CONVULSIONS (SEIZURES).ppt

Abnormal jerky movements in children

1. CONVULSIONS (SEIZURES)
PROF. DR. SHAHENAZ M. HUSSEIN

3. Seizures

4. Definition:-
A seizure is the clinical event that result from abnormal
excessive neuronal activity.
Etiology:-
-Alteration of consciousness, motor activity, behavior, sensation or
autonomic function.
-It may be viewed as a symptom of an underlying disease process.
Classification:-
•Acute non recurrent convulsions:-
One or more convulsive fits that occur during the same acute illness &
do not recur after recovery:-
–Febrile convulsions. –hypertensive encephalopathy.
–CNs infections:-meningitis, encephalitis.
–Intra cranial Hemorrhage: spontaneous, or traumatic
–Toxic:-e.g tetanus. –Intracranial tumors.
–Anoxic:-sudden severe asphyxia.
–Metabolic:-hypoglycemia, hypocalcaemia, hypo or
hypernateremia.

5. •Chronic recurrent convulsions:-
Recurrent attacks of convulsions with symptoms free intervals:-
*Epilepsy:
--Idiopathic.
--Neurocutaneous synd. Such as Sturge-weber,
neurofibromatosis, tuberous scelosis.
–Organic secondary to brain insult:-post-infection,
post-traumatic, post-hypoxic, post-toxic.
–Benign neonatal convulsions.
*Degenerativebrain disease.
*Congenital cerebral malformation.

6. Electrical rhythm in epilepsy

7. Epilepsy
Defined as Increased Neuronal Excitability
•
•Partial:-Epileptic focus start localized and
remain localized:
Classified according to level of consciousness:
–No loss of consciousness:
Motor –Sensory –Autonomic.
–Loss of Consciousness: Temporal lobe epilepsy.
•Generalized:-Epileptic focus start localized then
become generalized.
–Grandmal –Febrile -Status epilepticus –Myoclonic
–Clonic –Atonic.--Petite mal (typical and atypical) –Tonic.
•Unclassified

8. Generalized tonic clonic
(grand-mal epilepsy)
The commonest form of childhood convulsions 60%:-
-An aura:-unusual behaviors recognized by the mother.
-Tonic phase:-powerful sustained contraction(5 minutes):-
–The patient falls to the ground stiff due to powerful
sustained contraction of all muscles.
–Arm flexed -Legs extended.
-Clonic phase:-Rhythmical contraction and relaxation of muscles
of limbs and face:-Biting the tongue and incontinence may
occur during the clonic phase.
-Duration of attack is variable but if exceed 20 minutes it
considered status epilepticus.

9. -Post epileptic phase:-The child falls in deep sleep and
afterwards he may be confused or irritable.
Grand-mal epilepsy has good prognosis if the first
attack start after the age of 3years and the mental
development is normal.
Febrile convulsion
Definition:-Generalized tonic clonic convulsions which
occasionally occur at the onset of acute extra-cranial
infections.
Incidence:-3-5% in all children.

11. Etiology:-
At the onset of acute extra-cranial infections such as
tonsillitis.
-Febrile seizures may signify a serious underlying acute
infections.
-In association with high environmental temp.
Clinical picture:-
Criteria for diagnosis of simple febrile convulsions:-
–Patient type:-Age: 6month to 6years. -
Sex: male more than female.
–Family history: Strong positive.
-Neurologically & metabolically free.

12. Seizures stages:-
–Pre-Ictal:-Convulsions occur at the onset of
temperature 39
o
c or more.
–Ictal:-Generalized tonic clonic.
–Short duration:-5-15 minutes.
–Course:-Usually one convulsive fit during
the same illness.
–Post-ictal:-Short postictal stupor.

13. Investigation
Laboratory:-
CSF analysis: Indicated if any doubt exist regarding
the possibility of meningitis.
EEG:-Indicated in atypicalfebrile seizure persists for more than
15 minutes or recurrent more than 3 time/day, or focal
seizures.
A child at risk for developing epilepsy:-
–Positive family history of epilepsy
–Initial febrile seizures before the age of 6 months.
–A febrile seizure.
–Delayed developmental milestone.
–Associated Respiratory manifestation (cyanosis).

14. Prognosis:-Risk for developing epilepsy is 1% in
children without risk factors,9% with risk factors.
Treatment:-
–Immediate first aid measures.
–Measures to lower the temperature:-
Cold fomentation / Antipyretics.
–Treatment of the cause of fever e.g Antibiotics
for acute tonsillitis.
–Short acting anticonvulsant:-Diazepam (valium)
0.25mg/kg/dose.

15. Generalized absence = petit-mal epilepsy
-The commonest age 5-9 years.
-Rare below 2years and never continue after 15 years.
-Short sudden loss of consciousness.
-The child suddenly stops talking and stares for few
seconds.
-Recovery is immediate and child resumes talking.
-Not associated with limb movement.
-Recurrent up to more than 100 times/day.
-May affect school performance.

16. Myoclonic epilepsy
-Occurs at any age but is more seen in infants and young
children.
-Usually associated with mental retardation.
-The attack which is very frequent, present with sudden
symmetrical mass jerking involving all limbs.
Juvenile myoclonic epilepsy
-Occurs during adolescence
–A.D. -Chromosome No. 6
–The hallmark is morning myoclonus within 90 minutes after
awakening.
-Resolved with Valporic acid therapy for life.

17. Atonic (a kinetic) epilepsy
-It is a type of myoclonic epilepsy.
-Transient loss of consciousness and falling on the ground.
-Then immediately the child gets up and resumes activity.
-The condition may be confused with petit mal.
Benign neonatal convulsions
-A.D. -Chromosome No. 20
-Generalized clonic seizures
-Occurs toward the end of the 1
st
week of life.
-Called familial 5
th
day fits.
-Favorable prognosis.

18. Infantile spasm ( West syndrome)
•Brief convulsionof the neck, trunk and arm muscles followed by
sustained muscle contraction lasting 2 to 10 seconds.
•Occurs when the child awakening or going to sleep.
•Each jerk is followed by a brief period of relaxation, many clusters occurs
each day.
•EEG showed Hypsarrhythmia ( high-voltage slow waves, spikes and
polyspikes).
•Peak age 3-8 months. -It could be mistaken for infantile colic.
•Treatmentby ACTH,or oral steroids, or benzodiazepines,or valproic acid
and vigabatrinis also promising.

19. Status epilepticus
Definition:-
Continuous convulsion or repeated convulsions
without return of the level of consciousness more
than 20 min.
Causes:-
-Sudden withdrawal of anticonvulsant.
-Febrile convulsion in poorly controlled epileptic
patient.
-Metabolic or toxic.

20. Management:
1-Stop the convulsion by:-
-Diazepam 0.2 –0.4mg / kg / dose I.V. or 0.5mg/kg/dose rectally.
-Chloral hydrate or paraldehyde:-0.15 mg/kg diluted in saline I.V
or 0.5ml/kg/dose rectally
-If failed give general anesthesia (short acting barbiturates).
2-Long-term anticonvulsant:-
–Phenobarbitone 3-5mg/kg/day.
–Diphenylhydantoin 5-8mg/kg/day.
3-Evaluation of the patient: After the attack Todd's paralysis
may occur and then resolve completely.

21. Partial (focal) seizures
•Motor : Jacksonian epilepsy
(simple partial motor seizures):-
–Involve the motor area of the brain and the patient is
alert.
–Consists of clonic movements in a localized group of
muscles. Commonly at the Corner of mouth, Thumb,
and Great toe.
–Jacksonian march:-The neuronal discharge may
spread to other parts on the same side or become
generalized.
–Rarely may continue for hours or day (epilepsia
partialis continue).
–After the attack, there may be weakness of the part
involved (Todd's) paralysis.

22. •Sensory seizures:-(simple partial sensory seizures):-
–Localized or spreading parasethesia:-tingling,
coldness, numbness electricity or even pain.
•Autonomic seizures-(simple partial autonomic
seizures):-
Autonomic manifestation:
-Sweating. -Tachycardia.
–Diarrhea or Constipation.
–Hypertension.
–Abdominal pain (abdominal epilepsy).
–Pupillary dilatation or constriction.

23. Temporal lobe (psychomotor)
Partial complex epilepsy
Sequence of events:-
–Aura:-blinking of eyes, abnormal sound, taste, smell or
movement.
–Absence:-loss of consciousness.
–Automatism:-automatic movements e.g: chewing,
smacking of lips.
–Amnesia:-recent amnesia for all events during the
attack.
Treatment of epilepsy
Duration of therapy:-
–3 or 4 years after the last convulsions in grand-mal or
petit mal epilepsy in an otherwise normal child.
–Longer period or even life long for those with associated
neurological problems.

24. •Advice to parents & child:-
–Give full information about the drug therapy
and stress on not to stop the drugwithout
medical advice.
–Allow normal activities:-the child should be
attended by a responsible adult while bathing
or swimming.
–Give clear instructions about the first-aid
measures in case the seizures:
1.Ensure patent airway.
2.Avoid biting the tongue
3.Putting the child in the prone or side position with head
down.

25. •Anticonvulsants:
Type of seizuresDrug of choiceDaily dose Side effects
Neonatal Phenobarbitone3-5 mg/kg Irritability,overactivity
Grand-mal Na-Valproat,
Phentoin,
Carpamazepine
10-20mg/kg
4-8mg/kg
10-20mg/kg
-Hepatic dysfunction
-Ataxia,gum
hypertrophy.
-Rash, Leucopenia,
hepatic dysfunction
Focal motor Carpamazepine4-8mg/kg Rash, Leucopenia,
hepatic dysfunction
Psychomotor Carpamazepine4-8mg/kg Rash, Leucopenia,
hepatic dysfunction
Myoclonic, Akinetic Clonazepam 0.05-0.2mg/kgDrowsiness, salivation,
sedation
Petit-mal Ethosuximide 20-40mg/kg Rash, Leucopenia,
hepatic dysfunction
Status EpilepticusDiazepam 0.2-0.4mg/kgRespiratory depression

26. New drugs used for treatment of epilepsy:
-Forgeneralizedseizures:
•Lamotrigine
•Topiramate
•Zonisamide
-For partialseizures:
*Gabapentine
-ForInfatile spasm:
*Topiramate
*Vigabatrin