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Pediatric Seizures

Pediatric Seizures. An Overview. Childhood Seizures. Evaluation Classification Diagnosis Treatment Mimics. Evaluation. Frequency: 4-6/1,000 History Focal or Generalized Duration, State of Consciousness, Triggers Aura, Behavior, Posture, Post-ictal State Examination

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Pediatric Seizures

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  1. Pediatric Seizures An Overview

  2. Childhood Seizures • Evaluation • Classification • Diagnosis • Treatment • Mimics

  3. Evaluation • Frequency: 4-6/1,000 • History • 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 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

  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: 10-20 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 • 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 • 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 • 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 • 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 • 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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