86. seizures in children: febrile fits and epileptic syndromes Flashcards
febrile seizures
seizures with fever exceeding 38°C in the absence of 1)CNS infection, 2)metabolic abnormalities,
3)history of afebrile seizures.
Peak incidence: 2nd year of life; most commonly occurs between 6 months and 5 years of age
RF
unknown PP
Genetic predisposition(fam history)
High fever (> 40°C )
Viral infection ( HHV-6, influenza)
Recent immunization (especially MMR)
clinical sx by International League Against Epilepsy (ILAE) classification of febrile seizures
simple (75%)
- generalized
- tonic clonic
- symmetrical
- no other neuro sx
- over 15mins
- 1 seizure/24hrs
- 6mo-5yo
complex febrile (25%) -one 1 feature needed to be considered complex
- focal
- one side of the body
- transient speech impairment
- longer than 15mins
- more than 1/day
- younger than 6mo older than 5
what is the post ictal phase
phase immediately after the end of a seizure. Notable for typical neurological findings such as confusion, drowsiness, headache, speech impairment, and weakness. Can last for minutes to hours.
post ictal phase in febrile seizures
- quickly return to normal
- short time of confusion and drowsiness
- prolonged ictal sx siggests other condtion (meningitis/ status epilepticus)
dg of febrile seizures
determine cause
- physexam
- urine
- cbc w/ CRP, gluc
LUMBAR PUNC(exclude meningitis/ herpetic encephalitis
EEG
CT/MRI
rx of febrile seizures
simple seizures under 5 mins resolve spontaneously
comples/over 5 mins
-ABORTIVE THERAPY
#IV lorazepam
-after seizure ends
antipyretic rx w/ NSAIDS
PROG of febrile seizures
30% risk of reccurent febrile seiizures
risk of epilepsy increases w/ complex febrile seizures
define seizure
irregular electrical activity in the brain caused by hyperexcitability of neurons, (especially in cortical areas.) resulting in transient behavioural and EEG changes
Hyperexcitability is the result of altered cellular electrochemical properties
define epilepsy
chronic neurologic disorder characterized by
1) One unprovoked seizure with an underlying predisposition to seizures
2) 2+unprovoked seizures separated by more than 24 hours
Define symptomatic epilepsy
pilepsy due to an identifiable condition (e.g., brain tumor, structural abnormalities of the brain) that causes an increased predisposition to seizures
define cyrptogenic epilepsy
epilepsy due to an unknown cause (genetic association suspected)
define Nonepileptic seizure
seizures that are provoked by acute conditions (e.g., intoxication, metabolic disturbances).
define Epilepsy syndromes:
epileptic disorders defined by a collection of characteristic clinical manifestations and other features (e.g., age of onset, brain lesions)
Etio classification of seizures
1.genetic
(no met/ structural cause)
- structural/metabolic
- unknown/cryptogenic
classification according to anatomical origin and clinical sx
w/ abnormal cognitive features (LOC)
FOCAL
-from neuronal networks confined to one cerebral hemisphere
-can spread to other hemishpere and become 2NDARY GENERALIZED
#w/o abnormal cognitive features( no LOC)
PRIMARY GENERAL
-from neural connections across both hemispheres
types of primary general seizures
1) GRAND MAL(clonic-tonic)
2) abscence
3) myoclonic
4) clonic
5) tonic
6) atonic
clinical prorgression of seizures
ICTAL PHASE
Sudden onset
-Rapid onset of symptoms
-lasts 1–3 minutes
POSTICTAL PHASE
- confusion
- drowsiness
- todd’s paralysi
- lasts upt to a few hours
- -sx of cause(stroke. elec disturbance)
what is todd’s paralysis
Focal weakness (e.g., of extremity, speech, gaze) after a seizure,
resolves within 48 hours.
results from exhaustion of the primary motor cortex.
sx of FOCAL seizure w/o LOC
SIMPLE PARTIAL SEIZURE
origin in one hemisphere
ICTAL PHASE -prodrome sx (auras) -conscioiusness preseved -clonic movements (invol repetitive movment of CONTRALATERAL limbs/ facial muscle) -Jacksonian march -sensory sx #hallucinations #parasthesia #vertigo #unusual smells #unusual sounds
POST ICTAL PHASE
- todd’s paralysis
- residual neuro deficits
what’s Jacksonian march
spreading of paresthesia or uncontrolled motor activity from one part of the body to adjacent areas, usually distally to proximally
sx of focal seizure w/ LOC
COMPLEX PARTIAL SEIZURE
origin is temporal lobe in 70%
ICTAL PHASE
PRODROME: AURA
- dejavu/ fear/ vertigo. sx hallucination
- LOC
- AUTOMATISMS(coorrdinated automatic movement (chewing, swalling, lip smacking)
POST ICTAL
- confusion
- anterograde amnesia
- aphasia
- muscle flaccidity
- muscular pain
sx of GRAND MAL/TONIC CLONIC
ICTAL
-prodromal sx HRS b4 onset
#imparied conc
#anxiety/irritability
- LOC
- MOTOR SX
1) TONIC phase
-general muscl contrxn #ICTAL CRY(contrxn of laryngeal muscles) #rolled eyes
-increased sympathetic tone #dilated pupils #tachycardia #HTN
CLONIC PHASE
- rythmic muscle twitches
- bladder/bowel incontinence
- tongue biting
POST ICTAL PHASE -unresponsive pt -confusion -amnesia -hypersalivation muscle flaccidity and pain
sx of clonic seizure
ICTAL
- LOC
- rythmic jerky movement
NO POST ICTAL
sx of tonic seizure
-LOC usually when pt is already sleepy
-muscle contrxn
(flex/extension of head/ trunk)
NO POST ICTAL
sx of myoclonic seizure
ICTAL
- brief LOC
- sudden jerrky movements
NO POST ICTAL
atonic seizure sx
ICTAL
- brief LOC
- sudden loss of muscle tone (head drop/ collapsing)
NO POST ICTAL
abscence seizure sx
ICTAL -breif LOC -interupted activity(blank stare) -several x/day for 5-20 secs -subtle automatisms that may go unnoticed (head nodding)
POST ICTAL
- none
- rapid return of consiousness
- no residual neurp deficits
- pt unaware
dg of seizure
history of aura
witnesses
ictal EEG
-Epileptiform discharges (e.g., spikes, sharp waves)
exclude underlying conditn
-ECG: In every patient with loss of consciousness during an ictal event
#arrythmia
-CT: rule out structural lesions in 1st time seizures(e.g., brain tumors)
-LAB #glucose #electrolites #liver & kidney func tests
-Lumbar puncture #rule out CNS infec
dx of seizure
psychological
- pseudo seizure
- panic attack
syncope
-Stokes-Adams attack (sudden loss of consciousness, for a few seconds, due to an abnormal heart rhythm)
-orthohypo
(lack of post ictal state)
stroke
migraine
Breath-holding spell
-kids up to 8y/o
-periods of prolonged expiratory apnea
Followed by loss of consciousness (syncope) dx by EEG
rx of first seizures (epilepsy)
remove provoking factor
no longterm therapy req
how are reccurent seizures rx
antiepileptic drugs raise the pathologically lowered threshold
indications
1)2seizures/6months unknown cause/ un rxable cause
2) if first seizure shows path EEG/ structural pathology
rx if focal seizures
first line LAMOTRIGINE
children
PHENOBARBITOL
rx of grand mal
lamotrigine
phenobarb for kids
rx of abscence
ETHOSUXIMIDE first line
rx of myoclonic
rist line VALPROATE/ TOPIRAMATE
surgery for rx of epilepsy
only if medical rx fails
) resection of structural anaomalies
2) vagus nerve stim
3) deep brain stim (implantation of an electrode into the patient’s brain to deliver electrical stimuli.)
complications
ACUTE
-status epilepticus
-excitatory toxicity
-physical trauma #post dislocation of glenohumeral joint #positional asphyxia
CHRONIC
-psychiatric disorders
what is STATUS EPILEPTICUS
≥ 5 min of continuous seizures
OR
≥ 2 seizures with consciousness not being fully regained
caused by
- w/drawal from antieptileptic med
- drug toxicity
- CNS infec
RX
-IV LORAZEPAM
etiology of focal seizures in children
perinatal injury to the brain
teenagers: cerebral trauma/ encephalitis
other -metabolic imbalance -drugs -sttructural anomalies( hippocampal sclerosis) -
which focal seizure has a genetic cause
Benign epilepsy with centrotemporal spikes(benign rolandic epilepsy)
-most common GENETIC cause of paediatric epilepsy
clinical
- occurs during sleep
- facial twitching and aphasia
- can become 2ndary generalized
EEG:
centrotemporal spikes
BILATERAL
spontaneously resolve by ppuberty
rx: VALPROATE in severe cases
what is the rare form of inherited focal seizures
Benign childhood epilepsy with occipital spikes
early onset(before 10)
- freq vomiting
- night seizures for 5 mins
late onset (gastaut)
- visial sx common
- daytime seizure
- less than 5 mins
what is the most common form of focal epilepsy
Temporal lobe epilepsy
def: complex partial seizure originating in temporal lobe
d/2 Hippocampal sclerosis
sx ICTAL -aura -motorsx #lip smacking -absent minded but no LOC -autonomic sx #mydriasis #salivation #sweating
POSTICTAL
-confusio & fatigue
dg: tempral lobe spikes on EEG
rx
lamotrigine
poor prog, 60% still have sx
what is Frontal lobe epilepsy
Frontal lobe epilepsy is a simple partial seizure w/ motor sx
- head directed to affected side
- muscle tension
- autonomic sx
- JACKSONIAN MARCH
- TODD’s paralysis
NO AURA
NO POST ICTAL SX
what is parietal lobe epilepsy
parietal lobe epilepsy is a simplepartial seizure w/ SENSORY SX
- paresthesia
- pain
- sensory aphasia
tends to transition into temporal or frontal lobe epilepsy
what is occipital lobe epilepsy
occipital lobe epilepsy is a rare simple partial seizure w/ VISUAL HALLUCINATIONS
- gazze deviation
- cortical blindness
transition into temporal/ frontal lobe epilepsy
what is Epilepsia partialis continua
epilepsia partialis continua is a rare unspecific damage to the cortex causing focal epilepsy
sx -partial clonicity (clinic contrxns in a part of the body e/g/ mouth/ finger) -sx are CONTINOUS for several days -a focal type of status epilepticus
