Seizure Disorders in Children Maura B. Price MD FRCPC FAAP February 2010

Seizure Facts 2 % of ER visits 40% will have a recurrence after first seizure Incidence 1/1000

Seizures Diagnosis Abrupt loss of responsiveness Rhythmic clonic movements Sustained changes in posture or tone Simple automatic movements Staring without change in tone Changes in cerebral electrical activity

Seizure Questions Where was child, what were they doing? Loss of consciousness? Any warning signs? Stiffness, jerking? What did eyes do, color change, saliva, tongue, urine or bowel control? How long did it last? Post ictal phase? Has the child been well? PMH for meningitis, head injury, brain damage? Child’s development? Family history?

Seizure Mimics Psychogenic seizures Syncope Migraine Breath-holding spell Sleep disturbances Tics Shuddering attacks Gastroesophageal reflux Cardiac conduction abnormalities Self-stimulating behaviors Hyperexplexia Benign tonic upgaze of infancy Paroxysmal dystonia

Paroxysmal Event

Febrile Seizures Age 6 month to 6 years Acute febrile illness Non focal, brief (< 15 minutes) Minimal work-up Treat fever and infection if required No AED required Reassure

Risk Factors for First Simple Febrile Seizure Family history of febrile seizures Neonatal discharge > 28 days Delayed development Child care attendance Low serum sodium Very high fever

Risk Factors for Recurrence of Febrile Seizure Young age < 18 months Family history of febrile or non-febrile Short duration of fever before initial seizure Relatively lower fever at onset Developmental delay

Febrile seizure talking points Most children do well and the risk of epilepsy is low The earlier the age of the first febrile the more likely a recurrence Diagnostic tests should never be routine Meningitis should be ruled out Treatment does not reduce development of epilepsy and has side effects

Trauma Apparent from history and physical Attention to clues for non-accidental trauma Persistence of post-ictal phase Careful ophthalmologic exam CT Admitted for observation +/- AEDs and usually less than a year

Fluids and Lytes Most commonly hypoglycemia or hyperglycemia, sodium and calcium Less Mg, Cl, Ph Prior diagnosis? Gastroenteritis Treat underlying disorder No AEDs

CNS Infection Must differentiate from first febrile LP if < 1 year (12-18 months) Strongly consider LP if prolonged, atypical, focal or prolonged post-ictal

Remote symptomatic Etiology is remote from event Perinatal hypoxic injury, congenital stroke, progressive neurodegenerative disease and prior meningitis Previous diagnosis of developmental delay or cerebral palsy EEG then brain imaging (MRI) AEDs used Neurology usually involved to some extent

Risk Factors for the Development of Epilepsy Suspect or abnormal development Family history of afebrile seizures First febrile seizure - complex Three or more febrile seizures Duration of recognized fever less than 1 hour

Epilepsy Generalized begins simultaneously in both cerebral hemispheres Generalized include absence, atypical absence, myoclonic, clonic, tonic, atonic, and tonic-clonic Partial seizures begin in a localized area of the cerebral cortex Partial further subdivided into simple where consciousness isn’t impaired or complex partial where have LOC and partial evolving into generalized

Epilepsy talking points Precise classification is important for treatment and prognosis Anticonvulsants are rarely used after first seizure if normal development, negative EEG and negative family history A history of aura epigastric discomfort, frightened) indicates focal onset If seizure free for 2 years on meds and normal neurologically >75% remain seizure free

Idiopathic No underlying neurologic disorder Clearly defined syndromes with fairly clear prognosis and treatment Genetically inherited although sometimes it’s just the EEG abn inherited

Benign Rolandic Epilepsy Starts age 5-15 Primarily nocturnal seizures after falling asleep or just before wakening Generalized convulsions or slurring EEG: bilateral independent temporal and central spikes Outgrown by early adolescence. No AEDs

Childhood Absence and Juvenile Absence Starring spells with or without automatisms (mouthing, eye blinking, head jerking) Hyperventilate in office EEG: 3 Hz spike wave discharges Rx VPA, Lamotragine, Ethosuximide Childhood absence outgrown by adolescence, in juvenile absence less common but usual remittance

Juvenile Myoclonic Epilepsy Age years Morning myoclonic jerks, starring spells generalized convulsions EEG: 3 to 4 Hz generalized spike and poly spike Rarely outgrow AEDs VPA, lamotrigine, leviteracitam

Benign Occipital Epilepsy Prolonged poor but maintained responsiveness, starring and occasional ictal vomiting and headache Confused with migraine Rarely occipital lesion - do MRI EEG: bi-occipital spikes Outgrown by adolescence AEDs low dose variable drug

Treatment of Status Epileptius Stabilize the patient first including ABC’s Oxygen and antipyretics and +/- glucose Draw labs if necessary IV Lorazepam or rectal diazepam gel