Dr. Dafalla Ahmed Babiker

Jazan University

change in motor activity and/or behaviour due to abnormal electrical activity in the brain.

seizures in children either

- provoked by somatic disorders originating outside the brain, such as high fever, infection, syncope, head trauma, hypoxia, toxins, or cardiac arrhythmias

or - triggered recurrently from within the brain ,this is called epilepsy(Less than one third of seizures in children are caused by epilepsy)

epilepsy is considered to be present when two or more unprovoked seizures occur at an interval greater than 24hr apart within 6 month.

lifetime incidence of epilepsy is 3% and

more than half of cases begin in childhood.

prognosis is generally good, but 10–20% have persistent seizures refractory to drugs

Motor seizures may be focal or generalized and

- tonic-clonic - tonic (increased tone or rigidity) - clonic (rhythmic muscle contraction and

relaxation) - myoclonic (shock like contraction of a

muscle) - atonic (flaccidity or lack of movement

during a convulsion)

The most common seizure disorder during childhood, generally have an excellent prognosis

Be careful the underlying cause may be serious disease such as sepsis or bacterial meningitis.

So the child must be carefully examined and appropriately investigated for the cause of the fever , especially when it is the first seizure

There is genetic predisposition

Simple febrile seizures

usually associated with a core temperature that increases rapidly to 39°C or more

From 3 mo to 5 yr

Lasts less than 15 min

Once in 24 hr

Usually in the 1st 24 hr of the febrile illness

Generalised tonic clonic Family history of febrile seizures (not necessary)

Complex febrile seizures

Duration more than 15 min , recur more than once in 24 h, focal .

children with simple febrile seizures are at no greater risk of later epilepsy

If any doubt exists about the possibility of meningitis, a lumbar puncture with examination of the cerebrospinal fluid (CSF) is indicated.

If the child is less than 12 mo and the febrile seizure is complex strongly consider LP

EEG may be useful for evaluating patients with an atypical feature or with other risk factors for later epilepsy

ABC .

Benzodiazepine to control seizure

careful search for the cause of the fever

control the fever, by using antipyretics

To reduce the risk of febrile seizure :-

At the onset of each febrile illness, give oral diazepam,three times per day for 2–3 days? plus oral antipyretic .

First Seizure history before seizure during seizure detailed

description after seizure look for life-threatening causes of seizures

such as meningitis, systemic sepsis, head trauma, and ingestion of drugs

family history of epilepsy , neurologic

disorder, or history of seizure with fever

Physical examination

Temperature, blood pressure

CNS

Fundus examination

CVS

Hepatosplenomegaly (metabolic or storage disease)

Neurocutanous manifestations

serum electrolytes, toxicology screening, or urine and serum metabolic testing should be chosen based on individual clinical circumstances rather than on a routine basis

Blood glucose level and calcium should be tested especially in infants.

EEG , is recommended for identification of specific focal abnormalities and/or epileptic syndromes

Lumbar puncture is not recommended. Unless meningitis is suspected .

Neuroimaging is generally not recommended unless there is an indication for it on neurologic examination. MRI is superior to CT scan

Anticonvulsant medication is generally not recommended

Recurrent Seizures

Two unprovoked seizures greater than 24 hours apart within 6 mo, suggest the presence of an epileptic disorder

Seizures that occur during the early morning hours or with drowsiness, particularly during the initial phase of sleep, are common in childhood epilepsy.

irritability, mood swings, headache, and subtle personality changes may precede a seizure.

Ask parents to act out or re-create the

seizure, it is much more accurate than the verbal description

Ask about the frequency, time of day,

precipitating factors

A prolonged personality change or intellectual deterioration may suggest a degenerative disease of the CNS

constitutional symptoms, including vomiting and failure to thrive in infants, might indicate a primary metabolic disorder

History of anticonvulsant medication Family history of epilepsy Impact on schooling, activities,

psychosocially

full physical examination especially ophthalmologic and neurologic examination, can provide information about the presence of increased intracranial pressure. neurocutaneous or neuromatabolic syndromes. and structural brain abnormalities including malformations, injuries, infections, or tumors.

The EEG is indicated in all cases of epilepsy and is useful for determining the type of epilepsy and the future prognosis

MRI is indicated in children with newly diagnosed epilepsy , especially for those with neurologic deficits, partial seizures, or focal EEG

. PARTIAL SEIZURES Simple partial (consciousness

retained) Motor Sensory Autonomic Psychic Complex partial

(consciousness impaired) Simple partial, followed by

impaired consciousness Consciousness impaired at

onset Partial seizures with

secondary generalization

GENERALIZED SEIZURES Absences Typical Atypical Generalized tonic-clonic Tonic Clonic Myoclonic Atonic Infantile spasms UNCLASSIFIED SEIZURES

Large proportion of childhood seizures, up to 40%

classified as simple or complex Aura is more frequent in partial than in

generalized Simple Partial Seizures should be

differentiated from ticks Lip smacking, chewing, swallowing, and

excessive salivation are common features of complex Partial Seizures

Spreading of the epileptiform discharge during CPS can result in secondary generalization with a tonic-clonic convulsion

common type of partial epilepsy in childhood and has an excellent prognosis

peak age of onset of 9–10 yr motor signs and sensory symptoms are

often confined to the face Unilateral tonic-clonic contractures of the

lower face and clonic movements or paresthesias of the ipsilateral extremities. Consciousness may be intact or impaired, and the partial seizure may proceed to secondary generalization.

BPEC occurs during sleep in 75% of patients

The EEG pattern is diagnostic for BPEC and is characterized by a repetitive spike focus localized in the centrotemporal or rolandic area

Carbamazepine is the preferred drug, which is continued for at least 2 yr or until 14–16 yr of age, when spontaneous remission of BPEC usually occurs.

Absence Seizures.

Simple (typical) absence (petit mal) seizures are characterized by a sudden cessation of motor activity or speech with a blank facial expression and flickering of the eyelids

These seizures, which are uncommon before age 5 yr, are more prevalent in girls

No aura, no postictal state

Lasts for less than 30sec

Hyperventilation for 3–4 min routinely produces an absence seizure.

The EEG shows a typical 3/sec spike and generalized wave discharge

Generalized Tonic-Clonic Seizures very common may follow a partial seizure with a focal

onset (secondary generalization) or from the start.

They may be associated with an aura, suggesting a focal origin of the epileptiform discharge

Patients suddenly lose consciousness , may bite their tongue . Loss of sphincter control, particularly the bladder.

Postictally, children initially are semicomatose and typically remain in a deep sleep from 30min to 2h

Idiopathic seizure is a term applied when the cause of a generalized seizure is unknown

Myoclonic Epilepsies of Childhood

This disorder is characterized by repetitive seizures consisting of brief, often symmetric muscular contractions with loss of body tone and falling . 5 subgroupes

- Benign myoclonus of infancy

- Typical myoclonic epilepsy of early childhood.

- Complex myoclonic epilepsies

- Juvenile myoclonic epilepsy (janz syndrome).

- Progressive myoclonic epilepsies

Infantile Spasm (west syndrome)

Usually begin between the ages of 4 and 8 mo

characterized by brief symmetric contractions of the neck, trunk, and extremities

three types of infantile spasms: flexor, extensor, and mixed which is the most common type

Clusters of seizures may persist for minutes

EEG that is associated with infantile spasms is referred to as hypsarrhythmia

Infantile spasms are typically classified into two groups: cryptogenic and symptomatic

Infants with cryptogenic infantile spasms have a good prognosis, whereas those with the symptomatic type have an 80–90% risk of mental retardation

Ensure that the patient has a seizure disorder and not a condition that mimics epilepsy

If 1st attack with negative family history, negative result on a neurologic examination and EEG usually supports the approach of watchful waiting rather than administration of an anticonvulsant . Approximately 70% of these children will not experience another convulsion.

Family education

The drug of choice depends on the classification of the seizure

use of only one drug for the control of seizures. The drug is increased slowly until seizure controled ,if not controled add an other drug as adjunctive therapy

If complete seizure control is achieved by an anticonvulsant, a minimum of 2 seizure-free years for a patient with no risk factors is adequate and safe period of treatment. then tapper gradually over 3 -6 mo

risk factors includ

- age greater than 12 yr at onset

- neurologic dysfunction (motor handicap or mental retardation), a history of prior neonatal seizures,

- numerous seizures before control is achieved

Carbamazepine Generalized tonic-clonic , Partial

Clonazepam infantil spasm ,Absence, Myoclonic

Ethosuximide May increase tonic-clonic seizures , used for Absence

Gabapentin Adjuntive therapy

Lamotrigine Adjunctive therapy

Nitrazepam Absence , Myoclonic , Infantile spasms

Phenobarbital Generalized tonic-clonic , Partial, Status epilepticus

Phenytoin Generalized tonic-clonic ,Partial, Status epilepticus

Valproic acid Generalized tonic-clonic,Absence Myoclonic,Partia

Vigabatrin ,Infantile spasms,Adjunctive therapy

Status epilepticus is defined as a continuous convulsion lasting longer than 30 min or the occurrence of many convulsions between which there is no return of consciousness

Treatment :- in the ICU

- ABC

-pulse, temperature, respirations, and blood pressure are recorded

- gentle suction

- oxygen face mask ,ambu bag , assisted ventilation

-If hypoglycemia is confirmed by Dextrostix, a rapid infusion of 5mL/kg of 10% dextrose

Drugs should always be administered IV in the management of status epilepticus

benzodiazepine (diazepam, lorazepam, or midazolam)

loading dose of phenytoin infusion (ECG) In some centers, loading dose of

phenobarbital is given before phenytoin paraldehyde, a diazepam infusion,

barbiturate coma (thiopental)or general anesthesia (halothane , isoflurane)

when you insert the IV line blood is obtained for a CBC and electrolytes (including calcium, phosphorus, and magnesium), glucose, creatinine, lactate, and anticonvulsant levels, if indicated

Blood and urine may be obtained for metabolic studies and toxicology

Examination of the CSF is if meningitis or encephalitis is considered , unless there is a contraindication

evidence of : trauma; papilledema, a bulging anterior fontanel, neurologic signs suggesting increased ICP; manifestations of sepsis or meningitis

Thank you