Seizures & epilepsy

Question 1

Seizure reoccurence after afrebrile seizure?

Answer 1

1/3 over the next 2 years and 50% of these occur in next 6 months

Question 2

How common are febrile seizures?

Answer 2

3% of children

Question 3

In what ages do febrile seizures occur?

Answer 3

6mo-6yo

Reconsider Dx if outside these ages

Question 4

Presentation of febrile convulsions?

Answer 4

GTCS, lasting 15 minutes
Occur once in a febrile illness
Onset is sudden

Complex: >15min, occur in same illness
- R/F = previous afebrile seizures, CNS infection, underlying neurological condition

Question 5

Ix and Tx of febrile convulsions?

Answer 5

No standard, treat specific infection
- EEG is not indicated
Educate parents: benign, no risk of intellectual impairment/brain damage
1/3 chance of recurrence, especially if young
No effect of panadol on risk

Question 6

Risk of epilepsy in febrile convulsions

Answer 6

Slightly increased: 3% with no other risk factors

If have other R/F: risk can increase up to 10%

Question 7

Risk of epilepsy in febrile convulsions

Answer 7

Slightly increased: 3% with no other risk factors

If have other R/F: risk can increase up to 10%

Question 8

Breath-holding spells epidemiology and natural Hx

Answer 8

Very common in toddlers: start at 1-2yo, resolve by 3-4yo
Benign, no risk of death/ID etc. (reassure parents)
May be linked to iron def anaemia

Question 9

Presentation of breath-holding spells

Answer 9

Precipitated by emotional or physical trauma
Hold breath, become bradycardic, cyanotic/pale
May have hypoxic jerks/convulsive movements
May become floppy and LOC which will terminate event
Recovery is rapid, but may be drowsy

Question 10

EEG for breath-holding spells

Answer 10

Not necessary

Question 11

First presentation of the seizure - what are important points to ask on history?

Answer 11

Eye witness account of actual seizure
Previous seizure events?
Before - warning/prodrome/aura, precipitant? (fatigue, alcohol, fever, lights, reading/writing)
Context - febrile/illness, dehydration, environment, activity at time, time of the day/sleeping
After - Consequences/injuries from seizure, drowsiness/confusion
PMHx, FHX and social as per normal

Question 12

First presentation of the seizure - what are important examination?

Answer 12

Conscious state, vitals 
ABCD if relevant 
Neurological exam - focal signs, meningism, raised ICP
Development - i.e. dysmorphic features 
Bedside BGLs

Question 13

First presentation of the seizure - what possible DDx?

Answer 13

Syncope - vasovagal/cardiac 
Epilepsy 
Normal - day-dreaming, sleep jerking 
Breath holding 
Movement disorders 
Sleep related disorder 
Behavioural/psychiatric 
Migraine variants

Question 14

First presentation of the seizure - what Ix would you perform?

Answer 14

Bloods - glucose, electrolytes
EEG - if afebrile
? MRI if suspected mass effect as cause

Question 15

What is the definition of epilepsy?

Answer 15

> = 2 unprovoked seizures

Question 16

What are the causes of seizures?

Answer 16

Structural - mass/raised ICP, sclerosis 
Metabolic - electrolytes, glucose, metabolic disorders
Infective - CNS, high fever 
Vascular - CVA
Idiopathic 
Birth injury/hypoxia
Head trauma

Question 17

What are precipitating factors for epileptic seizures?

Answer 17

Fatigue, sleep deprivation
Stress
Flashing lights
Reading/writing 
Alcohol 
Drugs
Withdrawal 
Hypoglycaemia
Fever
Electrolytes
Hypoxia

Question 18

What are the differences between genetic (idiopathic/primary) and structural/metabolic (secondary/symptomatic) seizures?

Answer 18

Primary

• Age dependent (different for different syndromes)
• associated with specific epileptiform EEGs but otherwise generally well and no neurological features.
• FHX
• Good prognosis and control of seizures

Secondary

• Variable but usually young age presentation
• Variable findings on EEG but generally abnormal neurological exam or developmental delay
• Generally poor prognosis and control of seizures
• Typically history of prior cerebral insult - i.e. hypoxia in birth, CNS infection with scarring

Question 19

What are the general clinical features of tonic-clonic and absence seizures?

Answer 19

Tonic-clonic

• Tonic-stiffening, eyes open, moan/cry
• Clonic-rapid jerking movements
• Usually last 1-5mins
• Cyanosis or plethora
• Post-ictal confusion, drowsiness or agitation

Absence

• Brief pauses <10s
• Sudden with no warning
• Generally look blank
• May have associated automatisms
• Remain upright

Question 20

What Ix are useful in afebrile seizures and why?

Answer 20

EEG

• All afebrile seizures have one
• Epileptiform patterns can help diagnosis specific types of epilepsy
• Helps characterise seizure, direct medication choice and need for futher brain imaging
• Video EEG may be helpful as inter-ictal usually normal
• Can’t exclude epilepsy purely on normal EEG

Brain imaging

• If suspect structural cause
• MRI better than CT

Question 21

What are the first aid instructions for managing seizures?

Answer 21

• Time seizure from onset
• Do not hold/restrict child but remove obstacles and support head with something soft
• Do not put anything in their mouth
• Once seizure finished put in recovery position and call ambulance
• If seizure lasting >3-4 minutes provide rectal or buccal benzo (diazepam or midazolam)

Question 22

What advice do you give parents when providing diagnosis of epilepsy?

Answer 22

• Explanation of diagnosis and condition
• Reassure that medications to control it and if idiopathic generally good prognosis and ~25% grow out of it
• Discuss triggers to seizures and avoidance
• Discuss management plan - first aid advice, instructions on providing cessation medication if seizure prolonged
• Discuss safety re heights, water (swimming, baths, showers), driving, high-risk hobbies
• Medications - monotherapy usually, slowly titrate up, S/E (ataxia, drowsiness, tremor, N+V, mood disturbance, rash) and may need some monitoring of levels

Question 23

What is status epilepticus and the Rx?

Answer 23

• Prolonged seizure >10 mins
• Can cause hypoventilation - hypoxaemia and hypercarbia - cardiac arrest, brain damage, MSK injury
• Prepare treatment and provide if lasting >~4m
• Rectal, buccal or IV diazepam or midazolam
• Prepare for ventilation support - O2, CPAP, ventilation
• Investigations - BGLs, U&Es, CMP, septic screen, blood gas