Seizures E PILEPTIC / N on Epileptic What is that ??? Dr. Samir Khalil Consultant Pediatric Neurologist Makassed Hospital Clinical Assistant Professor Al-Quds University Dr. Samir Khalil Consultant Pediatric Neurologist Makassed Hospital Clinical Assistant Professor Al-Quds University School of Medicine Lectures 5 th year Updated September, 2012 Al-Quds University School of Medicine Lectures 5 th year Updated September, 2012

CONCEPTS & GLOSSARY Attack Seizure Convulsion Fit

Attack A violent act starting on with vigor

Attack Is used to describe epileptic & non-epileptic disorder. Is used to describe epileptic & non-epileptic disorder.

Attack Is used to describe epileptic & non-epileptic disorder. Is used to describe epileptic & non-epileptic disorder.

attack Is used to describe epileptic & non- epileptic disorder. Is used to describe epileptic & non- epileptic disorder. We say:  Attack of laughing  Breath Holding Attack / or spell  An attack of febrile convulsion  Conversion Reaction  Epileptic attack We say:  Attack of laughing  Breath Holding Attack / or spell  An attack of febrile convulsion  Conversion Reaction  Epileptic attack

attack ? Is used to describe epileptic & non- epileptic disorder. ? Is used to describe epileptic & non- epileptic disorder.

attack ? Is used to describe epileptic & non- epileptic disorder. ? Is used to describe epileptic & non- epileptic disorder.

convulsion An intense, paroxysmal, involuntary contraction or series of contractions of voluntary muscles An intense, paroxysmal, involuntary contraction or series of contractions of voluntary muscles

convulsion Is used to describe epileptic & non- epileptic motor act / shaking Is used to describe epileptic & non- epileptic motor act / shaking

convulsion Is used to describe epileptic & non- epileptic motor act / shaking Is used to describe epileptic & non- epileptic motor act / shaking

convulsion If there is no movement (displacement in place), the term “convulsion” is not applied. The term “convulsion” implies movement/s If there is no movement (displacement in place), the term “convulsion” is not applied. The term “convulsion” implies movement/s

convulsion We say:  Clonic convulsion but not tonic convulsions  Tonic-clonic convulsions  Myoclonic convulsion but not absence convulsion. ……Absence / Petit male is not a convulsion Neither arrhythmia nor tachycardia nor apnea We say:  Clonic convulsion but not tonic convulsions  Tonic-clonic convulsions  Myoclonic convulsion but not absence convulsion. ……Absence / Petit male is not a convulsion Neither arrhythmia nor tachycardia nor apnea

seizure A sudden, involuntary event/s that may include:   Motor activity   Altered level of consciousness   Somatosensory symptoms A sudden, involuntary event/s that may include:   Motor activity   Altered level of consciousness   Somatosensory symptoms

seizure Used to describe epileptic disorders

Seizure vs Convulsion  A convulsive attack:  Always labeled as seizure  Contrary, not all seizures convulse So a seizure is not synonym to convulsion We say Epileptic seizure/s. Grand male seizure/s. Petit male seizure/s. His absence seizures are completely controlled by Valproic acid  A convulsive attack:  Always labeled as seizure  Contrary, not all seizures convulse So a seizure is not synonym to convulsion We say Epileptic seizure/s. Grand male seizure/s. Petit male seizure/s. His absence seizures are completely controlled by Valproic acid

Fit A seizure or convulsion especially those of epileptic nature A seizure or convulsion especially those of epileptic nature

Seizures work up Pattern Duration Frequency Frequency Physiopathology Diagnosis Diagnosis Classification

Seizures’ Patterns M yoclonic I nfantile S pasm O pso M yoclonic O pso M yoclonic U n C lassified S tatus E pilepticus T ONIC C LONIC T ONIC- C LONIC T ONIC- C LONIC A TONIC A bsence

Seizures’ Pattern T ONIC

Seizures’ Pattern C LONIC

Seizures’ Pattern T ONIC- C LONIC ? T ONIC- C LONIC ?

Seizures’ Pattern M yoclonic

Seizures’ Pattern M yoclonic (Startels) M yoclonic (Startels)

Seizures’ Pattern Absence

Seizures’ Pattern Infantile Spasms

Seizures’ Pattern Opso Myoclonic

Seizures’ Pattern Opso Myoclonic

Seizures’ Pattern U n C lassified

Seizures’ Pattern Status Epilepticus Status Epilepticus A seizure for more than 30 minutes Or Frequent Seizures without Regaining Usual State of Consciousness A seizure for more than 30 minutes Or Frequent Seizures without Regaining Usual State of Consciousness

Seizures’ Pattern Status Epilepticus Status Epilepticus

Seizures’ Pattern I ntermitten t I llumination P rovoked S eizures I ntermitten t I llumination P rovoked S eizures

duration P re-ictal P ost-ictal I ctal ( Inrtra-ictal ) I ctal ( Inrtra-ictal ) I mmediate P ost - i ctal L ate P ost-ictal

frequency Attacks per hour per day per month Per year Attacks per hour per day per month Per year

Seizures’ Pattern Q Q S tatus E pilepticus Versus A bundant A ttacks S tatus E pilepticus Versus A bundant A ttacks

Seizures work up 1 st Key Question Is it a seizure ? 1 st Key Question Is it a seizure ?

Seizures work up 1 st Key Question Is it a seizure ? 1 st Key Question Is it a seizure ?

Seizures work up 1 st Key Question Is it a seizure ? 1 st Key Question Is it a seizure ?

Seizures work up 1 st Key Question Is it a seizure ? 1 st Key Question Is it a seizure ?

Seizures work up 2 nd Key Question Is it epileptic or non epileptic ? 2 nd Key Question Is it epileptic or non epileptic ?

Seizures work up 2 nd Key Question Is it epileptic or non epileptic ? 2 nd Key Question Is it epileptic or non epileptic ?

Seizures work up 3 rd Key Question which Type of epilepsy ? 3 rd Key Question which Type of epilepsy ?

Seizures work up 3 rd Key Question which Type of epilepsy ? 3 rd Key Question which Type of epilepsy ?

Seizures work up 3 rd Key Question which Type of epilepsy ? 3 rd Key Question which Type of epilepsy ?

Seizures work up 3 rd Key Question which Type of epilepsy ? 3 rd Key Question which Type of epilepsy ?

Seizures work up 3 rd Key Question which Type of epilepsy ? 3 rd Key Question which Type of epilepsy ?

Seizures work up 3 rd Key Question which Type of epilepsy ? 3 rd Key Question which Type of epilepsy ?

Seizures work up 3 rd Key Question which Type of epilepsy ? 3 rd Key Question which Type of epilepsy ?

1 st Key Question Is it a seizure ? 1 st Key Question Is it a seizure ? 3 rd Key Question Which type of epilepsy ? 3 rd Key Question Which type of epilepsy ? 4th Key Question How to classify ? 4th Key Question How to classify ? 2 nd Key Question Is it epileptic or non epileptic ? 2 nd Key Question Is it epileptic or non epileptic ? Seizures work up

Classification of Seizures Classification of Seizures Epileptic Non-epileptic

What epilepsy is ? Classification of Seizures Classification of Seizures Epileptic Non-epileptic

Classification of Seizures Classification of Seizures Non epileptic Non epileptic Epileptic Seizures are non occasional (non-provoked) chronic seizures in which one single attack is not considered as epilepsy.

Classification of Seizures Classification of Seizures Epileptic Non-epileptic seizures are occasional (provoked) seizures produced by an acute identified cause (pyretic, infectious, traumatic or metabolic)

Classification of Seizures Classification of Seizures Epileptic Seizures Non Occasional Chronic Non-Epileptic Seizures Occasional Acute

definition of epilepsy A chronic clinical condition defined as 2 or more seizures resulting from hypersynchronous electrical discharge of a population of neurons and not secondary to specific provocation factor such as fever, infection, electrolyte imbalances or trauma

Pathophysiology of epilepsy Pathophysiology of epilepsy Epilepsy Abnormal, hypersynchronous electrical activation of a population of neurons in the cerebral cortex, either in: Localized area Focal //Partial seizure Multiple areas Generalized seizure

Pathophysiology of epilepsy Pathophysiology of epilepsy (GABA) Gamma Aminobutyric Acid Excitatory Neurotransmitters Acetylcholine (Ach) Glutamate Aspartate Inhibitory

Pathophysiology of epilepsy Pathophysiology of epilepsy (GABA) Gamma Aminobutyric Acid Excitatory Neurotransmitters Acetylcholine (Ach) Glutamate Aspartate Inhibitory Any perturbation that interferes with the synthesis, release, re- uptake or metabolism of these neurotransmitters may result in the occurrence of a seizure.

Pathophysiology of epilepsy Pathophysiology of epilepsy Many pharmacologic therapies for seizures act upon these neurotransmitters Increase Inhibition Decrease Excitation

Controversy exists regarding the duration of seizure necessary to cause neuronal cell injury. Most, brief seizures, do not cause brain damage. Pathophysiology of epilepsy Pathophysiology of epilepsy

classification of epilepsy classification of epilepsy Idiopathic (Primary) Epilepsy Unknown etiology Neurological Examine absolutely normal Paraclinical explorations are normal Secondary Epilepsy A chronic affection of the brain by means of actual methods of exploration Cryptogenic Epilepsy A chronic affection of the brain which is obscure or doubtful by means of actual methods of exploration

classification of epilepsy classification of epilepsy Idiopathic (Primary) Epilepsy Unknown etiology Neurological Examine absolutely normal Paraclinical explorations are normal Secondary Epilepsy A chronic affection of the brain by means of actual methods of exploration Cryptogenic Epilepsy A chronic affection of the brain which is obscure or doubtful by means of actual methods of exploration

classification of epilepsy classification of epilepsy Idiopathic (Primary) Epilepsy Unknown etiology Neurological Examine absolutely normal Paraclinical explorations are normal Secondary Epilepsy A chronic affection of the brain by means of actual methods of exploration Cryptogenic Epilepsy A chronic affection of the brain which is obscure or doubtful by means of actual methods of exploration

classification of epilepsy classification of epilepsy Idiopathic (Primary) Epilepsy Unknown etiology Neurological Examine absolutely normal Paraclinical explorations are normal Secondary Epilepsy A chronic affection of the brain by means of actual methods of exploration Cryptogenic Epilepsy A chronic affection of the brain which is obscure or doubtful by means of actual methods of exploration

Generalized Epilepsy Secondary Generalized Epilepsy Status Epilepticus Partial epilepsy (simple & complex) Partial epilepsy (simple & complex) Classification of epilepsy Classification of epilepsy

Provoked seizures associated with a fever, electrolyte abnormality, or other metabolic derangement, are usually generalized rather than focal. Presentation epilepsy Presentation epilepsy

ThankyouThankyou ThankyouThankyou

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Classification of Epilepsy (According to Extension) By means of:  Clinical presentation  Electrical Guidance (EEG) 72

Status Epilepticus A continuous seizure activity lasting > 30 minutes, or The occurrence of ≥ 2 seizures in quick succession without return to usual level of consciousness 73 An emergency neurologic sequelae or death if treatment is delayed

Seizure Presentation On arrival at the ER On active seizure Shaking, deviation of eyes, frothy secretions,….  Staring Breath holding (apneic) with cyanosis Early post-ictal  Drowsy, in deep sleep, paralytic (odd),……… Late post-Ictal Free of any manifestation (conscious alert ……..the attack is past). 74

Seizure Presentation On arrival at the ER 1 st attack Previous attacks (1, 2 or more) Under treatment with AED ( withdrawal ) Never been treated with AED  fever 75

Seizure Presentation On arrival at the ER 76 The minority New onset, non- febrile seizure A very small % Status epilepticus Most not seizing upon arrival in the casualty department The Majority Febrile convulsion or A known previous seizures

Prognosis / expectations The majority of pediatric seizures are single events without neurologic sequelae and most recurrent seizures can be controlled with medications. Occasionally, however, seizures can be life- threatening (status epilepticus) 77

Febrile Convulsions 78

Incidence of Epilepsy More common in children than adults 1 st yr. of life / Highest incidence 79

Incidence of Epilepsy About 3-5% of children will have at least one seizure by the age of 5 yr.: >50% Benign febrile seizures. 15% acute provoked seizure: –The leading cause: »Children under 5yr. /CNS infection »Adolescents / Head trauma 10% Single unprovoked seizure and will never have another seizure The remaining 25% Recurrent seizures or epilepsy 80

Incidence of Epilepsy ¾ …… Idiopathic, with no known cause ¼ …… Identifiable brain pathology or underlying metabolic disorders. A family history of epilepsy in 1 st -degree relatives was found in 46.6% of patients. 81

Seizure work-up To R/O conditions mimic seizures The exact nature of the seizure: – Does the child have a known seizure disorder? – If this is the child’s 1 st seizure, was the seizure febrile or non-febrile? – Was the seizure partial, generalized, or partial with secondary generalization? – Was the seizure provoked or unprovoked? 82

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