Seizures/ Epilepsy Flashcards
Breath-holding attacks
Breath-holding attacks – toddler upset -> cries and holds breath -> goes blue, lose consciousness and goes limp
- Attacks resolve spontaneously, drug therapy unhelpful
- Manage with behaviour modification and distraction
Reflex anoxic seizures
Reflex anoxic seizures (infants and toddlers):
- Triggered by – pain, head trauma, cold food (ice cream), fright, fever
- Child becomes pale and falls to floor ± general tonic clonic fitting -> brief seizure and rapid recovery
- Episodes due to cardiac asystole due to vagal inhibition
Define seizures
Seizure - A seizure is a paroxysmal abnormality of motor, sensory, autonomic and/or cognitive function due to transient brain dysfunction.
This term includes:
* Epileptic
* Syncopal (anoxic)
* Brainstem (hydrocephalic, coning)
* Emotional
* Functional (psychogenic pseudo-seizures)
* Undetermined
**Epileptic Seizures **
- This is based on the nature of the underlying electrical activity in the brain, especially in the cerebral cortex
- They are due to excessive and hypersynchronous electrical activity, typically in neural networks in all or part of the cerebral cortex
**Convulsions **
* This is a seizure (epileptic or non-epileptic) with motor components
* Particularly stiff (tonic), a massive jerk (myoclonic), jerking (clonic), trembling (vibratory) or thrashing about (hypermotor)
* Non-convulsive seizures can manifest with motor arrest (e.g. unresponsive stare as in generalised epileptic absence seizures or focal epileptic seizures) or drop attack(epileptic atonic seizure)
**Epilepsy **
* This is a tendency to recurrent and unprovoked seizures
* Generally, epilepsy is recognised after ≥ 2 years of unprovoked epileptic seizures occurring > 24 hours apart
**Acute Symptomatic Epileptic Seizures **
* When epilepsy seizures are provoked by an acute brain injury e.g. acute cortical ischaemia during stroke, cortical inflammation from meningitis, cortical contusion from traumatic brain injury
Neonatal seizure
Seizures are unstimulated and usually appear as repetitive, rhythmic (clonic) movements of the limbs which PERSIST DESPITE RESTRAINT and are often accompanied by eye movements or changes in respiration
EEGs are used to confirm and monitor seizures (now, aEEGs/ cerebral function monitors are also used)
Causes of Seizures in Neonates
* Hypoxic-ischaemic encephalopathy
* Cerebral infarction
* Septicaemia/ meningitis
* Metabolic
* Hypoglycaemia
* Hypo/hypernatraemia
* Hypocalcaemia
* Hypomagnesaemia
Inborn errors of metabolism
* Pyridoxine dependency
* Intracranial haemorrhage
* Cerebral malformations
* Drug withdrawal e.g. maternal opiates
* Congenital infection
* Kernicterus
Give high-flow oxygen and place on a cardiac monitor
Get IV access
Whenever seizures are observed, hypoglycaemia and meningitis need to be EXCLUDED or TREATED URGENTLY
A cerebral USS can be performed to identify haemorrhage or cerebral malformations
Ongoing or repeated seizures will be treated with anti-convulsants
Treatment should be directed at the UNDERLYING CAUSE whenever possible
Febrile convulsion define
Febrile convulsion = a seizure and fever in the absence of intracranial infection or met disturbance
- 6m to 6yo (shouldn’t occur in older children)
- Genetic predisposition (30% will have further seizures)
- Any febrile illness can cause a febrile seizure
Usually caused by a minor viral infection but bacterial causes (inc meningitis) should be excluded
Tend to occur early in viral infection when the temperature is rising rapidly
* HHV6 is the commonest cause worldwise
Febrile seizures are dependent upon a threshold temperature, and this
seems to vary from individual to individual
RF’s
* Genetic predisposition
* High fever
* Viral infection
* Vaccinations (esp MMR, DTP)
Signs and symptoms of febrile convulsion
FEVER
- NOTE: There is not a good correlation between height of pyrexia and the severity of the illness and viral infections often cause fevers of 40 degrees or higher.
Lasts < 5 mins usually
Brief, generalised tonic-clonic seizure on background of fever
Simple febrile seizure do not cause brain damage and no increases risk of epilepsy
* Isolated
* Generalised tonic-clonic
* Symmetrical
* 15 min max duration but usually < 5 mins
* Does NOT recur within 24 hrs or within the same illness
* Complete recovery within 1 hr (confusion and drowsiness may be present for a short period of time)
Complex febrile seizures -> increased risk 4-12% of subsequent epilepsy
* Partial focal
* Pronounced on one side of the body
* Transient hemiparesis and speech impairment
* 15mins +
* Recurrence in same illness so more than 1 seizure in 24 hrs
* Incomplete recovery within 1 hr - prolonged ictal phase
Factors inc likelihood of febrile seizures
* Younger children
* Shorter duration of illness before seizure (e.g., earlier in illness)
* Lower temp at the same time of seizure
* Positive FHx
Investigation for febrile seizure
General Exam (inc ENT) and basic obs
Identify and manage cause of fever
- Urine dip
ECG
No other main investigations (EEG not recommended)
Potentially:
* Urine MC&S if infection source unclear
* Blood glucose
* Septic screen
1. WCC
2. CRP
3. Cultures
4. Blood gas
5. Lactate
6. Glucose
CXR
LP
Management of febrile seizure
Management during a seizure**:
- Protect from injury (cushion their head, remove nearby objects) and do not restrain
- Once seizure stops, check airways and put them into recovery position
- Seizure lasts <5 minutes -> do nothing (unless if… 1st seizure, severe cause, breathing problems)
- Seizure lasts >5 minutes (no drugs available) -> call ambulance (if no medication available)
Seizure lasts >5 minutes (drugs available) -> administer one of the below – doses on BNFc:
- PR diazepam (repeated once after 5 minutes if the seizure hasn’t stopped)
< 1 month= 1.25-2.5mg
1 month- 1 year= 5mg
2-11 years= 5-10mg
OR
- Buccal midazolam
< 6 months= 300mg/kg of body weight (max 2.5mg)
6 months-11 months= 2.5mg
1-4 years= 5mg
5-9 years= 7.5mg
10 minutes after first dose ongoing seizure, twitching, or another seizure before child has regained consciousness -> call ambulance
Management after a seizure -> immediately after– check ABCs and place in recovery position
Identify and manage the cause of fever
Urgently admit any child with suspected meningococcal disease
Use the NICE traffic light system to assess the likelihood of serious illness in a child with a fever
Arrange immediate hospital assessment by a paediatrician if:
1. First febrile seizure or if second seizure in a child who has not been assessed before
2. Diagnostic uncertainty about the cause of seizure
3. Seizure lasted > 15 minutes
4. Currently on Abx
5. Focal features during the seizure
6. Seizure recurred in the same febrile illness (or within 24 hours)
7. Incomplete recovery after 1 hour
8. < 18 months old
9. No serious clinical findings but is currently taking antibiotics
10. Parents are anxious and feel that they cannot cope
11. Suspected cause of the fever e.g. pneumonia
If the child has no apparent focus of infection, consider urgent hospital assessment for a period of observation
All other children can be managed AT HOME
- Inform parents about febrile convulsions
- They are NOT the same as epilepsy
- The risk of epilepsy in future is only slightly higher than the general population
- Short-lasting seizures are NOT harmful to the child
- 1/3 children will have another febrile convulsion
- Advise parents about what to do when a seizure occurs
- Protect them from injury
- Do not restrain or put anything in their mouth
- Check the airway and place in the recovery position when the seizure stops (explain that the child might be drowsy for up to 1 hour)
- Seek medical advice if the seizure lasts < 5 minutes, call an ambulance if it lasts > 5 minutes
- Advise parents about managing fever
- Reducing fever does NOT prevent recurrence
- Explain when and how to use paracetamol and ibuprofen
- Advise about maintaining adequate fluid intake
- Advise on when to seek prolonged symptoms
- Advise parents to carry on with routine immunisations
- Do NOT prescribe drugs to manage or prevent further seizures
- Arrange follow up
Complications of febrile seizure
Complications
* Parent anxiety
* Febrile status epilepticus
* Epilepsy
* Cognitive impairment (memory, language)
Prognosis
* Usually self-limiting
* Majority of children have normal growth and development
Define epileptic seizures
Epilepsy
- Two or more seizures unprovoked by any immediately identifiable cause
- A disease characterised by an enduring predisposition to generate epileptic seizures and by the neurobiological, cognitive, psychological and social consequences of the condition
Seizure → transient occurrence of signs or symptoms due to abnormal excessive or synchronous activity in the brain:
Focal (partial) → start in one part of the brain
Generalised → more distributed, affect both hemispheres of the brain
Risk factors
Risk factors:
Genetic predisposition
* Most of the recognised genetic epilepsies begin in childhood - Epilepsy syndromes
1. Infantile spasms (West’s syndrome): infantile spasms, developmental regression and hypsarrhyth- mia (a chaotic pattern)
2. Lennox-Gastaut syndrome
3. Benign-Rolandic epilepsy
4. Juvenile myoclonic epilepsy
Perinatal asphyxia
Metabolic disorders
* Glucose transporter deficiency
* Creatine deficiency syndromes
* Hypocalcaemia, Hyponatraemia
Trauma
Ischaemia, bleeding, tumour
Immune
Infections: meningitis, encephalitis
Neurocutaneous syndromes
Structural CNS abnormalities
Complex febrile seizures
Classification of epilepsy
New classification according to International League Against Epilepsy 2017:
- Where seizures begin in the brain
- Focal
- Unknown
- Generalised
- Focal to bilateral
- Level of awareness
- Focal aware (awareness intact)
- Focal impaired
- Awareness unknown (unwitnessed)
- Generalised (presumed to affect awareness)
- Other features of seizure
- Focal onset:
- Motor onset (movements can include → twitching, jerking, stiffening, automatisms)
- Non-motor (cognitive, emotional, sensory)
- Generalised onset:
Motor → tonic (stiffening) and clonic (jerking) = “Grand Mal”
Non-motor → absence, brief changes in awareness ± automatic/repeated movements
Benign rolandic epilepsy
Myoclonic:
- Brief arrhythmic repetitive muscular jerking movements followed by transient loss of muscle tone causing sudden fall to floor or drop of head
- Last a few seconds, sudden jerking or twitching
- Non-epileptic myoclonic movements are also seen in physiological hiccups (myoclonus of diaphragm) or passing stage II of sleep (sleep myoclonus)
**3-12yo Benign Rolandic Epilepsy (BRE) (most common childhood epilepsy) **
* S/S: seizures of face / upper limbs during sleep with hypersalivation & speech arrest
* AKA: Sylvian seizures
* Childhood (age 3-12yo) seizures – outgrown at end of puberty
12-18yo Juvenile myoclonic epilepsy:
* Usually involving neck, shoulders, upper arms, most occur after waking up
* Begin around puberty
Progressive myoclonic epilepsy:
* Rare syndromes
* Combination of myoclonic and tonic-clonic
* Patient deteriorates over time
Investigations
Mainly based on detailed history from the child and eyewitnesses
Clinical examination should include checking for skin markers for a neuro-cutaneous syndrome or neurological abnormalities.
It may be the presentation or a complication of an underlying neurological disorder
- ALWAYS CHECK GLUCOSE IN A CHILD HAVING A SEIZURE/ CONVULSION!
- Basic obs, urine dip
- Bloods - FBC, U&Es, CRP, glucose
- ECG
- Should be done in ALL children with seizures
- Do NOT want to miss convulsive syncope due to an arrhythmia (e.g. long QT syndrome)
- EEG
- Inter-ictal EEG is indicated whenever an epilepsy is diagnosed
- If seizures are frequent, then an ictal EEG can make the diagnosis
- If the standard inter-ictal EEG is normal, a sleep or sleep-deprived record can be helpful
Other techniques:
- 24 hour ambulatory EEG
- 5-day telemetry EEG
- Brain imaging
- Structural
- MRI and CT are required routinely in childhood epilepsies (done later on)
NOTE: MRI fluid-attenuated inversion recovery (FLAIR) sequences are better at detecting mesial temporal sclerosis in temporal lobe epilepsy- which can sometimes be surgically cured
Functional
- Abnormal metabolism may be suggestive of epileptogenic zones
- Examples: PET and SPECT (single photon emission CT) can identify metabolically active cells
- Ictal SPECT can locate areas of hypermetabolism during epileptic seizures
- Other
Metabolic investigations are indicated if there is developmental arrest or regression OR if seizures are related to feeds or fasting.
This should be considered in epilepsies starting in the first 2 years of life
LP? - done if suspecting meningitis etc.
Management of epilepsy
Urgent Referral to neurologist if suspecting 1st epileptic fit (“first fit clinic”) whilst waiting for referral, advise…
- How to recognise a seizure
- Video record future seizure
- Avoid dangerous activities (i.e. swimming)
- Seek help if another seizure before referral
Appropriate Antiepileptic Drug (AED) Choice:
- Appropriate AED for seizure and epilepsy type (as some make the seizures worse)
- Lamotrigine -> exacerbate myoclonic seizures
- Carbamazepine -> exacerbate absence seizures
- Monotherapy at lowest dose possible (potential adverse side effects)
- Can use adjuncts to monotherapy but aim for lowest dose possible
- Rescue therapy for prolonged epileptic seizures (convulsive with loss of consciousness >5 minutes)
- Buccal midazolam
- No monitoring requires (apart from carbamazepine)
- AED levels are NOT checked regularly but may be measured to check adherence
- AED therapy may be discontinued after 2 years free of seizures
Medical management of epilepsy
