Pediatric Epilepsy

Question 1

Non-Epileptic Events

Answer 1

• breath holding spells
• hyperventilation attacks
• motor tics
• movement disorders
• parasomnias (nightmares, terrors, sleep walking)
• syncope
• spasmus nutans
• remination
• sleep myoclonus
• head banging

Question 2

Psychogenic nonepileptic seizures (PNES)

Answer 2

-previously known as pseudoseizures
-paraoxysmal episodes that resemble epileptic seizures; PNES are psychological in origin
video EEG monitoring is an epilepsy monitoring unit (EMU) is helpful in diagnosis of this condition
(epileptiform activity is seen during seizures but NOT during psychodenic nonepileptic seizures)
some patients have both types of events

Question 3

Who has seizures?

Answer 3

-anyone

Question 4

Seizure Precautions

Answer 4

• showers are recommended rather than baths (must be supervised to prevent drowning)
• swimming should always be supervised
• biking & roller blading
• no driving for 6 months after seizure in TN

Question 5

Seizure First Aid

Answer 5

• stay calm & with child
• protect child from injury (move away sharp stuff)
• do not hold them down, turn on side
• do not put anything in mouth or try to hold tongue, impossible to swallow tongue (can wipe excess saliva)
• something flat & soft under head

Question 6

Seizure in Hospital

Answer 6

• ABCs: place patient on side, give oxygen
• ask nurse to give benzodiazepine (lorazepam, midazolam, diazepam)
• consider loading with an antiepileptic med
• if not sure: get EEG before you treat
• longer seizure lasts, the harder it is to treat

Question 7

Classification of Seizures

Answer 7

• Partial/Focal

- Generalized

Question 8

Partial Seizures

Answer 8

• those in which the 1st clinical & EEG changes indicate initial activation of a system of neurons limited to part of one cerebral hemisphere
• 2 types: simple & partial (is consciousness impaired)

Question 9

Generalized Seizure

Answer 9

-are those in which the first clinical changes indicated initial involvement of both hemispheres

Question 10

Impaired Consciousness

Answer 10

-inability to respond normally to exogenous stimuli

Question 11

Simple Partial Seizure

Answer 11

-consciousness preserved

Question 12

Complex Partial Seizure

Answer 12

-consciousness is impaired

Question 13

Absence Seizures

Answer 13

• Generalized Seizures
• characterized by sudden onset of interruption of activity (if walking will stop)
• usually the patient will be unresponsive if spoken to
• lasts a few seconds to half a min
• stops as rapidly as it started
• may be induced with hyperventilation
• no warning

Question 14

Febrile Seizures

Answer 14

• most common type of childhood seizures, affecting 2-5% of children in USA
• peak incidence at 18 months of age
• occur in febrile children b/w 6-60 months who do not have intracranial infection, metabolic disturbance or history of afebrile seizures

Question 15

Classicfication of Febrile Seizures

Answer 15

-Simple: isolated (once in 24 hr period), generalized brief (15min), associated with higher risk of afebrile seizures but not of febrile seizure recurrence

Question 16

Recurrence of Febrile Seizures

Answer 16

-32% have recurrent (9% 2 times, 6%>3 times)
-90% of children have recurrence within 1 yr onset
-Risk Factors for Recurrence:
young age at onset <1hr)

Question 17

Risk Factors for Epilepsy in Children with Febrile Seizures

Answer 17

• complex febrile seizures
• a family history of epilepsy
• neurologic impairment prior to the febrile seizure

Question 18

Neurodiagnositc Evaluation of Child with 1st Simple Febrile Seizure

Answer 18

• Practice Guideline
• Lumbar puncture: strongly considered in 12, <18 month, strongly considered in all children on prior antibiotic treat.
• EEG: should not be performed in evaluation of neruologically healthy with first simple febrile seizure
• Blood Studies: should not be routinely performed (electrolytes, Ca, Mg, CBC), lab testing directed towards identifying fever source
• Neuroimaging: should not be performed

Question 19

Long-term management of child with Simple Febrile Seizures

Answer 19

• anticonvulsant therapy for kids with 1 or more simple febrile seizures
• if parental anxiety is severe give oral diazepam at onset of febrile illness to prevent recurrence
• antipyretics do not prevent seizures
• discharge patient with Diastat prn seizure more than 3 min or seizure cluster (do not administer Diastat until dr. says its safe)

Question 20

Evaluating a First Non-Febrile Seizure in Children

Answer 20

• immediate: stabilization of the child, determine if a seizure has occurred, determine the cause of seizure
• Lab: individual circumstances, chemistries, CBC, tox screen considered
• Lumbar Puncture: optional (meningitis?)
• EEG: recommended, focal slowing, epileptiform discharges predictive of seizure recurrence (helps tell seizure type)
• Neuroimaging: MRI

Question 21

Epilepsy

Answer 21

-occurrence of multiple unprovoked seizures separated by more than 24 hrs

Question 22

Infantile Spasms

Answer 22

• onset 3-6 months
• seizures: brief bilateral symmetric conc. of the muscles of the neck, trunk, & extremities (flexor spasms, head is flexed arms extended, legs are drawn up, may cry or giggle, flush or pale or cyanotic, stomach crunches)
• extensor spasma - extension of arms, legs, trunk
• head nodding or lightening attacks which have single, momentary shock-like contraction of the entire body

Question 23

EEG of Infantile Spasms

Answer 23

-hypersarrhythmia, b/w seizures there is high voltage, chaotic activity, diffuse voltage depression during seizures

Question 24

West Syndrome

Answer 24

-triad of infantile spasms, hyperrhythmia, & developmental arrest/regression

Question 25

Lennox-Gastaut

Answer 25

- onset 1 to 8 yrs - some of the patients have had infantile spasms (9-39%) - Triad of specific seizures, specific EEG, and mental deficiencies (at least 2 seizure types: tonic, atypical absence and atonic seizures, slowing of mental development, "slow spike & wave"" of 1.5-2.5Hz) -life long, difficult to control

Question 26

Treatment of Lennox-Gastaut

Answer 26

- valproic acid, lamotrigine, topiramate, zonisamide, felbamate, benzodiazepines - ketogenic diet - corpus callostomy - vagus nerve stimulator

Question 27

Childhood Absence Epilepsy

Answer 27

- onset 4-8 yrs - normal neurologic status - absence seizures occur multiple times per day - generalized 3 Hz spike-and-wave discharges (may be triggered by hyperventilation) - normal EEG background - ethosuximide treatment if patient only has absence seizures, but CAE may also be treated with valproic acid or lamotrigine - tegretol may worsen seizures - benign outcome, treat 2-3 yrs

Question 28

Juvenile Myoclonic Epilepsy

Answer 28

-onset in adolescence -seizures may be tonic-clonic, myoclonic or absence ~7-13 yrs onset for absence, myoclonic jerks is 12-18 yrs, generalized tonic-clinic seizures 13 to 20 yrs -brief, bilateral but not always symmetric, flexor jerks of the arms which may be repetitice -jerks sometimes affect the legs, causing the patient to fall -(highest frequency of myoclonic jerks is in morning, consciousness retained) -Diagnosis is often delayed until a generalized tonic-clonic seizure brings the patient to medical attention

Question 29

Juvenile Myoclonic Epilepsy Seizures

Answer 29

- precipitated by sleep deprivation, alcohol ingestion, stress, & awakening from sleep - menstruation may also trigger - photic stimulation is a precipitating factor - neurologic examination is normal - neuroimaging is normal

Question 30

Juvenile Myoclonic Epilepsy Treatment

Answer 30

- usually requires life-long treatment - valproic acid, topiramate, levetiracetam, lamotrigine, zonisamide - Hereditary disorder (AD), linked to chromosome 6

Question 31

Benign Rolandic Epilepsy

Answer 31

- most common form of benign partial epilepsy of childhood - epileptiform discharges arise from lower Rolandic area of the brain - also known as benign epilepsy with centrotemproal spikes and benign focal epilpsy of childhood

Question 32

Benign Rolandic Epilepsy 2

Answer 32

- onset 4-12 yrs, peak at 8-9 yrs - normal neurologic status & imaging - most specific type of seizure: facial motor seizures - most common presentation: nocturnal generalized tonic-clonic seizures (80% of patients) - usually respond to carbamazepine or valproate but may not need to be treated - seizures usually remit by age 14-16 - characteristic EEG findings: central-temproal spikes