2. Early Diagnosis & Early Management of Pediatric Symptomatic Seizure & Epilepsy for GP_Arie Khairani, dr., Sp.S.ppt

Early Diagnosis & Early Management of Pediatric Symptomatic Seizure & Epilepsy for GP

1. Early Diagnosis and Management of
Pediatric Symptomatic Seizure and Epilepsy for GP
Arie Khairani, dr., Sp.S
AsclepioEdukasi Medika ©2020

2. Definition of Seizure
Episodes of paroxysmal event, can occur as:
-Altered behavior
-Altered consciousness / awareness
-Movement
-Sensation (sensoric)
-Autonomic function
Due to abnormal firing of a network of neurons

3. When a Seizure is Manifestation of Epilepsy?
•Acute disturbance of physiology
•Electrolyte imbalance
•Hypoglycemia
•Acute increased of intracranial pressure (eg.acutecerebral
hemorrhage)
•Acute ischemic insult to the brain
•Acute trauma
Provoked
•No immediate cause
•Brain predisposed to seizure occurrence (low seizure
threshold)Unprovoked
Gray Zone

4. Definition of Epilepsy
International League Against Epilepsy (ILAE)
•Epileptic seizure: transient occurrence of signs and / or symptoms due
to abnormal excessive or synchronous neuronal activity in the brain
•Epilepsy: disease characterized by enduring predisposition to generate
epileptic seizures an by the neurobiological, cognitive, psychological and
social consequences of this condition
Seizureis an event, epilepsyis the disease (seizure + other issues)

5. Incidence of Epilepsy
Worldwide 70 million people, 7.1 per 1000 population per year
Hauser and Hesdorffer (1990) 1% of all children would have at least one afebrile seizure by age
14 yo, 0.4-0.8% would have epilepsy by age 11 yo
Ngugi AK et al. Incidence of epilepsy: A systematic review and meta-analysis . Neurology. 2011;77(10):1005-1012
Hirtz D, et al. How common are the common neurologic disorders?.Neurology.2007;68(5): 326-337
Children-adolescent :
57 / 100.000 per year (41-65)
Infants and older people yielded higher
incidence

6. Seizure Classification

7. Focal Seizures
•Originates in a focal area in the cortex
•Sympoms / semiology depends on which areas involved
•Seizure network involve different areas in 1 seizure
•Secondary generalized seizure, now is called focal to bilateral tonic
clonic

8. Generalized Seizures
Might originate at some point within, which then rapidly
propagate bilaterally in the network.
Diagnosis semiology + EEG findings

9. FOCAL GENERALIZED

10. Clinical questions to be answered
Is it
epilepsy?
If yes, what
kind of
epilepsy?
Does it fit a
syndrome?
What is the
etiology?
What is the
prognosis?

11. Step to epilepsy diagnosis
Detailed history taking
EEG
Imaging (MRI is the modality of choice for
epilepsy)
If the case is not clear cut, wait and observe. Not to hurry in making the diagnosis.

12. EEG in new onset epilepsy
•All unprovoked seizure require EEG
•It serves as supportive evidence that event in question IS a seizure
•To determine onset focal or generalized?
•To determine syndrome diagnosis Benign rolandic epilepsy,
childhood absence epilepsy, infantile spasm etc
•Not necessarily determine the etiology need further workup
including imaging

13. Imaging in New Onset Epilepsy
•In ALL focal epilepsy except Benign Rolandic Epilepsy
•Not required in a straightforward idiopathic generalized epilepsy
syndromes
•To determine the etiology (structural cause)
•MRI is preferrable, but head CT can be performed if MRI is not
available or in acute settings

14. How likely epileptic seizure to recur
after 1
st
seizure?
1
st
unprovoked seizure
•2
nd
seizure 40%
•3
rd
seizure 80%
Berg and Shinner, 1991, Camfield et al 1985
Exceptions:
Normal child, 1
st
generalized onset seizure, normal EEG 20-30%
Impaired child, focal seizure, spikes on EEG 80-90%

15. Risk factors for seizure recurrence after 1
st
Remote symptomatic etiology
Abnormal EEG
Prior febrile seizures
Seizure while asleep
Todd’s paresis
Shinnars . 2000

16. Medication for epilepsy
•Is it truly epilepsy?
•Focal or generalized?
•Does it fulfill any epilepsy syndrome?
Start with correct diagnosis
•Type, frequency, severity, semiology
What is the seizure characteristics?
•Efficacy, potential side effects, titration schedule, drug interactions, dosing forms, cost (insurance
coverage)
Medication characteristics
•Co-morbidities, drug interaction, socioeconomic situation, compliance
Patient characteristics

17. What is the medication goal?

19. Epilepsy Mind Map

20. What is the chance of seizure remission?
M Sillanpaa, D Schmidt. 2017

21. What is the chance for successful medications
weaning off?
•If patient has been seizure free for 1-2 years, 50-70% patients would
successfully stop the meds.
•Predictors for good outcome generalized onset seizure, age of
onset <10 yo (childhood onset), clearance of interictal epileptiform
discharges on EEG
•All the risk factors mentioned before would generally decrease
success rate
Get an evaluation EEG, discuss weaning with parents (risk and benefit, what parents have to observe and
report, etc), wean slowly, observe the patients after some times after medications are off.

22. Status Epilepticus
•Condition resulting either from the failure of the mechanisms
responsible for seizure termination or from the initiation of
mechanisms, which lead to abnormally prolonged seizures (after time
point t1).
•Condition which can have long term consequences (after time point
t2), including neuronal death, neuronal injury and alteration of
neuronal networks depending on the type and duration of seizures
Trinka E, Kalviainen R. 2016

23. Trinka E, Kalviainen R. 2016

24. Diazepam
Pediatric: 0.2-0.5 mg/kg IV
Adult: 5-10 mg IV/IM
May be repeated 2x in 5 minutes interval, (<= 5 yomax.5 mg, >5 yomax 10 mg per
dose)ER / WARD
Phenytoin
20 mg/kg IV
Diluted only in NS 0.9%, not exceeding concentration of 10 mg / ml
Example: 1 gram should be diluted in NS 0.9% minimal 100 cc
Seizure continue
Midazolam
(not ventilated)
Drip 0.06 –0.1 mg/kg/hour
HIGH CARE UNIT/
STROKE CARE UNIT
Seizure continue
Seizure continue
Midazolam
Drip 0.1 -2 mg/kg/hour
Propofol
Bolus 1-3 mg/kg
Drip 2-10 mg/kg/hour
Pentobarbital
Bolus 5-15 mg
Drip 0.5-5 mg/kg/hour
INTUBATE –TRANSFER TO ICU
10 minutes
20
-
30 minutes
>40 minutes
30
-
40 minutes
NATIONAL BRAIN CENTER HOSPITAL
STATUS EPILEPTICUS ALGORITHM
Ketamine
Bolus 1-2 mg
Drip 0.6-10 mg/kg/hour

25. Refractory epilepsy
ILAE definition
•Failure of adequate drug trials of 2 tolerated appropriately chosen
and used antiepileptic drugs (whether as monotherapyor in
combination) to achieve sustained seizure freedom
Failures are not necessarily in term of efficacy, but also in tolerability.
If a medication fails due to intolerability, can still consider for other treatment options.

26. Some etiologies of refractory epilepsy in children
Structural Causes
•Hemimegaencephaly
•Tuberous Sclerosis Complex
•Focal Cortical dysplasia
•Patchygyria, Polymicrogyria
•Etc
Continuum: Lifelong Learning in neurology. Child Neurology Vol 24(1). 2018

27. Options other than anti seizure medications
Ketogenicdiet
Epilepsy
surgery

28. Ketogenic diet
•Any tipesof onset, fulfilling the definition of refractory epilepsy
•If focal , but risk of deficits from resection is too high
Types of epilepsy
•Preferably young age
•Tube fed
•Had no contraindications to KD
Patient
•Unwilling to do epilepsy surgery
•Willing to do the KD plan
Family

29. Epilepsy Surgery
Resection:
Removing a portion
of the brain (lobe or
sublobar)
Disconnection:
Corpus Callosotomy
Hemispherotomy
Devices:
VNS
RNS (DBS)

30. QUIZ
A. Discrete
B. Focal
C. Partial
D. Hemispheric
1.According to 2017 International League Against Epilepsy (ILAE) classification
system, which of the following terms should be used to describe a seizure
originating within a neuronal network limited to one hemisphere?

31. QUIZ
A. Idiopathic generalized epilepsy
B. Focal seizure with history of remote brain insult
C. Benign RolandicEpilepsy
D. Juvenile myoclonicepilepsy
2. Which seizure below is the indication for brain imaging?

32. QUIZ
A. Seizure characteristics
B. Patient characteristics
C. Comorbidities
D. Seizure onset
3. Below are considerations in choosing medications for epilepsy, except:

33. QUIZ
A. Remote symptomatic etiology
B. Nocturnal seizure
C. Todd’s paresis
D. Juvenile onset
4. Below are risk factors for seizure recurrence after 1
st
unprovoked seizure,
except:

34. QUIZ
A. 1 year seizure freedom
B. Focal onset seizure
C. Todd’s paresis
D. Childhood onset
5. Below are predictors of successful medication weaning off: