1. Pediatric Seizures
An Overview

2. Childhood Seizures Evaluation Classification Diagnosis Treatment
Mimics

3. Evaluation Frequency: 4-6/1,000 History Examination
Focal or Generalized
Duration, State of Consciousness, Triggers
Aura, Behavior, Posture, Post-ictal State
Examination
Vitals, HC, HSM, abnormal Neuro exam
Skin exam, Retinal exam, hyperventilation

4. Classification-Febrile Seizures
3-4% of population
Most common
Excellent prognosis
9 months to 5 years; peak months
Strong family history of febrile seizures
Rapid rising temp, >38 degrees Celsius
Generalized Tonic/Clonic; <10 minutes
If exam is normal, No further Work-up
Rectal Diazepam for recurrence

5. Febrile Seizures (2) Work up is necessary if:
More than one febrile seizure in 24 hours
Seizure last for more than 10 minutes
Focal seizure characteristics
Positive physical exam suggestive of infectious, structural, neurologic, congenital pathology

6. Classification-Partial Seizures
Simple Partial Seizures
Maintained Consciousness
Motor activity: Versive Seizures
Sensory: aura
Autonomic
No automatisms, No tics (can be suppressed)
EEG: spikes, sharp waves in a unilateral or bilateral or multifocal pattern
Duration: seconds

7. Partial Seizures (2) Complex Partial Seizures (impaired LOC)
Simple partial seizure followed by LOC
Consciousness impaired at onset of seizure
Aura: 1/3 of patients with PS
Automatisms: ¾ of patients with CPS
Following LOC into postictal phase, not recalled
Infant: alimentary; Child: gestural, unplanned

8. PS (3): CPS (cont’d)
Spreading of discharge throughout brain can lead to secondary generalization (tonic-clonic)
EEG: Anterior temporal lobe sharp waves, focal spikes or multifocal spikes
Normal EEG in 20%; must use sleep deprived, prolonged techniques
Duration: 1-2 minutes
Needs CT or MRI to rule out structural causes

9. PS (4): BPEC
Benign Partial Epilepsy with Centrotemporal Spikes (Rolandic Epilepsy)
Excellent Prognosis
Ages: 2 – 14; peak onset at 9 – 10 years old
Facial tonic-clonic symptoms
Normal exam, possible positive FamHx
One seizure: 20%; Repeated clusters: 25%
Occurs during sleep: 75%
EEG: repetitive spike in rolandic area, o/w nl.

10. Classification: Generalized
Absence
Simple: Cessation of activity with blank facial expression, flickering of eyelids
Usually after age 5, F>M, hyperventilation
No aura, no postictal state, duration <30 seconds
3/sec spike, generalized wave discharge
Complex: Associated motor symptoms
Myoclonic movements of face, fingers, extremities
May have loss of body tone
2-2.5/sec spike and wave discharge

11. Generalized (2) Generalized Tonic Clonic Focal Onset or De Novo
Aura can suggest origin
Tonic Contractions
LOC, eyes roll back, cyanosis, apnea
Clonic Contractions
Rhythmic contraction/relaxation, loss of sphincter
Post-ictal: 30 minutes to 2 hours
Truncal ataxia, hyperactive DTRs, Babinski’s
Vomiting, intense bifrontal headache

12. Generalized (3); T/C (2) Triggers Duration: Few minutes Idiopathic
Low grade fever
Fatigue
Stress
Drugs: Methylphenidate, psychotropics, etc…
Duration: Few minutes
Idiopathic

13. Generalized (4) Myoclonic Epilepsies of Childhood Repetitive seizures
Brief, symmetrical contractions
Loss of body tone—falling, slumping forward
Benign Myoclonus of Infancy
Myoclonic Epilepsy of Early Childhood
Complex Myoclonic Epilepsy
Juvenile Myoclonic Epilepsy

14. Generalized (5); MEC (2) Infancy Early Childhood
Neck, trunk, extremities
Normal EEG, Ends by 2 years, no meds
Early Childhood
6 months – 4 years
Favorable outcome, 50% seizure free
MR, social problems in the minority
Positive EEG, possible genetic background
May have concurrent tonic/clonic or febrile seizures

15. Generalized (6); MEC (3) Complex Poor prognosis
Focal or generalized seizures <1 year of age
History: hypoxic-ischemic encephalopathy, microcephaly
Positive EEG, less prominent FamHx
Refractory to meds
MR, behavioral problems in 75%
Lennox Gastaut syndrome

16. Generalized (7); MEC (4) Juvenile Between ages 12 – 16
5% of all epilepsies
Initial: Morning myoclonic jerks
Later: Morning Generalized Tonic Clonic szs
Positive EEG: 4-6/sec irregular spike
Enhanced with photic stimulation
Normal exam, lifelong meds (Valproic Acid)

17. Generalized (8) Infantile Spasms Between 4 – 8 months
Flexor, Extensor, or Mixed spasms
Cryptogenic: 10-20%, normal work-up
Good prognosis
Symptomatic: 80-90%, underlying pathology
Prenatal and Perinatal etiologies
MR 80-90%
Positive EEG: hypsarrhythmia pattern

18. Diagnosis Minimum EEG techniques: 40% of EEGs are normal CSF
Blood glucose, calcium, mag, lytes, EEG
EEG techniques: 40% of EEGs are normal
Sleep deprived, prolonged (72 hrs), photic
CSF
Infectious etiology suspected
Radiologic: CT or MRI1
Prolonged or intractable szs, neuro deficit, increased ICP
High risk: Predisposing factors, focal sz <33 months

19. Treatment
Treat after the first uncomplicated seizure with a negative work up—80% will NOT have another seizure2
Educate patient and family of possible long term use and side effects
May terminate meds after 2 seizure free years
Wean over 3-6 months due to possible recurrence or status.

20. Treatment (2) Carbamazepine or Tegretol Phenytoin or Dilantin
Gen T/C, partial; watch leukopenia, LFTs
Phenytoin or Dilantin
Gen T/C, partial; watch SJS, rashes, lupus-like
Phenobarbital
Gen T/C; watch behavioral changes
Sodium Valproate or Valproic Acid
Gen T/C, absence, myoclonic; watch LFTs, Reyes
ACTH
Infantile spasms; watch glucose, BP, lytes

21. Treatment (3) Ketogenic Diet Surgical Options
Increases GABA inhibition of seizure activity
Recalcitrant seizures
Complex myoclonic epilepsy
Fat diet, restriction of CHO and protein
Surgical Options
Vagal Nerve Stimulator3
Ablation therapy
Intractable seizures

22. Mimics BPV Night Terrors Breath Holding Spells Simple Syncope
Cough Syncope
Shuddering Attacks
Pseudoseizure
Benign Paroxysmal Torticollis of Infancy

23. Bibliography
1Sharma, et. al, “Role of Emergent Neuroimaging…,” Pediatrics, Vol 111, January, 2003.
2Shinnar, et. al, “Risk of Seizure Recurrence…,” Pediatrics, Vol 98, August, 1996.
3Parker, et. al, “VNS in Epileptic Encephalopathies,” Pediatrics, Vol 103, April, 1999.