Transcript Pediatric Seizures

Pediatric Seizures
An Overview
Childhood Seizures
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Evaluation
Classification
Diagnosis
Treatment
Mimics
Evaluation
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Frequency: 4-6/1,000
History
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Focal or Generalized
Duration, State of Consciousness, Triggers
Aura, Behavior, Posture, Post-ictal State
Examination
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Vitals, HC, HSM, abnormal Neuro exam
Skin exam, Retinal exam, hyperventilation
Classification-Febrile Seizures
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3-4% of population
Most common
Excellent prognosis
9 months to 5 years; peak 14-18 months
Strong family history of febrile seizures
Rapid rising temp, >38 degrees Celsius
Generalized Tonic/Clonic; <10 minutes
If exam is normal, No further Work-up
Rectal Diazepam for recurrence
Febrile Seizures (2)
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Work up is necessary if:
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More than one febrile seizure in 24 hours
Seizure last for more than 10 minutes
Focal seizure characteristics
Positive physical exam suggestive of infectious,
structural, neurologic, congenital pathology
Classification-Partial Seizures
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Simple Partial Seizures
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Maintained Consciousness
Motor activity: Versive Seizures
Sensory: aura
Autonomic
No automatisms, No tics (can be suppressed)
EEG: spikes, sharp waves in a unilateral or
bilateral or multifocal pattern
Duration: 10-20 seconds
Partial Seizures (2)
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Complex Partial Seizures (impaired LOC)
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Simple partial seizure followed by LOC
Consciousness impaired at onset of seizure
Aura: 1/3 of patients with PS
Automatisms: ¾ of patients with CPS
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Following LOC into postictal phase, not recalled
Infant: alimentary; Child: gestural, unplanned
PS (3): CPS (cont’d)
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Spreading of discharge throughout brain can lead to
secondary generalization (tonic-clonic)
EEG: Anterior temporal lobe sharp waves, focal
spikes or multifocal spikes
Normal EEG in 20%; must use sleep deprived,
prolonged techniques
Duration: 1-2 minutes
Needs CT or MRI to rule out structural causes
PS (4): BPEC
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Benign Partial Epilepsy with Centrotemporal
Spikes (Rolandic Epilepsy)
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Excellent Prognosis
Ages: 2 – 14; peak onset at 9 – 10 years old
Facial tonic-clonic symptoms
Normal exam, possible positive FamHx
One seizure: 20%; Repeated clusters: 25%
Occurs during sleep: 75%
EEG: repetitive spike in rolandic area, o/w nl.
Classification: Generalized
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Absence
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Simple: Cessation of activity with blank facial
expression, flickering of eyelids
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Usually after age 5, F>M, hyperventilation
No aura, no postictal state, duration <30 seconds
3/sec spike, generalized wave discharge
Complex: Associated motor symptoms
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Myoclonic movements of face, fingers, extremities
May have loss of body tone
2-2.5/sec spike and wave discharge
Generalized (2)
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Generalized Tonic Clonic
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Focal Onset or De Novo
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Tonic Contractions
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LOC, eyes roll back, cyanosis, apnea
Clonic Contractions
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Aura can suggest origin
Rhythmic contraction/relaxation, loss of sphincter
Post-ictal: 30 minutes to 2 hours
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Truncal ataxia, hyperactive DTRs, Babinski’s
Vomiting, intense bifrontal headache
Generalized (3); T/C (2)
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Triggers
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Low grade fever
Fatigue
Stress
Drugs: Methylphenidate, psychotropics, etc…
Duration: Few minutes
Idiopathic
Generalized (4)
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Myoclonic Epilepsies of Childhood
Repetitive seizures
Brief, symmetrical contractions
Loss of body tone—falling, slumping forward
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Benign Myoclonus of Infancy
Myoclonic Epilepsy of Early Childhood
Complex Myoclonic Epilepsy
Juvenile Myoclonic Epilepsy
Generalized (5); MEC (2)
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Infancy
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Neck, trunk, extremities
Normal EEG, Ends by 2 years, no meds
Early Childhood
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6 months – 4 years
Favorable outcome, 50% seizure free
MR, social problems in the minority
Positive EEG, possible genetic background
May have concurrent tonic/clonic or febrile seizures
Generalized (6); MEC (3)
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Complex
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Poor prognosis
Focal or generalized seizures <1 year of age
History: hypoxic-ischemic encephalopathy,
microcephaly
Positive EEG, less prominent FamHx
Refractory to meds
MR, behavioral problems in 75%
Lennox Gastaut syndrome
Generalized (7); MEC (4)
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Juvenile
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Between ages 12 – 16
5% of all epilepsies
Initial: Morning myoclonic jerks
Later: Morning Generalized Tonic Clonic szs
Positive EEG: 4-6/sec irregular spike
Enhanced with photic stimulation
Normal exam, lifelong meds (Valproic Acid)
Generalized (8)
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Infantile Spasms
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Between 4 – 8 months
Flexor, Extensor, or Mixed spasms
Cryptogenic: 10-20%, normal work-up
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Symptomatic: 80-90%, underlying pathology
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Good prognosis
Prenatal and Perinatal etiologies
MR 80-90%
Positive EEG: hypsarrhythmia pattern
Diagnosis
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Minimum
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EEG techniques: 40% of EEGs are normal
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Sleep deprived, prolonged (72 hrs), photic
CSF
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Blood glucose, calcium, mag, lytes, EEG
Infectious etiology suspected
Radiologic: CT or MRI1
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Prolonged or intractable szs, neuro deficit, increased ICP
High risk: Predisposing factors, focal sz <33 months
Treatment
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Treat after the first uncomplicated seizure with
a negative work up—80% will NOT have
another seizure2
Educate patient and family of possible long
term use and side effects
May terminate meds after 2 seizure free years
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Wean over 3-6 months due to possible recurrence
or status.
Treatment (2)
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Carbamazepine or Tegretol
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Phenytoin or Dilantin
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Gen T/C; watch behavioral changes
Sodium Valproate or Valproic Acid
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Gen T/C, partial; watch SJS, rashes, lupus-like
Phenobarbital
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Gen T/C, partial; watch leukopenia, LFTs
Gen T/C, absence, myoclonic; watch LFTs, Reyes
ACTH
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Infantile spasms; watch glucose, BP, lytes
Treatment (3)
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Ketogenic Diet
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Increases GABA inhibition of seizure activity
Recalcitrant seizures
Complex myoclonic epilepsy
Fat diet, restriction of CHO and protein
Surgical Options
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Vagal Nerve Stimulator3
Ablation therapy
Intractable seizures
Mimics
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BPV
Night Terrors
Breath Holding Spells
Simple Syncope
Cough Syncope
Shuddering Attacks
Pseudoseizure
Benign Paroxysmal Torticollis of Infancy
Bibliography
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1Sharma,
et. al, “Role of Emergent
Neuroimaging…,” Pediatrics, Vol 111,
January, 2003.
2Shinnar, et. al, “Risk of Seizure
Recurrence…,” Pediatrics, Vol 98, August,
1996.
3Parker, et. al, “VNS in Epileptic
Encephalopathies,” Pediatrics, Vol 103, April,
1999.