seizure disorders in children maura b. price md frcpc faap february 2010 [email protected]
TRANSCRIPT
Seizure Facts
• 2 % of ER visits
• 40% will have a recurrence after first seizure
• Incidence 1/1000
Seizures Diagnosis
• Abrupt loss of responsiveness
• Rhythmic clonic movements
• Sustained changes in posture or tone
• Simple automatic movements
• Staring without change in tone
• Changes in cerebral electrical activity
Seizure Questions
• Where was child, what were they doing?• Loss of consciousness?• Any warning signs?• Stiffness, jerking?• What did eyes do, color change, saliva, tongue, urine or bowel control?• How long did it last?• Post ictal phase?• Has the child been well?• PMH for meningitis, head injury, brain damage?• Child’s development?• Family history?
Seizure Mimics
• Psychogenic seizures• Syncope• Migraine• Breath-holding spell• Sleep disturbances• Tics• Shuddering attacks• Gastroesophageal reflux• Cardiac conduction abnormalities• Self-stimulating behaviors• Hyperexplexia• Benign tonic upgaze of infancy• Paroxysmal dystonia
Paroxysmal Event
Paroxysmal Events Classification
LP
Fever
CT
Trauma
Chemistries
Fluids or Lytes
LP
CNS Infection
Acute Symptomatic
Consider AEDs
EEG and MRI
Remote Symptomatic
? AEDs
? MRI
Syndrome
EEG
Idiopathic
Seizure
ECG
Cardiac Other
Non-epileptic eventType Title Here
History and Physical
Febrile Seizures
• Age 6 month to 6 years
• Acute febrile illness
• Non focal, brief (< 15 minutes)
• Minimal work-up
• Treat fever and infection if required
• No AED required
• Reassure
Risk Factors for First Simple Febrile Seizure
• Family history of febrile seizures
• Neonatal discharge > 28 days
• Delayed development
• Child care attendance
• Low serum sodium
• Very high fever
Risk Factors for Recurrence of Febrile Seizure
• Young age < 18 months
• Family history of febrile or non-febrile
• Short duration of fever before initial seizure
• Relatively lower fever at onset
• Developmental delay
Febrile seizure talking points
• Most children do well and the risk of epilepsy is low
• The earlier the age of the first febrile the more likely a recurrence
• Diagnostic tests should never be routine• Meningitis should be ruled out• Treatment does not reduce development of
epilepsy and has side effects
Trauma
• Apparent from history and physical• Attention to clues for non-accidental trauma• Persistence of post-ictal phase• Careful ophthalmologic exam• CT• Admitted for observation• +/- AEDs and usually less than a year
Fluids and Lytes
• Most commonly hypoglycemia or hyperglycemia, sodium and calcium
• Less Mg, Cl, Ph
• Prior diagnosis? Gastroenteritis
• Treat underlying disorder
• No AEDs
CNS Infection
• Must differentiate from first febrile
• LP if < 1 year (12-18 months)
• Strongly consider LP if prolonged, atypical, focal or prolonged post-ictal
Remote symptomatic
• Etiology is remote from event• Perinatal hypoxic injury, congenital stroke,
progressive neurodegenerative disease and prior meningitis
• Previous diagnosis of developmental delay or cerebral palsy
• EEG then brain imaging (MRI)• AEDs used• Neurology usually involved to some extent
Risk Factors for the Development of Epilepsy
• Suspect or abnormal development
• Family history of afebrile seizures
• First febrile seizure - complex
• Three or more febrile seizures
• Duration of recognized fever less than 1 hour
Epilepsy
• Generalized begins simultaneously in both cerebral hemispheres
• Generalized include absence, atypical absence, myoclonic, clonic, tonic, atonic, and tonic-clonic
• Partial seizures begin in a localized area of the cerebral cortex
• Partial further subdivided into simple where consciousness isn’t impaired or complex partial where have LOC and partial evolving into generalized
Epilepsy talking points
• Precise classification is important for treatment and prognosis
• Anticonvulsants are rarely used after first seizure if normal development, negative EEG and negative family history
• A history of aura epigastric discomfort, frightened) indicates focal onset
• If seizure free for 2 years on meds and normal neurologically >75% remain seizure free
Idiopathic
• No underlying neurologic disorder
• Clearly defined syndromes with fairly clear prognosis and treatment
• Genetically inherited although sometimes it’s just the EEG abn inherited
Benign Rolandic Epilepsy
• Starts age 5-15• Primarily nocturnal seizures after falling
asleep or just before wakening• Generalized convulsions or slurring• EEG: bilateral independent temporal
and central spikes• Outgrown by early adolescence.• No AEDs
Childhood Absence and Juvenile Absence
• Starring spells with or without automatisms (mouthing, eye blinking, head jerking)
• Hyperventilate in office• EEG: 3 Hz spike wave discharges• Rx VPA, Lamotragine, Ethosuximide• Childhood absence outgrown by
adolescence, in juvenile absence less common but usual remittance
Juvenile Myoclonic Epilepsy
• Age 10-15 years
• Morning myoclonic jerks, starring spells generalized convulsions
• EEG: 3 to 4 Hz generalized spike and poly spike
• Rarely outgrow
• AEDs VPA, lamotrigine, leviteracitam
Benign Occipital Epilepsy
• Prolonged poor but maintained responsiveness, starring and occasional ictal vomiting and headache
• Confused with migraine• Rarely occipital lesion - do MRI• EEG: bi-occipital spikes• Outgrown by adolescence• AEDs low dose variable drug