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Pediatric Seizures An Overview.

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Presentation on theme: "Pediatric Seizures An Overview."— Presentation transcript:

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.


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