Seizures in children, dr.amit vatkar, pediatric neurologist

pediatric epilepsy, pediatric neurologist, seizure management, epilepsy management

1. Diagnosis & Treatment of Pediatric Epilepsy

2. Ayurveda and epilepsy APASMARA/ APASMRITI 4 Types – Vata Pitta Kapha Sannipata Caraka Samhita - 1000- 800 BC Nidana Sthana (Diagnosis) Chikitsha Sthana (Treatment)

3. Definitions Seizure Acute clinical change due to an abnormal neuronal discharge Epilepsy Two or more unprovoked seizures more than 24 hrs apart – epileptic tendency One Seizure with abnormal Neurological Examination Or EEG Or MRI Situation related Seizures provoked by illness / metabolic disturbance / toxic event, does not denote epileptic tendency

4. How do children differ? 70% of epilepsy starts in childhood Age related seizures eg. Infantile spasms, febrile seizures Status epilepticus is common Generalized seizures common Effects on brain development Drugs – dosage, side effects High rate of spontaneous remission

5. Clinical Presentation Events That Mimic Seizures Apnea Breath Holding Dizziness Myoclonus Pseudoseizures Psychogenic Seizures Rigors Shuddering Syncope Tics Transient Ischemic Attacks

6. Seizure precipitants Stress, emotion Sleep/sleep deprivation Hyperventilation Fever Medications, metabolic disturbance Reflex epilepsy Photic stimuli: TV, flashing lights, visual patterns Startle, music, reading, eating

7. First Unprovoked Seizure: Diagnostic Testing Laboratory tests are based on individual clinical circumstances and may include: CBC with differential Blood glucose Electrolytes Calcium, magnesium, phosphorous Urine drug/toxicology screen Urine HCG (age dependent) Lumbar puncture is only indicated if there are other symptoms that suggest a diagnosis of meningitis.

8. First Unprovoked Seizure: Diagnostic Testing – MRI Outpatient MRI should be considered for: Children under 1 year of age All children with significant acute cognitive or motor impairment Unexplained abnormalities on neurologic exam Seizure of focal onset without generalization Abnormal EEG Abnormalities on MRI are seen in up to 1/3 rd of children However, most abnormalities do not influence immediate treatment or management (such as need for hospitalization)

9. First Unprovoked Seizure: Diagnostic Testing – EEG Obtain on ALL children in whom a nonfebrile seizure has been diagnosed Can be arranged as an outpatient Should be interpreted by a neurologist (preferably pediatric neurologist) EEG results will: Help predict the risk of recurrence Classify the seizure type or epilepsy syndrome Influence the decision to perform additional neuroimaging studies

10. Overall Recurrence Risk 42% recurrence Mean time to recurrence 11.3 months 36% in first month 53% in 6 months 88% in 2 years

11. Why do we treat? Reduce recurrence risk Prevent prolonged seizures Minimize impact on development/academic achievement Does NOT affect natural history if you are going to outgrow it, you will regardless of treatment

12. Treatment? Every child/family is different Treatment may reduce recurrence risk by as much as 50%. AED’s are toxic medications! For the most part we do not treat after a first time seizure. The one exception- Remote symptomatic presenting in status.

13. Treatment options Daily anti-epileptic drugs (AED’s) Abortive medications Specialized diets Surgery Resective Devices, ie Vagal nerve stimulator

14. No seizures and No side effects!

15. First vs Second generation First generation Phenobarbital Phenytoin ( Dilantin ) Carbamazepine ( Tegretol ) Ethosuxamide ( Zarontin ) Valproate ( Depakote,Depakene ) Benzodiazepines Lorazepam ( Ativan ) Midazolam (Versed) Diazepam (Valium) Clonazepam ( Klonipin ) Chlorazepate ( Tranxene ) Second generation Ox- carbazepine ( Trileptal ) Lamotrigine ( Lamictal ) Gabapentin ( Neurontin ) Topiramate ( Topamax ) Levetiracetam ( Keppra ) Zonisamide ( Zonegran ) Pregabalin ( Lyrica ) Lacosamide ( Vimpat )

16. Side Effects Phenobarbital-sedation Valproate -weight gain, liver toxicity, decreased platelets, pancreatitis Sodium abnormalities-ox- carbazepine Lamotrigine -Steven’s Johnson syndrome Topiramate -weight loss, language dysfunction, kidney stones, glaucoma Levetiracetam-irritability,agitation

17. Long Term Follow-up 37 year f/u of 144 patients 31% enter remission in first year of Rx 19% are resistant from the beginning Overall 67% achieve terminal remission 14% on AED ’ s 86% off AED ’ s

18. Lesional epilepsy Complete resection of lesion AND electrographically abnormal region 92% have good outcome sz free or >90% reduction Electrographically abnormal region Electrocortiography Chronic subdural grid recordings

19. THANK YOU