Pediatric Seizures An Overview Childhood Seizures n n

Pediatric Seizures An Overview

Childhood Seizures n n n Evaluation Classification Diagnosis Treatment Mimics

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

Classification-Febrile Seizures n n n n n 3 -4% of population Most common Excellent prognosis 9 months to 5 years; peak 14 -18 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

Febrile Seizures (2) n Work up is necessary if: n n 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

Classification-Partial Seizures n Simple Partial Seizures n n n n 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: 10 -20 seconds

Partial Seizures (2) n Complex Partial Seizures (impaired LOC) n n 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 n Infant: alimentary; Child: gestural, unplanned n

PS (3): CPS (cont’d) n n n 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

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

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

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

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

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

Generalized (5); MEC (2) n Infancy n n n Neck, trunk, extremities Normal EEG, Ends by 2 years, no meds Early Childhood n n n 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

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

Generalized (7); MEC (4) n Juvenile n n n n 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)

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

Diagnosis n Minimum n n EEG techniques: 40% of EEGs are normal n n Sleep deprived, prolonged (72 hrs), photic CSF n n Blood glucose, calcium, mag, lytes, EEG Infectious etiology suspected Radiologic: CT or MRI 1 n n Prolonged or intractable szs, neuro deficit, increased ICP High risk: Predisposing factors, focal sz <33 months

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

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

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

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

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