SEIZURES_IN_CHILDREN- br Rashmi kumar prof and head

PowerPoints for medical students

1. SEIZURES IN CHILDREN
Rashmi Kumar
Prof & Head, Pediatrics
King George Medical University
Lucknow

2. •Prevalence
•Definition
•Conditions that mimic seizures
•Pathophysiology
•Etiology
•Age wise etiology
•Classification
•Assessment
•Febrile seizures
•Management

3. SEIZURES
•One of the most common life threatening events in
childhood, more than adults
•Paroxysmal electrical activity in brain -->
motor/sensory/autonomic disturbance with
/without alteration of consciousness
•Convulsion – seizure with motor activity 5%
•Epilepsy – recurrent (2 or more) unprovoked
seizures beyond newborn period 0.5%

4. Seizures: DDx
Tremors –distal, rhythmic, equal amplitude, no loss of
consciousness
Jitteriness
Breath holding spells –always after crying, sequence of
events important
Syncope – after prolonged standing/emotional upset,
gradual loss of consciousness, slow pulse, pallor, sweating,
improves in supine/head down position
Pseudoseizures – older girl, never hurts herself, bizarre
movements, normal s Prolactin
Detailed sequence of events necessary – HISTORY, HISTORY, HISTORY

5. Seizures: Pathophysiology:
Sustained partial depolarisation in a group of
neurons -->excitability --> sudden
depolarisation in response to stimuli --
>conduction to surrounding cells, distant
synaptically connected cells & subcortical
neurons -->dissemination -->loss of
consciousness

6. SEIZURES - ETIOLOGY
1st fit/ recurrent fits
I Symptomatic
•Infectious/ post infectious (including granulomas)
•Anoxic/post anoxic
•Vascular
•Trauma/post traumatic
•Tumour
•Congenital - porencephaly, lissencephaly, agenesis of corpus callosum,
neurocutaneous syndromes
•Degenerative
•Metabolic - hypocalcemia/hypomagnesemia
• hypo/hypernatremia
• hypoglycemia
• pyridoxine deficiency
• Inborn errors
•Drugs/Toxins -aminophylline,antihistamines,steroids,phenothiazines,
• hexachlorophene, strychnine, camphor, INH, tetanus, lead,
• shigella/salmonella
•Acute cerebral edema - Hypertension
•Febrile
II Idiopathic

7. Newborn 1-6 mths 6m-3 yrs >3 yrs
Birth asphyxia/trauma birth asphyxia Febrile idiopathic
IVH cranial malformations CNS infections
Hypocal/hypoglyc inborn errors
IU infections IU infections
Degenerative
Meningitis metabolic
Tetanus
tumour
Inborn errors other
Kernicterus
Polycythemia
Narcotic withdrawal

8. CLASSIFICATION OF EPILEPTIC
SEIZURES: ILAE 1981
•I Partial 54%
–Simple - motor/sensory/autonomic 7.7%
–Complex 35.5%
–Partial with secondary generalization 56.4%
•II Generalised 40.4%
–Tonic clonic 69%
–Absence 3%
–Myoclonic 20.5%
–Tonic 4.1%
–Atonic 3.1%
•III Unclassifiable 6% (hospital based study in Mumbai)
•However, same patient can have more than 1 type
•Many patients show a distinct evolution of disease

9. CLASSIFICATION OF EPILEPTIC
SYNDROMES : ILAE 1989
I Localisation related
•Symptomatic
•Cryptogenic
•Idiopathic
II Generalised
•Idiopathic
•Cryptogenic
–West syndrome
–Lennox Gastaut syndrome
–epilepsy with myoclonic astatic seizures
–epilepsy with myoclonic absences
•Symptomatic
–Non specific
–specific
III Epilepsies undetermined whether focal or generalised
IV Special syndromes
CLASSIFICATIO
N OF EPILEPSY
STILL EVOLVING

10. EPILEPSY - SPECIAL TYPES:
GTCS: v common
•Aura  tonic spasm loss of consciousness  fall  clonic
movements
•Rolling of eyeballs/Frothing at mouth/Distortion of face
•Incontinence/ Jerky breathing
•Post ictal sleep

11. Absence epilepsy
•2-4% of childhood idiopathic epilepsy
•Girls 3-7 yrs, normal IQ
•Transient loss of consciousness for few secs
•No loss of tone
•Ppted by hyperventilation -
•Treatment – Ethosuximide, valproate
•May develop GTCS
•EEG - 3/sec spike & wave activity

13. EPILEPSY - SPECIAL TYPES:
Infantile spasms: Onset in 1st year
•Sudden flexion/extension in series esp on awakening
•Upto 100 times /day
•60% secondary, 30% cryptogenic
•Treatment - ACTH/steroids/ vigabatrin
•Associated with mental regression
•EEG - hypsarrhythmic
•May develop GTCS
Lennox Gastaut:
• 1-8 yrs,
• tonic/atonic/absence type
• EEG - diffuse 2 Hz spike-waves
• Very difficult to control

15. EPILEPSY - SPECIAL TYPES:
Psychomotor (Temporal lobe) seizures: Complex partial seizures
with origin in temporal lobe.
• Purposeful but inappropriate acts 'automatisms'
• Associated with behavioral problems
• Difficult to diagnose or treat.
Benign epilepsy with centrotemporal spikes: Partial, idiopathic,
• orofacial/hemifacial, 3-13 yrs, often during sleep. Easy to
control
Myoclonic: heterogenous, multiple causes
Juvenile myoclonic: myoclonic jerks esp after awakening
•EEG - 4-6 Hz polyspike, photosensitivity, GTCS may occur
•Good response to Valproate

16. FEBRILE SEIZURES:
•2-4% of children
•3m - 5 yr age
•Assn with fever due to extracranial infection
•Generalised, Short lasting, only one sz per illness
•No mental/neurological/EEG abnormality
•Typical vs Atypical (complex)
• Focal
• Prolonged
• >1 seizure during illness
•1/3 have at least 1 recurrence
•1/6 have multiple recurrences
•Risk of epilepsy:
–Fh/o epilepsy
–Atypical
–Abnormal neurologic/mental status

17. Febrile Seizures: Management
•Exclude CNS infection
•Control fever
•Look for & treat cause of fever
•Rectal diazepam
•Explain to parents, reassure
•If multiple - intermittent oral diazepam   by
80%
•If high risk for epilepsy  long term
phenobarb/valproate.

18. Seizures: ASSESSMENT
History:
•1st seizure/ recurrent seizures
•Fever
•Precipitating factors – diarrhea/ vomiting/ drug/ toxin/ metabolic
•Headache/vomiting/visual loss
•Duration
•Age at onset
•No of attacks
•Frequency /, change in seizure type, last seizure when?
•Exact description
– Aura
– partial/generalised onset
– Loss of consciousness
– Tonic/clonic phase
– Associated events - bed wetting/fall/tongue bite
– Duration
– Post ictal
•Precipitating factors
•Diurnal
•Family history
•Antecedant events - trauma/CNS infection/asphyxia
•Personality change/intellectual deterioration
•Failure to thrive
•Developmental milestones
•Treatment

19. Seizures: ASSESSMENT
Examination:
•BP
•Head circumference
•Skin lesions
•Facial features
•Organomegaly
•Fundus
•Meningeal signs
•Neurological deficit
•Development

20. Seizures: Investigations
• If features of CNS infection - CSF examination
• Glucose, Ca, Mg - low yield
• Skull Xray - calcification/  ICT - low yield
• EEG: Always diagnostic during a seizure
• Interictal record : normal in 40-50% of epileptics (spikes/sharp waves &
spikes –slow wave complexes)
  yield with sleep, sleep deprivation, hyperventilation, photic stimulation
• 2-10% normal population may have epileptic changes
• EEG indicated in all cases of epilepsy for:
• -confirmation of diagnosis & syndrome
• -type of seizures - absence vs temporal lobe,
• primary generalised vs secondarily generalised
• -presence of underlying lesion/ idiopathic vs symptomatic
• -follow up
• -before withdrawal of AEDs
• -localisation of focus before surgery
• Video EEG

21. Seizures: Imaging - CT/MRI
Has revolutionised the management of epilepsy
Indications: focal features on exam, EEG
Features of  ICT
Intractable
However, now indicated in every case with unknown cause
Not necessary in febrile/absence/BETS/ JME etc.
Western studies - 30% abnormal (30-50% of focal)
-only 3% treatable
Indian studies:
Very high prevalence of granuloma like lesions –recent onset
partial seizures in child/young adult
40% abn even after 1st seizure
 indicated in every case

24. MCQ
•The following are features of benign
(typical) febrile seizures except:
•They are short lasting
•They are always generalised
•They only occur within 4 hours of fever
onset
•They do not recur in the same febrile
illness

25. The typical EEG pattern in absence epilepsy
is:
•Intermittent spike and slow waves
•Hypsarrythmia
•Burst suppression
•3 per second spike and waves

26. The following is true about absence
epilepsy
•It occurs more commonly in boys
•There is loss of tone
•It is precipitated by hyperventilation
•Imaging is usually abnormal

27. Definition of epilepsy includes:
•At least 3 seizures
•EEG is abnormal
•Imaging is abnormal
•Beyond neonatal period

28. The following is true about breath holding
spells:
•It is usually preceded by crying
•Child is always blue
•There is no loss of consciousness
•EEG may show spikes

29. The following is true about infantile spasms
except:
•They occur in clusters
•They may appear like ‘startling’
•They usually occur during sleep
•They are also called ‘salaam attacks’

30. West syndrome usually has the following
features except:
•Infantile spasms
•Onset in newborn period
•Hypsarrythmia on EEG
•Psychomotor retardation or regression

31. Imaging in seizures is not indicated in:
•Generalised tonic clonic seizures
•Absence seizures
•Temporal lobe seizures
•Infantile spasms

32. Prevention of febrile seizures can be
achieved by:
•Intermittent phenobarb
•Long term phenytoin
•Intermittent diazepam
•Long term carbamazepine

33. Emergency dose of IV diazepam for seizure
control is:
•1 mg/kg
•0.5 mg/kg
•0.1 mg/kg
•0.3 mg/kg

34. Seizures - Management
•I Management of acute attack:
•Calm down
•Head down lateral position
•Prevent hurt
•If does'nt stop convulsing in 3-5 min,
• Inj Diazepam 0.3 mg/kg slow iv bolus
•Maybe repeated after 20 min
•Effect lasts 0.5-3 hrs
•SE- hypotension, respiratory depression, secretions
• or
•Rectal diazepam 0.5 mg/kg dose/ nasal midzolam
0.2 mg/kg/dose

35. Domiciliary Mx
•Rectal Diazepam 0.5 mg/kg
•Intranasal midzolam 0.2 mg/kg

36. Seizures: Status epilepticus:
•Prolonged seizure for >20 min or repeated
seizures without regaining consciousness
•Persistent seizure activity  hypoxia,
hypoglycemia, hyperthermia, cerebral
edema & vasomotor instability
•Life threatening
•Risk of permanent brain damage 
Medical emergency

37. Mx of Status epilepticus
ICU, monitoring
IV dextrose drip
Oxygen
IV Inj Diazepam 0.3 mg/kg or Lorazepam 0.1 mg/kg (longer action) or
Midzolam (lesser respiratory depression)
Inj phenytoin 15-20 mg/kg iv at a rate of <1mk/kg/min

Inj Phenobarbitone 20 mg/kg iv at a rate of 1 mg/kg/min or IV
Valproate 20 mg/kg as infusion in 50 ml NS over 30 min
Ventilatory support + diazepam/midzolam infusion

`` Thiopental infusion

38. LONG TERM MANAGEMENT OF
EPILEPSY:
I General advice:
•As normal a life style as possible
•No swimming/cycling on road/driving
•Inform teacher
•First aid
•Seizure dairy
•Regularity

39. LONG TERM MANAGEMENT OF
EPILEPSY:
Drugs:
•When to start? If 2 or more seizures within a 12 month
period
•Monotherapy:
•Start at lower limit & build up gradually till toxicity/control
•If no effect at maximum dose, taper off while introducing
2nd drug
•4 first line drugs - Carbamazepine, phenytoin, valproate
and phenobarbitone
•No drug completely safe
•70% can be controlled

40. First line AEDs
Carbamazepine:
•Ind: Partial, tonic clonic
•Dose: 10-30 mg/kg/d in 2-3 doses13-18 hrs,
•Adv: Relatively safe, improves cognitive fn.
•SE: Diplopia,drowsiness, giddiness
initially.Hepatitis, skin rash, BM depression, drug
interactions, dystonia, can aggravate minor motor
seizures

41. First line AEDs
Sodium valproate:
Ind: Broad spectrum
Dose: 20-30 mg/kg/d (upto 80) in 2-3 doses
Half Life; 7-10 hrs
SE: Nausea, vomiting, wt gain, hair loss,
hepatic failure, tremors, platelets, s
ammonia, s carnitine, no correlation
between drug levels & toxicity, levels of
other AEDs

42. First line AEDs
Phenobarbitone
Ind: Tonic-clonic, partial, febrile
Dose: 3-6 mg/kg/d as single doses
level:10-15 g/ml20-80 hrs
Adv: Cheap, once daily dose
SE: Drowsiness, hyperkinesia, cognitive
impairment ??, rash, rickets

43. First line AEDs
Diphenylhydantoin:
Ind: Tonic-clonic, atonic, partia
Dose: l4-8 mg/kg/d in 2 doses
level: 10-20 g/ml
Half Life: Upto 20 hrs
SE: Hirsutism, gum hyperplasia, rickets,
ataxia, lymphoma like syndrome, Sle like
illness, megaloblastic anemia, rash, low
margin of safety

44. Ethosuximide:
Ind: Absence seizures
Dose: 20-25 mg/kg/d in 2 doses
Half Life: 4-30 hrs
SE: Photophobia, WBC, nephrosis, blood
dyscrasia
ACTH:
Ind: West syndrome
Dose: 20-40 u/d for 4-6 wks
SE: hypercortisolism

45. Nitrazepam
Ind: Myoclonus, atypical absence
Dose: 0.5 mg/kg/d in 2 doses
SE: Sleepiness, salivation,hypotonia, ataxia, tolerance
Clonazepam
Dose: 0.05-0.25 mg/kg/d in 3 doses\
•Drug level monitoring
•EEGs
•When to stop ? 2-3 yrs seizure free

46. Newer AEDs
Clobazam
Ind: Partial, generalised & myoclonus (add on drug)
Dose: 0.5 mg/kg/d single dose
SE: Drowsiness, tolerance,  secretions
Gabapentin
Ind: Secondarily generalised, complex partial
SE: liver enzymes, impaired swallowing & aspiration,
somnolence, fatigue, dizziness, wt gain
Lamotrigine
Ind: Generalised, absence, JME, LG syndrome
SE: Synergy with valproate, skin rash, SJ syndrome

47. Newer AEDs/ Other modalities
Topiramate:
Ind: Partial, generalised, drop attacks, LG syndrome
SE: ?cognitive impairment
Vigabatrine:
Ind: Partial, infantile spasms
Dose: 40-80 mg/kg/d
SE: Drowsiness, agitation, confusion
Oxcarbazepine:
Derivative of carbamazepine
•Ketogenic diet
•Surgery