Seizures and Epilepsy

Question 1

Definition of seizures

Answer 1

Paroxysmal involuntary disturbance of brain function, manifested by abnormal motor activities, sensory disturbance, autonomic dysfunction or behavioral abnormalities.

Question 2

Etiology of Seizures

Answer 2

A- Acute convulsions
1- Febrile convulsions
2- First epileptic fit.
3- CNS causes:
⯐ Infection: Meningitis, encephalitis and brain abscess.
⯐ Irritation: Brain edema.
⯐ Tumors of the brain.
⯐ Toxic: e.g. tetanus or drugs (aminophylline and antihistaminic).
⯐ Hemorrhage : Trauma, rupture aneurysm and Hemorrhagic blood diseases.
⯐ Hypoxia: Asphyxia, apnea…
⯐ Hypertensive encephalopathy, uremic encephalopathy, ……..
4- Metabolic:
⯐ Hypo (glycaemia, calcaemia, magnesaemia).
⯐ Hypo or hypernatremia.
⯐ Pyridoxine (B6) deficiency.
B- Recurrent convulsions
1- Recurrent febrile convulsions.
2- Epilepsy and conditions mimic epilepsy.
3- Tetany.
4- Chronic metabolic causes:
⯐ Recurrent hypoglycaemia (hyperinsulinism, hypopituitarism, glycogen storage diseases).
⯐ Uraemic encephalopathy (CRF).
⯐ Hepatic encephalopathy.
⯐ Inborn errors of metabolism (Phenyl ketonuria, hyper-ammonaemia, maple
syrup urine disease, …..).

Question 3

Definition of Febrile convulsion

Answer 3

Convulsions in children due to rapid increase of body temperature due to extracranial cause (e.g. tonsillitis, pneumonia, …)

Question 4

Diagnosis of Febrile convulsion

Answer 4

1) Age 6months to 5yo
2) Temperature usually >39 degrees convulsions occur within 8-12 hours from the onset of fever.
3)No evidence of CNS infection
4) Evidence of Extracranial infection
5) Types:
A- Simple febrile convulsions;
∙ The most common form.
∙ Usually generalized tonic – clonic.
∙ Short duration (<15 min.).
∙ Usually one fit only within 24 hours.
B- Complex febrile convulsions:
∙ Uncommon.
∙ May be focal.
∙ Prolonged duration.
∙ Fits may recur within 24 hours.
6) Investigations: CSF if there is doubt in complex type.

Question 5

ttt of febrile convulsions

Answer 5

1- Control of convulsions: Diazepam 0.3-0.5 mg/Kg (I.V. or rectally) Recently buccal midazolam may be used.
2- Measures to lower body temperature:
✰Cold backs or baths. ✰ Antipyretic drugs.
3-Treatment of the underlying cause e.g. antibiotics.
4-Prophylactic anti-convulsant therapy e.g. Na valproate. Not indicated except in complex form. Recurrent cases can be prevented by oral diazepam for 2 days starting from the onset of fever.

Question 6

Definition of Epilepsy

Answer 6

Two or more unprovoked seizures (not related to fever or acute brain insult) greater than 24 hs apart.

Question 7

Compare the types of focal seizures

Answer 7

a- Simple partial seizures (SPS): b- Complex partial seizures (CPS):
⬥ No aura VS⬥ Preceded by aura in 1/3rd of cases (fear, photophobia…).
⬥ No automatism. VS ⬥ Automatism may occur
⬥ No loss of consciousness. VS ⬥ Consciousness is impaired.
⬥ May be motor, sensory or autonomic fits. VS⬥ Only motor fits occur.

c- Partial seizures with 2ry generalization:
⬥ Focal seizures followed by generalization (involvement of whole body).

Question 8

What are absence seizures (Petit mal)?

Answer 8

⬥ Sudden cessation of all motor activities and speech (Awareness of the surroundings is cut off).
⬥ Precipitated by hyperventilation or photic stimulation.
⬥ Rarely persists more than 30 seconds (but frequently recurrent).
⬥ Usually not associated with loss of consciousness.
⬥ No aura.
⬥ No post-ictal phase.

Question 9

What are generalized tonic-clonic seizures (Grand mal)?

Answer 9

❖ The commonest type, passes into 3 phases:
1- Aura (pre ictal): Before the attack as a warning sign which may be motor (localized muscular spasms), sensory (paresthesia) or autonomic (intestinal pain).
2- Attack (Ictal):
-Sudden loss of consciousness (not more than 10 min).
-Tonic phase: Rigid posture with rolling of the eyes, drooling of saliva, clinching of the teeth and incontinence to urine and stool.
- Clonic phase: Rapid relaxation and contraction of muscles (clonic motor activity).
3- Post ictal phase: Headache, sleep or Todd’s paralysis.

Question 10

Describe Myoclonic epilepsy

Answer 10

Sudden shock like repetitive contractions of group of muscles.

Question 11

Describe infantile epilepsy

Answer 11

Repetitive tonic contractions of the neck and trunk muscles which occur in the first year of life and carry a poor prognosis

Question 12

Describe atonic seizures

Answer 12

Sudden loss of body tone & falling down.

Question 13

Investigations used in Epilepsy

Answer 13

1- Electro-encephalo-gram (EEG): must be done for all cases (despite it is -ve in 40%). It may show specific pattern like
a- 3-spike slow wave complex/sec in absence epilepsy
b- Hypsarrhythmia in infantile spasms.
2- CT scan or MRI brain: indicated in: focal lesions (e.g. hge), resistant to ttt evidence of ↑ ICP.
3- CSF: Only indicated in suspected CNS infection.
4- Metabolic screen: Na, K, Ca, Mg, ……. (to exclude metabolic causes).
5- Recently functional MRI to detect the site of epileptic focus.

Question 14

DD of epilepsy

Answer 14

1- Of causes of recurrent convulsions esp. conditions mimic epilepsy which are:
∙ Syncopal attacks.
∙ Breath-holding attacks.
∙ Rage attacks.
∙ Paroxysmal vertigo.
∙ Pseudo-seizures.
2- D.D. of the cause (Idiopathic or 2ry ….)

Question 15

ttt of epilepsy in between attacks

Answer 15

1- Moderation of activities and avoidance of the predisposing factors.
2- Health education of the parents about the disease and advise them to watch their child during swimming, running, passing the traffic,…
3- Drug therapy:
∙ Only one drug is used in low dose then slightly ↑ if no response.
∙ If still no response 2nd drug may be tried either alone or in combination with the first drug.
∙ Duration of therapy is at least for 2 years after the last attack.

Question 16

Drugs used inbetween attacks in epilepsy

Answer 16

• Na valproate (Depakine): Broad spectrum (General + Hepatotoxicity Alopecia Obesity)
• Carbamazepine (Tegretol) : Grand mal and partial (General + Hepatotoxicity Eye: (diplopia and nystagmus))
• Phenobarbitone (Sominaletta) : Broad spectrum (General + Rickets Behavioral changes)
• Phenytoin (Epanutin): Grand mal ( General + Rickets Hirsutism + gum hyperplasia)
• Ethoxumide (Zarontine): Petit mal only (General + Blood dyscriasis )

Clonazepam (Rivotril) : Broad spectrum (Increases salivation and trachea-bronchial secretions)

General side effects: Drowsiness, Ataxia and GIT disturbances (Except phenobarbitone)

Recent drugs:
Lamotrigine: Used as adjuvant in most types
Vegabatrine: Mainly in infantile spasms
Topiramate: In generalized and partial type
Levitriacetam: Effective add-on therapy.

Question 17

TTT during attack in epilepsy

Answer 17

1) General: O2 and suction of secretions
2) Drugs:
❖ Diazepam 0.3-0.5 mg/kg/I.V.
❖ If no response → Phenobarbitone 10-15 mg/kg/I.V.
❖ If no response → Phenytoin 10-15 mg/kg/I.V.

Question 18

TTT of status epilepticus

Answer 18

Convulsions lasting more than 30 minutes or repetitive convulsions without return of consciousness.
1- Admission to ICU.
2- ABC
- Airway (keep patent airway with suction of secretions.
- Breathing (O2 bag and mask ventilation pulse oxymetry for O2 saturation).
- Circulation (IV access, IV fluids and blood samples for electrolytes).
3- Drugs →
Diazepam (if no response) → phenobarbitone (if no response) → phenytoin (if no response) → Diazepam continuos infusion (if no response) → paraldehyde I.V. (if no response) → General anaesthesia.