SEIZURESSEIZURES

DefDef:: Paroxysmal involuntary disturbance of Paroxysmal involuntary disturbance of

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

1- 1- Febrile convulsionsFebrile convulsions 2- 2- First epileptic fitFirst epileptic fit.. 3- 3- MetabolicMetabolic:: Hypo (glycaemia, calcaemia, Hypo (glycaemia, calcaemia,

magnesaemia).magnesaemia). Hypo or hypernatraemia.Hypo or hypernatraemia. Pyridoxine (B6) deficiency.Pyridoxine (B6) deficiency.

44 CNS causesCNS causes: : Infection: Meningitis, encephalitis and brain Infection: Meningitis, encephalitis and brain

abscess.abscess. Irritation: Brain oedema.Irritation: Brain oedema. Tumours of the brain.Tumours of the brain. Toxic: e.g. tetanus or drugs (aminophylline Toxic: e.g. tetanus or drugs (aminophylline

and antihistamincs).and antihistamincs). Hge: Trauma, rupture aneurysm and Hgic Hge: Trauma, rupture aneurysm and Hgic

blood diseases.blood diseases. Hypoxia: Asphyxia, apnea, ……..Hypoxia: Asphyxia, apnea, …….. Hypertensive encephalopathy, uraemic Hypertensive encephalopathy, uraemic

encephalopathy, ……..encephalopathy, ……..

B- B- Recurrent convulsionsRecurrent convulsions 1- 1- Recurrent febrile Recurrent febrile

convulsionsconvulsions.. 2- 2- Epilepsy & conditions mimic Epilepsy & conditions mimic

epilepsyepilepsy.. 3-3- TetanyTetany. .

4- 4- Chronic metabolic causesChronic metabolic causes:: Recurrent hypoglycaemia Recurrent hypoglycaemia

(Hyperinsulinism, hypopituitarism, (Hyperinsulinism, hypopituitarism, glycogen storage diseases).glycogen storage diseases).

Uraemic encephalopathy (CRF).Uraemic encephalopathy (CRF). Hepatic encephalopathy.Hepatic encephalopathy. Inborn errors of metabolism (Phenyl Inborn errors of metabolism (Phenyl

ketonuria, hyper-ammonaemia, maple ketonuria, hyper-ammonaemia, maple

syrup urine disease, …..)syrup urine disease, …..)

FEBRILE CONVULSIONSFEBRILE CONVULSIONS

DefDef:: Convulsions in children due to rapid Convulsions in children due to rapid

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

IncidenceIncidence:: 4% of children.4% of children. Family history in about 20% of cases.Family history in about 20% of cases.

DiagnosisDiagnosis:: 1- 1- AgeAge: 6 months : 6 months 5 years (convulsions 5 years (convulsions

below 6 months or above 5 years are not below 6 months or above 5 years are not considered febrile).considered febrile). 2- 2- TemperatureTemperature: usually > 39: usually > 39 convulsions convulsions

occur within 8-12 hours from the onset of occur within 8-12 hours from the onset of fever.fever.

3- 3- No evidence of CNS infectionNo evidence of CNS infection: e.g. : e.g. meningitis, abscess, ….meningitis, abscess, ….

4- 4- Evidence of extracranial infectionEvidence of extracranial infection: e.g. : e.g. sepsis, tonsillitis, ……sepsis, tonsillitis, ……

55 - -Types of convulsionsTypes of convulsions::

A- A- Simple febrile Simple febrile convulsionsconvulsions::

The most common The most common form.form.

Usually generalized Usually generalized tonic – clonic.tonic – clonic.

Short duration (<15 Short duration (<15 min.).min.).

Usually one fit only Usually one fit only during 24 hours.during 24 hours.

B- B- Complex febrile Complex febrile convulsionsconvulsions::

Uncommon.Uncommon. May be focal.May be focal. Prolonged duration.Prolonged duration. Fits may recur during Fits may recur during

the same illness.the same illness.

6- 6- InvestigationsInvestigations:: Not needed, but complex form may be Not needed, but complex form may be

mistaken with CNS infection, so CSF is mistaken with CNS infection, so CSF is done in doubtful diagnosis.done in doubtful diagnosis.

7- 7- D.D.D.D.:: Other causes of convulsions.Other causes of convulsions.

TreatmentTreatment:: 1- 1- Control of convulsionsControl of convulsions: Diazepam : Diazepam

0.3-0.5 mg/Kg (I.V. or rectally).0.3-0.5 mg/Kg (I.V. or rectally). 2- 2- Measures to lower body temperatureMeasures to lower body temperature: : Cold backs or baths.Cold backs or baths. Antipyretic drugs.Antipyretic drugs. 3- 3- Treatment of the underlying causeTreatment of the underlying cause

e.g. antibiotics.e.g. antibiotics. 4- 4- Prophylactic anti-convulsant therapyProphylactic anti-convulsant therapy

e.g. Na valproate.e.g. Na valproate. Not indicated except in recurrent Not indicated except in recurrent

attacks (esp. complex form).attacks (esp. complex form).

PrognosisPrognosis:: Recurrence rate about 25%.Recurrence rate about 25%. The risk for developing epilepsy is The risk for developing epilepsy is

increased with:increased with: Family history of epilepsy.Family history of epilepsy. Pre-existing neurological disease. Pre-existing neurological disease. Complex formComplex form..

EPILEPSYEPILEPSY Def.Def.:: Recurrent seizures not related to fever or acute Recurrent seizures not related to fever or acute

brain insult.brain insult. AetiologyAetiology:: 1- 1- Idiopathic (1ry)Idiopathic (1ry): 80% of cases either hereditary or : 80% of cases either hereditary or

not.not. 2- 2- Organic (2ry)Organic (2ry): 20% of cases, may be:: 20% of cases, may be: Congenital cerebral malformation.Congenital cerebral malformation. Degenerative brain diseases.Degenerative brain diseases. Post-traumatic.Post-traumatic. Post-hgic.Post-hgic. Post-infection.Post-infection. Post-toxic.Post-toxic. Post-anoxic.Post-anoxic.

ClassificationClassification:: 1- 1- Focal (partial) seizuresFocal (partial) seizures:: Only one part of the body is involved Only one part of the body is involved

(focal).(focal). Only one type of movements (tonic or Only one type of movements (tonic or

clonic). clonic). It has 3 types:It has 3 types: a- Simple partial seizures (SPSa- Simple partial seizures (SPS (( b- Complex partial seizures (CPS)b- Complex partial seizures (CPS) c-c- Partial seizures with 2ry Partial seizures with 2ry

generalizationgeneralization

a- Simple partial seizures (SPS): b- Complex partial seizures (CPS):

No aura Preceded by aura in 1/3rd of cases (fear, photophobia...).

No automatism. Automatism may occur (automatic behaviors e.g. chewing, swelling, suckling or aggressive maneuvers).

No loss of consciousness. Consciousness is impaired. May be motor, sensory or

autonomic fits. Only motor fits occur.

2- 2- Generalized seizuresGeneralized seizures:: Affect the whole body from the start.Affect the whole body from the start. Classified into:Classified into: a- Absence seizures (petit mal)a- Absence seizures (petit mal):: Sudden cessation of all motor activities and speech Sudden cessation of all motor activities and speech

(Awareness of (Awareness of the surroundings is cut off).the surroundings is cut off). Precipitated by hyperventilation or photic stimulation.Precipitated by hyperventilation or photic stimulation. Rarely persists more than 30 seconds (but frequently Rarely persists more than 30 seconds (but frequently

recurrent).recurrent). Usually not associated with loss of consciousness.Usually not associated with loss of consciousness. No aura.No aura. No post-ictal phase.No post-ictal phase.

b- Generalized tonic-clonic seizures (Grand-b- Generalized tonic-clonic seizures (Grand-mal)mal): The commonest type, : The commonest type,

passes into 3 phases:passes into 3 phases: 1- Aura (pre ictal): Before the attack as a warning 1- Aura (pre ictal): Before the attack as a warning

sign which may be motor sign which may be motor (localized muscular spasms), sensory (parasthesia) (localized muscular spasms), sensory (parasthesia)

or autonomic (intestinal pain).or autonomic (intestinal pain). 2- Attack (Ictal):2- Attack (Ictal): Sudden loss of consciousness (not more than 10 Sudden loss of consciousness (not more than 10

min).min). Tonic phase: Rigid posture with rolling of the eyes, Tonic phase: Rigid posture with rolling of the eyes,

drooling of saliva, clinching of the teeth and drooling of saliva, clinching of the teeth and incontinence to urine and stool.incontinence to urine and stool.

Clonic phase: Rapid relaxation and contraction of Clonic phase: Rapid relaxation and contraction of muscles (clonic motor activity).muscles (clonic motor activity).

3- Post ictal phase: Headache, sleep or Todd’s 3- Post ictal phase: Headache, sleep or Todd’s paralysis.paralysis.

cc- - Myoclonic epilepsyMyoclonic epilepsy: : Sudden shock like repetitive contractions Sudden shock like repetitive contractions

of group of musclesof group of muscles.. dd-- Infantile spasmsInfantile spasms: : Repetitive tonic contractions of the neck Repetitive tonic contractions of the neck

and trunk muscles which occur in the first and trunk muscles which occur in the first year of life and carry a poor prognosisyear of life and carry a poor prognosis

ee-- Atonic seizuresAtonic seizures:: Sudden loss of body tone and falling Sudden loss of body tone and falling

downdown..

InvestigationsInvestigations:: 1- 1- Electro-encephalo-gramElectro-encephalo-gram (EEG): (EEG):

must be done for all cases (despite it is must be done for all cases (despite it is -ve in 40%). -ve in 40%).

2- 2- CT scan or MRI brainCT scan or MRI brain: indicated in: : indicated in: focal lesions (e.g. hge), resistant to ttt focal lesions (e.g. hge), resistant to ttt evidence of evidence of ICT. ICT.

3- 3- CSFCSF: Only indicated in suspected : Only indicated in suspected CNS infection.CNS infection.

4- 4- Metabolic screenMetabolic screen: Na, K, Ca, Mg, : Na, K, Ca, Mg, ……. (to exclude metabolic causes).……. (to exclude metabolic causes).

D.DD.D:: 1- 1- Of causes of recurrent convulsionsOf causes of recurrent convulsions

esp. conditions mimic epilepsy which are:esp. conditions mimic epilepsy which are: Syncopal attacks.Syncopal attacks. Breath-holding attacks.Breath-holding attacks. Rage attacks.Rage attacks. Paroxysmal vertigo.Paroxysmal vertigo. Pseudo-seizures.Pseudo-seizures. 2- 2- D.D. of the causeD.D. of the cause (Idiopathic or 2ry (Idiopathic or 2ry

….)….)

TreatmentTreatment:: I- I- INBETWEEN THE ATTACKSINBETWEEN THE ATTACKS:: 1- 1- ModerationModeration of activities and avoidance of the of activities and avoidance of the

predisposing factors.predisposing factors. 2- 2- Health educationHealth education of the parents about the disease of the parents about the disease

and advise them to watch and advise them to watch their child during swimming, running, passing the their child during swimming, running, passing the

traffic, …. traffic, …. 3-3- Drug therapy Drug therapy:: Only one drug is used in low dose then slightly Only one drug is used in low dose then slightly if no if no

response.response. If still no response 2nd drug may be tried either alone If still no response 2nd drug may be tried either alone

or in combination with the or in combination with the first drug.first drug. Duration of therapy is at least for 2 years after the last Duration of therapy is at least for 2 years after the last

attack.attack.

General side effects of antiGeneral side effects of anti--epileptics epileptics areare: :

1.1. DrowsinessDrowsiness

2.2. AtaxiaAtaxia

3.3. GIT disturbances GIT disturbances ((exceptexcept Phenobarbitone)Phenobarbitone)

Drug Indications Dose Side effects

Na valproate (Depakine)

Broad spectrum 20-40 mg/k/d General + Hepatotoxicity, alopecia and obesity.

Carbamazepine (Tegretol)

Partial and generalized

seizures

10-20 mg/k/d General + Hepatotoxicity and eye (diplopia and nystagmus).

Phenobarbitone (Sominaletta)

Broad spectrum 3-8 mg/k/d General + Rickets, behavioural changes

Phenytoin (Epanutin)

Generalized seizures

3-8 mg/k/d General + Rickets, hirsutism & gum hyperplasia

Ethoxumide (Zarontine)

Absence seizures 20-40 mg/k/d General + blood dyscriasis

II- II- DURING THE ATTACKDURING THE ATTACK:: 1- 1- GeneralGeneral: O2 and suction of : O2 and suction of

secretions.secretions. 2- 2- DrugsDrugs:: Diazepam 0.3-0.5 Diazepam 0.3-0.5

mg/kg/I.V. mg/kg/I.V. if no response if no response Phenobarbitone 10-15 mg/kg/I.V. Phenobarbitone 10-15 mg/kg/I.V. if no response if no response Phenytoin 10-15 mg/kg/I.V.Phenytoin 10-15 mg/kg/I.V.

III- III- STATUS EPILEPTICUSSTATUS EPILEPTICUS Convulsions lasting more than 30 minutes or Convulsions lasting more than 30 minutes or

repetitive convulsions without return of repetitive convulsions without return of consciousness.consciousness.

1- 1- Admission to ICUAdmission to ICU.. 2- 2- ABCABC Airway (keep patent airway with suction of Airway (keep patent airway with suction of

secretions. secretions. Breathing (O2 Breathing (O2 bag and mask ventilation bag and mask ventilation

pulse oxymetry for O2 saturation). pulse oxymetry for O2 saturation). Circulation (IV access, IV fluids & blood Circulation (IV access, IV fluids & blood

samples for electrolytes). samples for electrolytes).

3- 3- DrugsDrugs Diazepam (if no response) Diazepam (if no response)

phenobarbitone (if no response) phenobarbitone (if no response) phenytoin (if no response) phenytoin (if no response) Diazepam Diazepam continuos infusion (if no response) continuos infusion (if no response) paraldehyde I.V. (if no response) paraldehyde I.V. (if no response) General anaesthesia. General anaesthesia.