86. seizures in children: febrile fits and epileptic syndromes

Question 1

febrile seizures

Answer 1

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

Question 2

RF

Answer 2

unknown PP

Genetic predisposition(fam history)

High fever (> 40°C )

Viral infection ( HHV-6, influenza)

Recent immunization (especially MMR)

Question 3

clinical sx by International League Against Epilepsy (ILAE) classification of febrile seizures

Answer 3

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

Question 4

what is the post ictal phase

Answer 4

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.

Question 5

post ictal phase in febrile seizures

Answer 5

• quickly return to normal
• short time of confusion and drowsiness
• prolonged ictal sx siggests other condtion (meningitis/ status epilepticus)

Question 6

dg of febrile seizures

Answer 6

determine cause

• physexam
• urine
• cbc w/ CRP, gluc

LUMBAR PUNC(exclude meningitis/ herpetic encephalitis

EEG

CT/MRI

Question 7

rx of febrile seizures

Answer 7

simple seizures under 5 mins resolve spontaneously

comples/over 5 mins
-ABORTIVE THERAPY
#IV lorazepam

-after seizure ends
antipyretic rx w/ NSAIDS

Question 8

PROG of febrile seizures

Answer 8

30% risk of reccurent febrile seiizures

risk of epilepsy increases w/ complex febrile seizures

Question 9

define seizure

Answer 9

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

Question 10

define epilepsy

Answer 10

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

Question 11

Define symptomatic epilepsy

Answer 11

pilepsy due to an identifiable condition (e.g., brain tumor, structural abnormalities of the brain) that causes an increased predisposition to seizures

Question 12

define cyrptogenic epilepsy

Answer 12

epilepsy due to an unknown cause (genetic association suspected)

Question 13

define Nonepileptic seizure

Answer 13

seizures that are provoked by acute conditions (e.g., intoxication, metabolic disturbances).

Question 14

define Epilepsy syndromes:

Answer 14

epileptic disorders defined by a collection of characteristic clinical manifestations and other features (e.g., age of onset, brain lesions)

Question 15

Etio classification of seizures

Answer 15

1.genetic
(no met/ structural cause)

2. structural/metabolic
3. unknown/cryptogenic

Question 16

classification according to anatomical origin and clinical sx

Answer 16

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

Question 17

types of primary general seizures

Answer 17

1) GRAND MAL(clonic-tonic)
2) abscence
3) myoclonic
4) clonic
5) tonic
6) atonic

Question 18

clinical prorgression of seizures

Answer 18

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)

Question 19

what is todd’s paralysis

Answer 19

Focal weakness (e.g., of extremity, speech, gaze) after a seizure,

resolves within 48 hours.
results from exhaustion of the primary motor cortex.

Question 20

sx of FOCAL seizure w/o LOC

SIMPLE PARTIAL SEIZURE

Answer 20

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

Question 21

what’s Jacksonian march

Answer 21

spreading of paresthesia or uncontrolled motor activity from one part of the body to adjacent areas, usually distally to proximally

Question 22

sx of focal seizure w/ LOC

COMPLEX PARTIAL SEIZURE

Answer 22

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

Question 23

sx of GRAND MAL/TONIC CLONIC

Answer 23

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

Question 24

sx of clonic seizure

Answer 24

ICTAL

• LOC
• rythmic jerky movement

NO POST ICTAL

Question 25

sx of tonic seizure

Answer 25

-LOC usually when pt is already sleepy -muscle contrxn (flex/extension of head/ trunk) NO POST ICTAL

Question 26

sx of myoclonic seizure

Answer 26

ICTAL - brief LOC - sudden jerrky movements NO POST ICTAL

Question 27

atonic seizure sx

Answer 27

ICTAL - brief LOC - sudden loss of muscle tone (head drop/ collapsing) NO POST ICTAL

Question 28

abscence seizure sx

Answer 28

``` 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

Question 29

dg of seizure

Answer 29

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 ```

Question 30

dx of seizure

Answer 30

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

Question 31

rx of first seizures (epilepsy)

Answer 31

remove provoking factor no longterm therapy req

Question 32

how are reccurent seizures rx

Answer 32

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

Question 33

rx if focal seizures

Answer 33

first line LAMOTRIGINE children PHENOBARBITOL

Question 34

rx of grand mal

Answer 34

lamotrigine | phenobarb for kids

Question 35

rx of abscence

Answer 35

ETHOSUXIMIDE first line

Question 36

rx of myoclonic

Answer 36

rist line VALPROATE/ TOPIRAMATE

Question 37

surgery for rx of epilepsy

Answer 37

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.)

Question 38

complications

Answer 38

ACUTE -status epilepticus -excitatory toxicity ``` -physical trauma #post dislocation of glenohumeral joint #positional asphyxia ``` CHRONIC -psychiatric disorders

Question 39

what is STATUS EPILEPTICUS

Answer 39

≥ 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

Question 40

etiology of focal seizures in children

Answer 40

perinatal injury to the brain teenagers: cerebral trauma/ encephalitis ``` other -metabolic imbalance -drugs -sttructural anomalies( hippocampal sclerosis) - ```

Question 41

which focal seizure has a genetic cause

Answer 41

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

Question 42

what is the rare form of inherited focal seizures

Answer 42

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

Question 43

what is the most common form of focal epilepsy

Answer 43

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

Question 44

what is Frontal lobe epilepsy

Answer 44

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

Question 45

what is parietal lobe epilepsy

Answer 45

parietal lobe epilepsy is a simplepartial seizure w/ SENSORY SX - paresthesia - pain - sensory aphasia tends to transition into temporal or frontal lobe epilepsy

Question 46

what is occipital lobe epilepsy

Answer 46

occipital lobe epilepsy is a rare simple partial seizure w/ VISUAL HALLUCINATIONS - gazze deviation - cortical blindness transition into temporal/ frontal lobe epilepsy

Question 47

what is Epilepsia partialis continua

Answer 47

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 ```