Neurology - Childhood Epilepsy

Question 1

Defintion

Answer 1

The recurrent tendency to spontaneous intermittent, abnormal electrical activity in part of the brain, manifesting in seizures

Question 2

Types of seizures

Answer 2

• Generalised Tonic-Clonic Seizure
• Focal Seizures
• Absence Seizures
• Atonic Seizures
• Myoclonic Seizures
• Infantile Spasms

Question 3

Generalised Tonic-Clonic Seizures

Answer 3

Signs and symptoms:
- Loss of consciousness
- Muscle tensing (TONIC)
- Muscle jerking (CLONIC)
Typically the tonic phase comes before the clinic phase.
Associated:
- Tongue biting,
- Incontinence
- Groaning and irregular breathing
After the seizure is a prolonged post-ictal period = person is confused, drowsy and feels irritable or low

Treatment:
- FIRST LINE = SODIUM VALPORATE
- SECOND LINE = LAMOTRIGINE or CARBAMAZEPINE

Question 4

Focal seizure

Answer 4

Start in temporal lobes, affecting:
- hearing
- speech
- memory
- emotions
There are various ways a focal seizure can present:
- Hallucinations
- Memory flashbacks
- Deja vu
- Doing strange things on autopilot

Treatment
- FIRST LINE = LAMOTRIGINE or LEVETIRACETAM
- SECOND LINE = CARBEMAZAPINE

Question 5

Absent Seizures

Answer 5

Typically seen in children:
- Patient becomes blank
- Stares into space
- Abruptly returns to normal
- During the episode they are unaware of their surroundings and won’t respond
- Typically lasts 10-20 seconds

Treatment
- Most people stop having absent seizures as they get older
- FIRST LINE = ETHOSUXIMADE
- SECOND LIKE =
male: sodium valproate
female: lamotrigine or levetiracetam

Question 6

Atonic seizures

Answer 6

Also known as drop attacks. Characterised by brief lapses in muscle tone.
- They dont usually last more than 3 minutes
- Typically begin in childhood
- May be indicative of Lennox-Gastaut syndrome

Treatment
- FIRST LINE = SODIUM VALPORATE
- SECOND LINE = LAMOTRIGINE

Question 7

Myoclonic Seizures

Answer 7

• Present as sudden brief muscle contractions, like a sudden “jump”.
• The patient usually remains awake during the episode.
• They occur in various forms of epilepsy but typically happen in children as part of juvenile Myoclonic epilepsy.

Treatment:
- FIRST LINE = SODIUM VALPORATE
- Other options = LAMOTRIGINE, LEVETIRACETAM, or TOPIRAMATE

Question 8

Infantile Spasms

Answer 8

Also known as West Syndrome
Rare (1 in 4000)
Disorder starting in infancy at around 6 months of age
Characterised by clusters of full body spasms
Poor prognosis: 1/3 die by age 25 however 1.3 are seizure free.

Treatment:
It can be difficult to treat but FIRST LINE:
- PREDNISOLONE
- VIGABATRIN

Question 9

Diagnosis

Answer 9

Good History
- Important to establish that any episodes were seizures, as opposed to vasovagal episodes or febrile convulsions
EEG
- Perform after second simple tonic clonic seizure
- Children are allowed one simple seizure before being investigated for epilepsy
MRI brain
- diagnose structural problems e.g tumours
- should be considered when:
= first seizure is in children under 2
= focal seizure
= there is no response to first line anti-epileptic medications

Question 10

General advice

Answer 10

Patients and families presenting with seizures need to be given advice about safety precautions, recognising, managing and reporting further seizures. It is important to avoid situations where a seizure may put the child in danger, with advise to:
- Take showers rather than baths
- Be very cautious with swimming unless seizures are well controlled and they are closely supervised
- Be cautious with heights
- Be cautious with traffic
- Be cautious with any heavy, hot or electrical equipment
- Teenagers avoid driving unless meet specific criteria

Question 11

Sodium Valporate Side Effects

Answer 11

Teratogenic = careful about contraception
Liver damage + hepatitis
Hair loss
Tremor

Question 12

Carbamazepine Side Effects

Answer 12

Agranulocytosis
Aplastic anaemia
Induces the P450 system so there are many drug interactions

Question 13

Phenytoin Side Effects

Answer 13

Folate and vitamin D deficiency
Megaloblastic anaemia (folate deficiency)
Osteomalacia (vitamin D deficiency)

Question 14

Ethosuximide Side Effects

Answer 14

Night terrors
Rashes

Question 15

Lamotrigine Side Effects

Answer 15

Stevens-Johnson syndrome or DRESS syndrome. These are life threatening skin rashes.
Leukopenia

Question 16

Management of Seizures

Answer 16

• Put the patient in a safe position (e.g. on a carpeted floor)
• Place in the recovery position if possible
• Put something soft under their head to protect against head injury
• Remove obstacles that could lead to injury
• Make a note of the time at the start and end of the seizure
• Call an ambulance if lasting more than 5 minutes or this is their first seizure.

Question 17

Status Epilepticus

Answer 17

It is defined as a seizure lasting more than 5 minutes or 2 or more seizures without regaining consciousness in the interim.

Treatment:
- ABCDE = Secure the airway
- Give high-concentration oxygen
- Assess cardiac and respiratory function
- Check blood glucose levels
- Gain intravenous access (insert a cannula)
- IV lorazepam, repeated after 10 minutes if the seizure continues
- If the seizures persist the final step is an infusion of IV phenobarbital or phenytoin.
- At this point intubation and ventilation to secure the airway needs to be considered, along with transfer to the intensive care unit if appropriate.

Medical options in the community:
- Buccal midazolam
- Rectal diazepam