1 / 42

بسم الله الرحمن الرحيم

بسم الله الرحمن الرحيم. بسم الله الرحمن الرحيم. 1. Childhood Epilepsy. Dr. Mohammed AL- Jaradi Sana’a 24-25/4/2013. Helpful tools for diagnosis. Accurate history and description of events Provoking factors Electroencephalogram. 3. Epilepsy syndrome.

bruis
Download Presentation

بسم الله الرحمن الرحيم

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. بسم الله الرحمنالرحيم بسم الله الرحمن الرحيم 1

  2. Childhood Epilepsy Dr. Mohammed AL- Jaradi Sana’a 24-25/4/2013

  3. Helpful tools for diagnosis • Accurate history and description of events • Provoking factors • Electroencephalogram 3

  4. Epilepsy syndrome A complex of signs and symptoms that define a unique epilepsy condition 4

  5. Etiological categories of syndromes • idiopathic no underlying structural brain disease, presumed genetic • symptomatic seizures are the result of lesional or metabolic disease of the brain • probably symptomatic (cryptogenic) believed symptomatic but no etiology established

  6. Seizures: focal & generalized • Generalized seizure • a seizure whose initial semiology indicates, or is consistent with, more than minimal involvement of both hemispheres • Focal seizure (partial, localization-related) • a seizure whose initial semiology indicates, or is consistent with, initial activation of only part of one cerebral hemisphere 6

  7. Generalized seizure types 7

  8. Generalized epilepsies Idiopathic generalized epilepsies Benign myoclonic epilepsy in infancy Epilepsy with myoclonic-astatic seizures Epilepsy with myoclonic absence seizures Childhood absence epilepsy Juvenile absence, JME, epilepsy with GTC only Generalized epilepsies with febrile seizures plus 8

  9. Epileptic encephalopathy Syndromes of infancyEarly myoclonic encephalopathy; West syndromes Lennox-Gastaut syndrome Epilepsy with continuous spike waves in SW sleep

  10. Focal seizure types 10

  11. Common Childhood Epilepsy Syndromes 11

  12. Infantile spasmsWest syndrome • Onset ages 3-12 months • Brief axial contractions • usually bilateral, may be asymmetrical • typically flexor, may be extensor • usually in clusters, less likely random • typically on awakening, or when drowsy • EEG shows hypsarrhythmia • multifocal spikes • high voltage, chaotic background 12

  13. EEG Record 13

  14. Infantile spasms • Often “cryptogenic” • no definite cause established but child is delayed • Rarely “idiopathic” • no cause established and child is normal • “Symptomatic” cases • congenital infections • CNS malformations • metabolic disorders • genetic syndromes • tuberous sclerosis • perinatal asphyxia • postnatal trauma • acquired infections • immunizations 14

  15. Infantile spasms • Short term treatment to stop spasms, improve EEG • ACTH {Adrenocorticotropic Hormone } effective, dose not established • oral steroids not proven effective • Vigabatrin, especially in tuberous sclerosis • potential retinal toxicity 15

  16. West Syndrome • Infantile Spasms • Hypsarrhythmia on EEG • Developmental regression that begins concurrently with the onset of spasms 16

  17. Outcome • Idiopathic cases: • Normal school 37% • Death 6% • Other seizure types 43% • Neurologic abnormality 31% 17

  18. Outcome • Symptomatic cases: • Normal school - none • Death 37% • Other seizure types 59% • Neurological abnormality 65% • Large number progress to develop Lennox Gastaut Syndrome 18

  19. Rolandic epilepsy • Onset ages 2-12 yrs, peak 5-10 yrs • Characteristic seizures • Infrequent simple partial seizures • tingling in mouth, on face, speech arrest • rare GTCS in sleep • to many drugs 19

  20. Resolve by puberty • Characteristic EEG • high voltage centrotemporal spikes • usually bilateral • Imaging normal • Considered an idiopathic focal epilepsy • some evidence for genetic basis • Treatment • may not be necessary • may respond

  21. Centrotemporal spikes in Benign Rolandic Epilepsy 21

  22. Presentation of “staring spells” • Complex partial seizures • Absence seizures • Behavior staring

  23. Complex Partial Seizures • Commonly temporal lobe focus • Begins in one area, then spreads enough to impair consciousness, but not to evoke a generalized tonic-clonic seizure • Staring is often part of the initial spread • Also can see automatisms…

  24. Automatisms • Coordinated involuntary movements • Consciousness impaired • Patient does not recall activity • Simple • Lip smacking, chewing, uttering sounds, picking, tapping, walking straight or in circles • Complex (behavior involved) • Undressing, chewing inedible objects, wandering, aggression

  25. Treatment of complex partial seizures • Use medications for focal onset seizures • Levetiracetam (Keppra) • Oxcarbamazepine (Trileptal) • Carbamazepine (Tegretol/ Carbatrol) • Lamotrigine (Lamictal) • Topiramate (Topamax) • Zonisimide (Zonegran) • Phenobarbital • Valproic Acid (Depakote) • Lacosamide (Vimpat)

  26. Absence epilepsy

  27. Childhood absence (petit mal) epilepsy • Peak onset age 4-6 years • Many seizures daily • Seizures last seconds • 70+% have associated automatisms • eyelid flutter • simple vocalizations • picking movements • Typical EEG with 3 Hz spike wave • Majority resolve by adolescence

  28. slightly irregular 3 per second spike wave▼

  29. Treating absence seizures • Ethosuximide (Zarontin) • Valproic Acid (Depaken) • Lamotrigine (Lamictal) • Levetiracetam (Keppra)

  30. Absence v. Complex Partial Sz • Absence • < 30 sec • Non-convulsive status epilepticus • Frequent (100’s a day) • Sudden onset, sudden termination • No post-ictal state • Hyperventilation a trigger • EEG: 3-4 Hz spike and wave • Rare interictal abnormalities • Complex Partial • > 1 minute • Rare non-convulsive epilepticus • Occur ≤ daily • Frequent simple, complex automatisms • Evolve to other sz manifestations • Post-ictal state • EEG: Interictal focal abnormalities

  31. Behavioral Staring • Most commonly seen in children with ADD and MR • Occurs when “bored” or over-stimulated • Does not typically make the patient fall or stop an activity abruptly • Can be stopped with close contact / stimulation • Also can be seen in children with epilepsy!

  32. Evaluation of a 1st unprovoked seizure • Good evidence recommends EEG • EEG can help diagnose the event • EEG can identify a specific syndrome • EEG can help with prognosis • timing of EEG not determined Generalized burst Benign focal spike 32

  33. immediate EEG may show abnormality or post ictal slowing • abnormal EEG best predictor of recurrence in neurologically normal children • abnormal neuro exam also strong predictor of recurrence

  34. Evaluation of a 1st unprovoked seizure • Insufficient evidence for routine labs, LP, imaging • consider emergent imaging • if postictal focal deficit, or not at baseline in several hours • consider nonurgent MRI • with significant neuro abnormalities of unknown etiology • a seizure of focal onset • in children under 1 year of age • consider LP • in the very young child (<6 months) • in the patient who fails to return to baseline • in any patient with meningeal signs • if increased ICP suspected, image before LP 34

  35. How likely is a 2nd seizure? • Evidence from multiple Class III studies • Recurrence ranged from 14%-65% • Most recurrences early (in 1st year) • Factors increasing recurrence risk • abnormal EEG • etiology • remote symptomatic seizure recurrence >50% • idiopathic seizure recurrence 30-50% 35

  36. Summary of evidence:Treatment of 1st unprovoked seizure • Most children with a 1st seizure have few or no recurrences • 10% will have many seizures regardless of initial Rx • Rx after 1st vs. 2nd seizure does not affect long term prognosis • Rx in adults and children leads to decreased recurrences 36

  37. Recommendations:Treatment of a 1st Seizure • Anticonvulsant treatment after a 1st seizure must be individualized • treatment is not indicated for prevention of epilepsy • treatment may be considered if risks of recurrent seizure out weigh risks of Rx • Treatment must take into account patient and family preferences 37

  38. Febrile seizures • The most common seizures in childhood • In US affect 2-4% of children < age 5 yrs • 1/3 have at least 1 recurrence • Risk factors for recurrence • first febrile seizure < 1 year of age • low degree of fever at first febrile seizure • family history of febrile seizures • brief duration between fever onset and febrile seizure • 4 risk factors = 70% recurrence • No risk factors = 20% recurrence 38

  39. Febrile seizures • Simple • generalized • and <15 minutes duration • Complex • focal • or >15 minutes • or recurrent within 24 hours 39

  40. Evaluation of the child with simple febrile seizures • Lumbar puncture • if meningeal signs • in infants < 12 months • with prior antibiotic Rx • Blood studies not needed routinely • Imaging not necessary • EEG not necessary in simple febrile seizures 40

  41. Treatment of the child with simple febrile seizures • Effective in reducing recurrences but with potential toxicities • continuous Phenobarbital or valporic acid • intermittent diazepam 41

  42. Thank you! شـــــــــــــــــــــــــــــــــــــكــــــــــــــــــــــــــــــــــــــــرا

More Related