Fits, Faints and Funny Turns

Question 1

What are fits, faints and funny turns?

Answer 1

Seizures and seizure mimics

Question 2

What is a seizure?

Answer 2

Any sudden attack from whatever cause

Question 3

What is syncope?

Answer 3

Fainting

Question 4

What are convulsions?

Answer 4

Seizure where there is prominent motor activity

Question 5

What are epileptic seizures?

Answer 5

An abnormal excessive hyper synchronous discharge from a group of (cortical) neurons

Question 6

What are the features of an epileptic seizure?

Answer 6

It may have clinical manifestations
Paroxysmal change in motor, sensory or cognitive function
Depends on seizure’s location, degree of anatomical spread over cortex, duration

Question 7

What is epilepsy?

Answer 7

A tendency to recurrent, unprovoked (spontaneous) epileptic seizures

A question that must be answered clinically, with recourse to EEG only for supportive evidence

Question 8

What are examples of non-epileptic seizures and other mimics in children?

Answer 8

Acute symptomatic seizures: due to acute insults eg. Hypoxia-ischaemia, hypoglycemia, infection, trauma FEBRILE CONVULSION

Reflex anoxic seizure: common in toddlers

Syncope

Parasomnias eg. night terrors

Behavioural stereotypies

Psychogenic non-epileptic seizures (PNES)

Question 9

What isi febrile convulsion?

Answer 9

An seizure occurring in infancy/childhood
Usually between 3 months and 5 years of age
Associated with fever but without evidence of intracranial infection or defined cause for the seizure
Commonest cause of ‘acute symptomatic seizure’ in childhood

Question 10

What are jerk/shake seizures classified as?

Answer 10

Clonic, myoclonic, spasms

Question 11

What are stiff seizures classified as?

Answer 11

Usually a tonic seizure

Question 12

What are fall seizures classified as?

Answer 12

Atonic, tonic, myoclonic

Question 13

What are vacant attack seizures classified as?

Answer 13

Absence, complex partial seizure

Question 14

What are the chemical triggers on an epileptic fit?

Answer 14

Decreased inhibition (gama-amino-butyric acid, GABA)
Excessive excitation (glutamate and aspartate)
Excessive influx of Na and Ca ions

Question 15

How does chemical stimulation produce an epileptic fit?

Answer 15

It produces an electrical current
Summation of a multitude of electrical potentials results in depolarization of many neurons which can lead to seizures, can be recorded from surface electrodes (Electroencephalogram)

Question 16

What are the 2 types of epileptic seizure?

Answer 16

Partial and generalised

Generalised more common

Question 17

Why might diagnosis of epilepsy in a child be difficult?

Answer 17

Non-epileptic paroxysmal disorders are more common in children
Difficulty in explaining (Children are not young adults)
Difficulty in interpretation (witness)
Difficulty in interpretation and synthesising information (physician)

Question 18

What is a stepwise approach to diagnosing epilepsy?

Answer 18

Is the paroxysmal event epileptic in nature?
Is it epilepsy?
What seizure types are occurring?
What is the epilepsy syndrome?
What is the etiology?
What are the social and educational effects on the child?

Question 19

What is the role of the electroencephalogram (EEG) in diagnosing epilepsy?

Answer 19

• An interictal EEG has limited value in deciding when the individual has epilepsy
• Sensitivity of first routine interictal EEG: 30- 60%
• Problematic false positive rates: paroxysmal activity seen in 30%, frankly epileptiform activity in 5% of normal children
• Useful in identifying seizure types, seizure syndrome and etiology

Question 20

How might a diagnosis of epilepsy be made overall?

Answer 20

History
Video recording of event
ECG in convulsive seizures
Interictal/ictal EEG
MRI Brain: to determine etiology eg. Brain malformations/ brain damage
Genetics: idiopathic epilepsies are mostly familial; also single gene disorders eg. Tuberous sclerosis
Metabolic tests: esp if associated with developmental delay/ regression

Question 21

How is epilepsy managed in children?

Answer 21

Anti-epileptic drugs (AED) should only be considered if diagnosis is clear even if this means delaying treatment

Role of AED is to control seizures, not cure the epilepsy

Start with one AED: slow upward titration until side-effects manifest or drug is considered to be inefficient.

Question 22

What considerations should be made when prescribing AEDs?

Answer 22

Age
Gender
Type of seizures
Epilepsy

Question 23

What are the side effects of AEDs?

Answer 23

CNS related can be detrimental

Drowsiness, effect on learning, cognition and behavioural

Question 24

What are the AEDs used in child epilepsy?

Answer 24

FIRST LINE FOR GENERALISED:

• Sodium Valproate (not in girls- recent MHRA advice)
• Levetiracetam

FIRST LINE FOR FOCAL:
-Carbamazepine

Question 25

What are some new AEDs with more tolerability and fewer side effects?

Answer 25

Levatiracetam
Lamotrigine
Perampanel

Question 26

What are some other therapies used for epilepsy?

Answer 26

Steroids
Immunoglobulins
Ketogenic diet

(mostly for drug-resistant epilepsies)

Question 27

What is VNS?

Answer 27

Vagus nerve stimulation

-Sends tiny electrical shocks to vagus nerve
-3 pieces of equipment;
programmable generator
lead with two coils at the end
hand-held magnet

(like an epilepsy pacemaker)
Lessens burden of seizures in refractory patient, palliative
Parents hold the hand-held magnet during seizure

Question 28

How is surgery for epilepsy carries out?

Answer 28

Parts of brain responsible for seizures are resected