Approach to Seizures Flashcards
What are the 5 questions you have to ask when a child presents with seizures?
- Is a true seizure?
- What type of seizure is it?
- Is it unprovoked or provoked?
- Special investigations we have to do
- The management
What other conditions mimic seizures?
- Day dreaming
- Syncope
- Night terrors
- Sleep myoclonus
- Infantile self gratification
- Pseudo seizures
- Breath holding episodes
What age does breath holding usually occur?
18 months to 6 years
How does breath holding present clinically?
- 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
How does sleep myoclonus present?
- cessation upon waking
- hypnagogic jerks especially on the onset of sleep
How do pseudo seizures present?
- usually triggered by emotional factors
- child has seen a seizure before
- alert to sexual abuse!
- semi-purposeful limb movement
What type of seizures are there?
- Generalised seizures
2. Focal or partial seizures
What type of generalised seizures are there?
- Tonic
- Clonic
- Myoclonic
- Tonic-clonic
- Absence
- Infantile spasms
- Atonic
What type of partial seizures are?
- Simple partial(no loss of awareness)
- Complex partial(loss of awareness)
- Secondary generalised seizures
What symptoms would we expect in the frontal lobe?
-motor symptoms
What symptoms do we expect in temporal lobes?
-emotions, smells, hearing(often feels like deja vu or butterflies in the stomach)
What symptoms can we expect in the occipital lobe?
Visual symptoms
What symptoms can we expect in parietal lobe?
Sensation or pain
What does post-it all mean?
After a seizure
What does aura mean?
Sensation seconds before a seizure
What are provoked seizures?
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
What is an unprovoked seizure?
A seizure that occurs spontaneously without a known cause
What are remote symptomatic seizures?
These are seizures that are a sequalae of progressive or static CNS disorder
- Congenital brain malformation
- Previous stroke
- Perinatal asphyxia
What special investigations would you do?
- Do urea and electrolytes if there is a history of vomiting and diarrhea
- Do toxicology screen if hx of substance abuse
- Do LP if there is fever+ meningeal signs and under 18 months because signs may be absent provided there are no contra-indications
When would we do EEG?
- When there has been >2 seizures
- Do not delay EEG in infantile spasms because it is a neurological emergency
- Sleep increases the chance of a positive result in 30% of children especially in temporal lobe seizures
What neuroimaging do we prefer doing?
MRI
When do we urgently do an neuroimaging(MRI)
- Status epilepticus without obvious cause
- Child who does not return to baseline quickly
- Child suspected with raised intracranial pressure
When do we do an MRI routinely?
- Significant neuro development delay of unknown cause
- Child <1 year with unprovoked seizure
- Child who is stable and has a focal seizure of unknown cause
- Unexplained abnormal neurological findings
What is the recurrence rate of seizures after the 1st seizure?
- Majority reoccur in the 1st-2nd year after they occur
2. 3% chance after 5 years
What are infantile seizures?
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
What are the two types of infantile spasms?
- Symptomatic
2. Cryptogenic
Which ages are usually affected by infantile spasms?
3-6 months but may present later
What are the causes of the symptomatic type of infantile spasms?
- Infections-torch, meningitis and encephalitis
- tuberous sclerosus
- Hypoxia/ischaemia
- Metabolic and toxic-, maple syrup ursine disease
- Structural abnormalities- hydrocephaly, absent corpus colossum
What is the cryptogenic infantile spasm characterised by?
- A better prognosis
2. No specific causes
What is the treatment for infantile spasms?
- Steroids or vigabatrin
2. For long-term use: sodium valproate or benzodiazepines
What are temporal lobe seizures?
They are complex partial seizures arising from the temporal lobe
What does the temporal lobe affect?
- Olfactory
- Gustatory
- Psychosensory (auditory and hallucinations)
What are the clinical symptoms of temporal lobe seizures?
- Feeling of deja vu
- Sensations of pleasure/displeasure
- Fear+anxiety
- Hollow feeling in stomach/butterflies in stomach
Later presents with tonic clonic seizures if it eventually spreads to other parts of the brain
What is benign partial epilepsy with rolandic/centro-temporal spikes?
These are seizures that occur mostly in 2-14 year olds(peaks at 5-8 years)
What are the clinical features of benign partial epilepsy with rolandic spikes?
-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
What is the prognosis we can expect in patients with benign partial epilepsy with rolandic spikes?
Good prognosis
- usually ends by end of 15 years
- treat with sodium valproate or carbamazepine but we hardly use anti-convulsants to treat it
What is status epilepticus?
These are seizures that last longer than 30 minutes and have no recovery of consciousness in between seizures
Which age group is affected by by status epilepticus?
<5 years
How does it usually present?
It is caused by any seizure but more so generalised and tonic clonic
What is the immediate effect on the brain when it happens?
- Compensatory phase-increased brain flow and causes tachycardia, hypertension, increased central venous pressure
- decompensation phase: decrease in tachycardia, decreased cardiac output, raised intracranial pressure, metabolic acidosis and cell death
What is the management for status epilepticus?
- It is a medical emergency
- 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!
- Wait 3 minutes then repeat the benzos if patient is still convulsing
- Wait 10 minutes
- Give anti-convulsant: phenobarbitone 20mg/kg loading dose over 5 minutes
- Repeat phenobarbitone 3-4 x and wait 10 minutes each time (10mg/kg)
- Give phenytoin 10mg/kg( make sure you attach to cardiac monitor)
- If still having a seizure then give lignocaine (2-3mg/kg initial dose)
- If the person is still convulsing take to ICU and give thiopentone and intubate(RSI)
