Fits, faints and funny turns Flashcards
What is a seizure? What is a convulsion?
Seizure / Fit: any attack from whatever cause
Convulsion: Seizure with prominent motor activity
What is syncope due to?
Fainting - due to neuro-cardiogenic mechanism
What is an epileptic seizure?
An abnormal excessive hyper synchronous discharge from a group of cortical neurons
Can have many clinical manifestations (motor, sensory, cognitive)
What are some important non-epileptic seiuzure causes in children?
- Acute symptomatic seizures (caused by acute insult to brain - hypoxia, hypoglycaemia, infection)
- Reflex anoxic seizures: common in toddlers, caused by vagal overstimulation. Always provoked (eg. fright)
- Parasomnias
- Psychogenic non-epileptic seizures
What is a febrile convulsion? Who does it occur to?
Seizure that is associated with a fever but there is no evidence of intracranial infection or precipitating factor
- Commonest cause of acute symptomatic seizure
Occurs to children aged 3 months to 5 years
What are some signs of an absence seizure occuring?
- Upwards rolling of eyeballs
- Eyelid blinking
- Brief duration
What are some signs of a myoclonic seizure?
Brief duration attack with muscle spasms
- Often patient will drop things
- Might fall down
What are some signs of an atonic seizure?
- Sudden and abrupt loss of tone (patient just flops)
- Potential for significant injury
What happens in a tonic clonic seizure?
Tonic phase - patients muscles go stiff and they fall / drop things
Clonic phase - rhythmic jerking seen
Eyes of the patient usually open
What triggers the discharges that cause seizures?
An imbalance between excitatory and inhibitory neurotransmitters
Main inhibitor neurotransmitter: GABA (decreased in seizure)
Main excitatory: glutamate, aspartate (increases in seizure)
Causes an excessive influx of Ca and Na, depolarization results in seizure symptoms
What are the main types of epileptic seizures?
Focal / partial - the seizure focus is restricted to one hemisphere or part of one hemisphere
Generalized - Neurons are recruited from both hemispheres of the brain
What types of seizure is more common in children?
More common to have generalized seizures
Most are idiopathic in origin
What are some of the limitations of the EEG in diagnosing and classifying epilepsy?
- The EEG done in the interictal (between seizures) period cannot always pick-up epileptic activity (sensitivity of 30-60%)
- High chance of false positive as many non-epileptic paroxysmal attacks may be seen on EEG (30% FP)
What are some of the advantages of an EEG when investigating seizures?
- Useful at determining seizure type (focal / generalized)
- Useful in classifying seizure syndromes
If a child presents with convulsive seizures what is an important test to do first off? Why?
ECG
Because there are arrhythmias that may cause convulsive seizures and if they are not identified they may be classified as epilepsy and treated incorrectly - with bad consequence
If epilepsy is suspected in a child, what tests should be done?
ECG
EEG (interictal or ideally ictal)
MRI brain (cause - eg. structural abnormality)
Metabolic testing (if associated with growth regression etc)
Genetic testing
What are some of the important steps in managing a childs epilepsy?
- MAKE SURE IT’S EPILEPSY
- Anti-epileptic drugs (AED): choose one and perform slow upwards titration (symptomatic improvements?)
- Monitor side effects of the drug (can be detrimental - drowsiness / effects on cognition)
What are the first line AEDs for children?
Generalized epilepsies:
Boys - sodium valproate
Girls - Levetiracetam
Focal epilepsy:
- Carbamazepine
If the patient has tried 2 AED’s and is still having seizures what are they termed as? Management from there?
Drug refractory epilepsy
- Offer other AEDs
- Other therapies: immunomodulation with steroids, ketogenic diets, surgery
What is VNS surgery? Who is given it?
Vagal nerve stimulator: electrical signal generator inserted below clavicle and wrapped around the left vagus nerve, functions to inhibit seizure activity
Parents / carers can use a hand held magnet to set it off during seizure
Palliative care, given to those with drug refractory epilepsy
What term is used to describe a baby with a big head? Small head?
Macrocephaly
Microcephaly
What is the major difference between a babies skull and an adults skull?
The presence of fontanelles
Anterior & posterior fontanelles
When do each of the fontanelles on a babies skull tend to close?
Posterior fontanelle - 2-3 months after birth
Anterior fontanelle - between 1-3 years of age
What is measured in regards to head size?
Occipito-frontal circumference
(front of tape measure above eyebrows, posteriorly the tape measure should go over the most prominent part of the occiput)
How is microcephaly categorized?
If the occipitofrontal circumference is less than 2 standard deviations below average - mild microcephaly
Less than 3 SD - moderate to severe
How big does a childs head have to be to be considered macrocephalic?
More than 2 standard deviations bigger than average
What is plagiocephaly? Brachycephaly? Scaphocephaly?
Palgiocephaly - flat head
Brachycephaly - Short head or flat at the back
Scaphocephaly - boat shaped skull
What is craniosynostosis?
Fusion of one or more of the sutures of the babies skull excessively quickly
Caused deformed head shape that may result in raised ICP and may be reflected in facial features
What is Gower’s sign?
Sign of muscle weakness, particularly around the pelvic girdle
Demonstrated by having child lie flat on their back and ask them to get up as quick as possible, sign is positive if they have to roll onto their front and then push themselves up onto their feet
Who is affected by Duchenne Muscular Dystrophy? What are the signs / symptoms?
Boys - present in childhood
Delayed motor skills, late walking, symmetrical proximal weakness (waddling gait), Gower’s sign positive
What is myotonia? What is it a sign of?
Inability of muscles to relax after sustained period of contraction
Neuromuscular disease
What are some important signs that may indicate myopathy instead of neuropathy?
Proximal muscle weakness more common in myopathies
Usually pure motor (no sensory) signs in myopathies
Fasciculations usually only present in neuropathies
Contractures only develop in myopathies
Myocardial dysfunction common in myopathies
