Approach to Seizures

Question 1

What are the 5 questions you have to ask when a child presents with seizures?

Answer 1

1. Is a true seizure?
2. What type of seizure is it?
3. Is it unprovoked or provoked?
4. Special investigations we have to do
5. The management

Question 2

What other conditions mimic seizures?

Answer 2

1. Day dreaming
2. Syncope
3. Night terrors
4. Sleep myoclonus
5. Infantile self gratification
6. Pseudo seizures
7. Breath holding episodes

Question 3

What age does breath holding usually occur?

Answer 3

18 months to 6 years

Question 4

How does breath holding present clinically?

Answer 4

• usually preceded by crying, anger or being frightened
• child stops breathing, becomes rapidly cyanosed and loses consciousness
• may have brief tonic posturing of the limbs
• recovers rapidly

Question 5

How does sleep myoclonus present?

Answer 5

• cessation upon waking

- hypnagogic jerks especially on the onset of sleep

Question 6

How do pseudo seizures present?

Answer 6

• usually triggered by emotional factors
• child has seen a seizure before
• alert to sexual abuse!
• semi-purposeful limb movement

Question 7

What type of seizures are there?

Answer 7

1. Generalised seizures

2. Focal or partial seizures

Question 8

What type of generalised seizures are there?

Answer 8

1. Tonic
2. Clonic
3. Myoclonic
4. Tonic-clonic
5. Absence
6. Infantile spasms
7. Atonic

Question 9

What type of partial seizures are?

Answer 9

1. Simple partial(no loss of awareness)
2. Complex partial(loss of awareness)
3. Secondary generalised seizures

Question 10

What symptoms would we expect in the frontal lobe?

Answer 10

-motor symptoms

Question 11

What symptoms do we expect in temporal lobes?

Answer 11

-emotions, smells, hearing(often feels like deja vu or butterflies in the stomach)

Question 12

What symptoms can we expect in the occipital lobe?

Answer 12

Visual symptoms

Question 13

What symptoms can we expect in parietal lobe?

Answer 13

Sensation or pain

Question 14

What does post-it all mean?

Answer 14

After a seizure

Question 15

What does aura mean?

Answer 15

Sensation seconds before a seizure

Question 16

What are provoked seizures?

Answer 16

These are seizures caused by a acute or CNS event
These include:
1. Hypoglycaemia 
2. Fever-febrile seizures
3. Acute ischaemic stroke 
4. CNS infection/meningitis 
5. Toxins

Question 17

What is an unprovoked seizure?

Answer 17

A seizure that occurs spontaneously without a known cause

Question 18

What are remote symptomatic seizures?

Answer 18

These are seizures that are a sequalae of progressive or static CNS disorder

1. Congenital brain malformation
2. Previous stroke
3. Perinatal asphyxia

Question 19

What special investigations would you do?

Answer 19

1. Do urea and electrolytes if there is a history of vomiting and diarrhea
2. Do toxicology screen if hx of substance abuse
3. Do LP if there is fever+ meningeal signs and under 18 months because signs may be absent provided there are no contra-indications

Question 20

When would we do EEG?

Answer 20

1. When there has been >2 seizures
2. Do not delay EEG in infantile spasms because it is a neurological emergency
3. Sleep increases the chance of a positive result in 30% of children especially in temporal lobe seizures

Question 21

What neuroimaging do we prefer doing?

Answer 21

MRI

Question 22

When do we urgently do an neuroimaging(MRI)

Answer 22

1. Status epilepticus without obvious cause
2. Child who does not return to baseline quickly
3. Child suspected with raised intracranial pressure

Question 23

When do we do an MRI routinely?

Answer 23

1. Significant neuro development delay of unknown cause
2. Child <1 year with unprovoked seizure
3. Child who is stable and has a focal seizure of unknown cause
4. Unexplained abnormal neurological findings

Question 24

What is the recurrence rate of seizures after the 1st seizure?

Answer 24

1. Majority reoccur in the 1st-2nd year after they occur

2. 3% chance after 5 years

Question 25

What are infantile seizures?

Answer 25

Unique form of seizure with clusters of head nodding, trunk flexion, eye deviation and crying and facial flushing - they are usually for 1-2 seconds - they are repetitive, bilateral and symmetrical

Question 26

What are the two types of infantile spasms?

Answer 26

1. Symptomatic | 2. Cryptogenic

Question 27

Which ages are usually affected by infantile spasms?

Answer 27

3-6 months but may present later

Question 28

What are the causes of the symptomatic type of infantile spasms?

Answer 28

1. Infections-torch, meningitis and encephalitis 2. - tuberous sclerosus 3. Hypoxia/ischaemia 4. Metabolic and toxic-, maple syrup ursine disease 5. Structural abnormalities- hydrocephaly, absent corpus colossum

Question 29

What is the cryptogenic infantile spasm characterised by?

Answer 29

1. A better prognosis | 2. No specific causes

Question 30

What is the treatment for infantile spasms?

Answer 30

1. Steroids or vigabatrin | 2. For long-term use: sodium valproate or benzodiazepines

Question 31

What are temporal lobe seizures?

Answer 31

They are complex partial seizures arising from the temporal lobe

Question 32

What does the temporal lobe affect?

Answer 32

1. Olfactory 2. Gustatory 3. Psychosensory (auditory and hallucinations)

Question 33

What are the clinical symptoms of temporal lobe seizures?

Answer 33

1. Feeling of deja vu 2. Sensations of pleasure/displeasure 3. Fear+anxiety 4. Hollow feeling in stomach/butterflies in stomach Later presents with tonic clonic seizures if it eventually spreads to other parts of the brain

Question 34

What is benign partial epilepsy with rolandic/centro-temporal spikes?

Answer 34

These are seizures that occur mostly in 2-14 year olds(peaks at 5-8 years)

Question 35

What are the clinical features of benign partial epilepsy with rolandic spikes?

Answer 35

-usually occur nocturnally or early morning -usually unilateral face movements Movement of the mouth, contraction of the jaw, feelings of suffocation, guttural vocalisations, drooling -most are brief but if they are longer can become Todd’s paresis

Question 36

What is the prognosis we can expect in patients with benign partial epilepsy with rolandic spikes?

Answer 36

Good prognosis - usually ends by end of 15 years - treat with sodium valproate or carbamazepine but we hardly use anti-convulsants to treat it

Question 37

What is status epilepticus?

Answer 37

These are seizures that last longer than 30 minutes and have no recovery of consciousness in between seizures

Question 38

Which age group is affected by by status epilepticus?

Answer 38

<5 years

Question 39

How does it usually present?

Answer 39

It is caused by any seizure but more so generalised and tonic clonic

Question 40

What is the immediate effect on the brain when it happens?

Answer 40

1. Compensatory phase-increased brain flow and causes tachycardia, hypertension, increased central venous pressure 2. decompensation phase: decrease in tachycardia, decreased cardiac output, raised intracranial pressure, metabolic acidosis and cell death

Question 41

What is the management for status epilepticus?

Answer 41

1. It is a medical emergency 2. Start with benzodiazepines Diazepam 0,5mg/kg rectally or Lorazepam 0,1mg/kg IV which is faster Then get IV access-take bloods, FBC, Blood gas, blood culture, elcterolytes and glucose! 3. Wait 3 minutes then repeat the benzos if patient is still convulsing 4. Wait 10 minutes 5. Give anti-convulsant: phenobarbitone 20mg/kg loading dose over 5 minutes 6. Repeat phenobarbitone 3-4 x and wait 10 minutes each time (10mg/kg) 7. Give phenytoin 10mg/kg( make sure you attach to cardiac monitor) 8. If still having a seizure then give lignocaine (2-3mg/kg initial dose) 9. If the person is still convulsing take to ICU and give thiopentone and intubate(RSI)