Transcript m5zn_2c3f66e03667359

SEIZURES
  Def:
 Paroxysmal involuntary disturbance of
brain function, manifested by abnormal
motor activities, sensory disturbance,
autonomic dysfunction or behavioral
abnormalities.
 1- Febrile convulsions
 2- First epileptic fit.
 3- Metabolic:
  Hypo (glycaemia, calcaemia,
magnesaemia).
  Hypo or hypernatraemia.
  Pyridoxine (B6) deficiency.
 4 CNS causes:
  Infection: Meningitis, encephalitis and brain






abscess.
 Irritation: Brain oedema.
 Tumours of the brain.
 Toxic: e.g. tetanus or drugs (aminophylline
and antihistamincs).
 Hge: Trauma, rupture aneurysm and Hgic
blood diseases.
 Hypoxia: Asphyxia, apnea, ……..
 Hypertensive encephalopathy, uraemic
encephalopathy, ……..
 B- Recurrent convulsions
 1- Recurrent febrile
convulsions.
 2- Epilepsy & 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, …..)
FEBRILE CONVULSIONS
  Def:
 Convulsions in children due to rapid
increase of body temperature due to
extracranial cause (e.g. tonsillitis,
pneumonia, …)
  Incidence:
  4% of children.
  Family history in about 20% of cases.
  Diagnosis:
 1- Age: 6 months  5 years (convulsions




below 6 months or above 5 years are not
considered febrile).
2- Temperature: usually > 39 convulsions
occur within 8-12 hours from the onset of
fever.
3- No evidence of CNS infection: e.g.
meningitis, abscess, ….
4- Evidence of extracranial infection: e.g.
sepsis, tonsillitis, ……
5- Types of convulsions:
 A- Simple febrile




convulsions:
 The most common
form.
 Usually generalized
tonic – clonic.
 Short duration (<15
min.).
 Usually one fit only
during 24 hours.
 B- Complex febrile




convulsions:
 Uncommon.
 May be focal.
 Prolonged duration.
 Fits may recur during
the same illness.
 6- Investigations:
 Not needed, but complex form may be
mistaken with CNS infection, so CSF is
done in doubtful diagnosis.
 7- D.D.:
 Other causes of convulsions.








 Treatment:
1- Control of convulsions: Diazepam
0.3-0.5 mg/Kg (I.V. or rectally).
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 recurrent
attacks (esp. complex form).
  Prognosis:
  Recurrence rate about 25%.
  The risk for developing epilepsy is
increased with:
  Family history of epilepsy.
  Pre-existing neurological disease.
  Complex form.
EPILEPSY
  Def.:

Recurrent seizures not related to fever or acute
brain insult.
  Aetiology:
 1- Idiopathic (1ry): 80% of cases either hereditary or
not.
 2- Organic (2ry): 20% of cases, may be:
  Congenital cerebral malformation.
  Degenerative brain diseases.
  Post-traumatic.
  Post-hgic.
  Post-infection.
  Post-toxic.
  Post-anoxic.
  Classification:
 1- Focal (partial) seizures:
  Only one part of the body is involved





(focal).
 Only one type of movements (tonic or
clonic).
 It has 3 types:
a- Simple partial seizures (SPS )
b- Complex partial seizures (CPS)
c- Partial seizures with 2ry
generalization
a- Simple partial seizures (SPS): b- Complex partial seizures
(CPS):
 No aura
 No automatism.
 No loss of consciousness.
 May be motor, sensory or
autonomic fits.
 Preceded by aura in 1/3 rd of
cases (fear, photophobia...).
 Automatism may occur
(automatic behaviors e.g.
chewing, swelling,
suckling or aggressive
maneuvers).
 Consciousness is impaired.
 Only motor fits occur.











2- Generalized seizures:
 Affect the whole body from the start.
 Classified into:
a- Absence seizures (petit mal):
 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.








b- Generalized tonic-clonic seizures (Grandmal): 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
(parasthesia) 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.
 c- Myoclonic epilepsy :
 Sudden shock like repetitive




contractions of group of muscles.
d -Infantile spasms :
Repetitive tonic contractions of the neck
and trunk muscles which occur in the
first year of life and carry a poor
prognosis
e -Atonic seizures:
Sudden loss of body tone and falling
down.
  Investigations:
 1- Electro-encephalo-gram (EEG):
must be done for all cases (despite it is
-ve in 40%).
 2- CT scan or MRI brain: indicated in:
focal lesions (e.g. hge), resistant to ttt
evidence of  ICT.
 3- CSF: Only indicated in suspected
CNS infection.
 4- Metabolic screen: Na, K, Ca, Mg,
……. (to exclude metabolic causes).
  D.D:
 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
….)
  Treatment:
 I- INBETWEEN THE ATTACKS:
 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.
 General side effects of anti-epileptics
are :
1. Drowsiness
2. Ataxia
3. GIT disturbances (except
Phenobarbitone)
Drug
Na
valproate
(Depakine)
Carbamazep
ine
(Tegretol)
Phenobarbit
one
(Sominalett
a)
Phenytoin
(Epanutin)
Ethoxumide
(Zarontine)
Indications
Broad spectrum
Dose
20-40 mg/k/d
Side effects
Hepatotoxicity,
+
General
alopecia and obesity.
Partial and
generalized
seizures
Broad spectrum
10-20 mg/k/d
General + Hepatotoxicity and
eye (diplopia and nystagmus).
3-8 mg/k/d
General + Rickets, behavioural
changes
Generalized
seizures
Absence seizures
3-8 mg/k/d
General + Rickets, hirsutism &
gum hyperplasia
General + blood dyscriasis
20-40 mg/k/d
 II- DURING THE ATTACK:
 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.
 III- STATUS EPILEPTICUS
 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 & 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.