Pediatric Epilepsy Flashcards
What are some non-epileptic mimicing events?
There are many types of events that appear to be seizures but are not. EEG and video-EEG monitoring are helpful in differentiating these events from seizures.
Breath holding spells, Hyperventilation attacks
Motor tics,Movement disorders
Parasomnias (nightmares, night terrors, sleep walking)
Syncope
Spasmus nutans
Rumination
Sleep myoclonus
Head banging
What are psychogenic nonepileptic seizures (PNES) (formery pseudoseizures)?
Paroxysmal episodes that resemble epileptic seizures; however, PNES are psychological in origin.
How can PNES be diagnosed?
–Video-EEG monitoring in an epilepsy monitoring unit (EMU) is helpful in diagnosis of this condition.
•Epileptiform activity is seen on the EEG during seizures but NOT during psychogenic nonepileptic seizures.
–To make matters more confusing, some patients have both types of events.
What are some characteristics of psychogenic seizures?
may be of prolonged duration
only in daytime only
injury, tongue biting, urinary incontinence, and postictal confusion are rare
motor activity is prolonged, uncoordinated
psychiatric disturbances common
What are the lab/imaging findings of psychogenic seizures?
Interictal and ictal EEGs normal
Describe the findings of epileptic seizures
usually stereotypes
brief duration
can occur nocturnally or during the day
injury, tongue biting, and urinary continence common (especially with tonic-clonic seizures)
EEGs abnormal
What is Diastat?
Diastat (rectal diazepam) is for status epilepticus and seizure clusters
What should you do if a person has a seizure in the hospital?
ABCs: Place the patient on his/her side and Administer oxygen.
Ask the nurse to administer a benzodiazepine (lorazepam, midazolam, diazepam).
Consider loading with an antiepileptic medication.
What are the two main types of seizures?
partial/focal
generalized
What is a partial seizure?
those in which the first clinical and EEG changes indicate initial activation of a system of neurons limited to part of one cerebral hemisphere
NOTE: Generalized seizures are those in which the first clinical changes indicate initial involvement of both hemispheres
What are the types of partial seizures?
–Simple partial
–Complex partial
The classification of partial seizures depends on whether or not consciousness is impaired
What is ‘impaired’ consciousnes?
Impaired consciousness is defined as the inability to respond normally to exogenous stimuli.
When consciousness is preserved, the seizure is classified as a simple partial seizure.
When consciousness is impaired, the seizure is classified as complex partial.
What are the types of generalized seizures?
–Absence or atypical absence
–Myoclonic
–Clonic
–Tonic
–Tonic-Clonic
–Atonic
Describe absence seizures?
–Characterized by the sudden onset of interruption of activity.
•If walking, the patient will stop. If eating, the food will stop on the way to the patient’s mouth. If talking, speech will slow or stop.
–Usually the patient will be unresponsive if spoken to.
–Lasts a few seconds to half a minute.
–Stops as rapidly as it started.
Absence seizures may be e induced by what?
hyperventilation.
Absence seizures need to differentiated from complex partial seizures. Describe absence seizures
Childhood in onset
no aura or warning
abrupt onset and lasting only seconds in duration, and termination is abrupt
automatisms are simple
provocation by hyperventilation common
no postictal phase
neuroimagina normal
Absence seizures need to differentiated from complex partial seizures. Describe complex partial seizures
age of onset at any age
aura or warning frequent
onset and termination gradual, and lasting minutes
frequency only occasional
postictal phase common, marked by confusion and fatigue
neuroimaging may show focal lesions
What is the most common type of childhood seizure?
Febrile seizures (affecting 2-5% of children in the USA and peaking in incidence at 18 months of age)
Define febrile seizures
“Seizures that occur in febrile children between the ages of 6 and 60 months who do not have an intracranial infection, metabolic disturbance, or history of afebrile seizures.”
What are the types of febrile seizure?
simple (isolated (once in a 24 hr period), generalized, and brief (less than 15 min))
complex (multiple occurences in 24 hr, focal, and prolonged (15+ min)) (Associated with a higher risk of afebrile seizures but not of febrile seizure recurrence)
How common is recurrence of febrile seizures?
32% experienced recurrent seizures –(17.1% - 1 recurrence, 9% - 2 recurrences, 6% - > 3 recurrences)
90% of children have recurrence within 1 year of onset
What are the risk factors for recurrence of a febrile seizure?
–young age at onset (< 18 months)
–febrile seizure in 1st degree relative
–low grade fever in E.R.
–brief duration between fever and seizure (< 1 hr.)
What are the risk factors for epilepsy in children with febrile seizures?
–Complex febrile seizures
–A family history of epilepsy
–Neurologic impairment prior to the febrile seizure
How should the neurodiagnostic Evaluation of the Child with a First Simple Febrile Seizure be handled?
Practice Guideline (AAP)
Lumbar puncture
–strongly considered if < 12 mo. old
–considered if >12, < 18 mo. old
–not routine, but recommended if meningeal signs are present in a patient who is > 18 mo. old
–strongly considered in all children on prior antibiotic treatment
EEG
–Should not be performed in the evaluation of neurologically healthy child with a first simple febrile seizure.
More on Neurodiagnostic Evaluation of the Child with a First Simple Febrile Seizure
Blood studies
–Should not be routinely performed (electrolytes, calcium, magnesium, CBC)
–Laboratory testing directed towards identifying the source of the fever
Neuroimaging –Should not be performed
What part of the body is most commonly affected by Infantile spasms?
Most commonly, flexor spasms are seen
–The head is flexed, the arms are extended, and the legs are drawn up. The patient may cry or giggle. He/she may flush or turn pale or cyanotic. Parents may report stomach crunches.
Patients may have extensor spasms characterized by extension of arms, legs, and trunk.
Less common presentations include head nodding or lightening attacks, which involve a single, momentary shock-like contraction of the entire body.
These EEGs show background slowing (high amplitude delta waves) and multifocal spikes.
This diagram shows which medications are used to treat partial seizures, which medications treat generalized seizures, and which medications treat both.
Ethosuximide only treats absence seizures, but absence seizures can be treated with other medications such as lamotrigine or valproate. Patients who have generalized tonic-clonic seizures in addition to absence seizures should not be treated with ethosuximide, as it will not treat the generalized tonic-clonic seizures.
ACTH is only used to treat infantile spasms.
What AEDs can tx both partial and generalized seizures?
Valproic acid (valproate), lamotrigine, topiramate, felbamate, and zonisamide are broad-spectrum agents. I would also add levetiracetam to this list. These medications can be used to treat generalized seizures or partial seizures.
Medications such as ______, _______, ______, _____, _______, and ________ are more useful for treating partial seizures than generalized seizures. In fact, they may worsen generalized seizures.
phenytoin, carbamazepine, phenobarbital, gabapentin, tiagabine, and oxcarbazepine
In this diagram, LEV stands for levetiracetam. As I mentioned before, I would consider this broad spectrum; it can be used for partial and generalized seizures.
Lacosamide is approved for patients over 17 years of age with partial seizures.
Rufinamide is approved for patients with Lennox-Gastaut syndrome over age 4 years.
In 2000, Kwan and Brodie showed that only 4% became seizure-free with the third drug or multiple AEDs.
This diagram shows an approach to treating epilepsy.
The EMU is the epilepsy monitoring unit, where video-EEG monitoring is performed.
