >20 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
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 <1mk/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
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Thiopental infusion
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
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
First line AEDs
Carbamazepine:
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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
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
First line AEDs
Phenobarbitone
Ind: Tonic-clonic, partial, febrile
Dose: 3-6 mg/kg/d as single doses
level:10-15 g/ml20-80 hrs
Adv: Cheap, once daily dose
SE: Drowsiness, hyperkinesia, cognitive
impairment ??, rash, rickets
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
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
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
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
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