Fits, Faints and Funny Turns Flashcards
What are fits, faints and funny turns?
Seizures and seizure mimics
What is a seizure?
Any sudden attack from whatever cause
What is syncope?
Fainting
What are convulsions?
Seizure where there is prominent motor activity
What are epileptic seizures?
An abnormal excessive hyper synchronous discharge from a group of (cortical) neurons
What are the features of an epileptic seizure?
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
What is epilepsy?
A tendency to recurrent, unprovoked (spontaneous) epileptic seizures
A question that must be answered clinically, with recourse to EEG only for supportive evidence
What are examples of non-epileptic seizures and other mimics in children?
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)
What isi febrile convulsion?
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
What are jerk/shake seizures classified as?
Clonic, myoclonic, spasms
What are stiff seizures classified as?
Usually a tonic seizure
What are fall seizures classified as?
Atonic, tonic, myoclonic
What are vacant attack seizures classified as?
Absence, complex partial seizure
What are the chemical triggers on an epileptic fit?
Decreased inhibition (gama-amino-butyric acid, GABA) Excessive excitation (glutamate and aspartate) Excessive influx of Na and Ca ions
How does chemical stimulation produce an epileptic fit?
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)
What are the 2 types of epileptic seizure?
Partial and generalised
Generalised more common
Why might diagnosis of epilepsy in a child be difficult?
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)
What is a stepwise approach to diagnosing epilepsy?
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?
What is the role of the electroencephalogram (EEG) in diagnosing epilepsy?
- 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
How might a diagnosis of epilepsy be made overall?
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
How is epilepsy managed in children?
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.
What considerations should be made when prescribing AEDs?
Age
Gender
Type of seizures
Epilepsy
What are the side effects of AEDs?
CNS related can be detrimental
Drowsiness, effect on learning, cognition and behavioural
What are the AEDs used in child epilepsy?
FIRST LINE FOR GENERALISED:
- Sodium Valproate (not in girls- recent MHRA advice)
- Levetiracetam
FIRST LINE FOR FOCAL:
-Carbamazepine
What are some new AEDs with more tolerability and fewer side effects?
Levatiracetam
Lamotrigine
Perampanel
What are some other therapies used for epilepsy?
Steroids
Immunoglobulins
Ketogenic diet
(mostly for drug-resistant epilepsies)
What is VNS?
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
How is surgery for epilepsy carries out?
Parts of brain responsible for seizures are resected
