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I. Neonatal I. Neonatal Seizures Seizures II. Conditions II. Conditions That Mimic That Mimic Seizures Seizures

I. Neonatal Seizures II. Conditions That Mimic Seizures

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Page 1: I. Neonatal Seizures II. Conditions That Mimic Seizures

I. Neonatal SeizuresI. Neonatal Seizures

II. Conditions That II. Conditions That Mimic SeizuresMimic Seizures

Page 2: I. Neonatal Seizures II. Conditions That Mimic Seizures

SeizureSeizure transienttransient andand reversiblereversible alteration of behavior alteration of behavior caused by a paroxysmal, abnormal and excessive caused by a paroxysmal, abnormal and excessive neuronal dischargeneuronal discharge attack ofattack of cerebralcerebral originorigin

sudden and transitory abnormal phenomenasudden and transitory abnormal phenomena motor, sensory, autonomic, or psychicmotor, sensory, autonomic, or psychic

transient dysfunction of part or all of the brain

Page 3: I. Neonatal Seizures II. Conditions That Mimic Seizures

EpilepsyEpilepsyA A paroxysmalparoxysmal brain disorder of various etiologies brain disorder of various etiologies characterized bycharacterized by recurrent seizuresrecurrent seizures due todue to excessive electrical discharge of cerebral neuronsexcessive electrical discharge of cerebral neurons associated with a variety of clinical and laboratory associated with a variety of clinical and laboratory manifestationsmanifestations

two or more seizurestwo or more seizures not directly provokednot directly provoked by by intracranial infection, drug withdrawal, acute intracranial infection, drug withdrawal, acute metabolic changes or fevermetabolic changes or fever

Page 4: I. Neonatal Seizures II. Conditions That Mimic Seizures

Neonatal SeizuresNeonatal Seizures• Tonic Seizures—focal or generalized, may mimic

decorticate or decerebrate posturing, primarily seen in preterms with intracranial hemorrhage & generally have poor prognosis

• Subtle seizures– Consist of chewing motion, excessive salivation and

alteration in respiratory rate including apnea, blinking, nystagmus, bicycling and pedaling movements, changes in color

Page 5: I. Neonatal Seizures II. Conditions That Mimic Seizures

ClonicClonic- focal (repetitive movements localized to a - focal (repetitive movements localized to a single limb) or multifocal (random migration of single limb) or multifocal (random migration of movements from limb to limb), consciousness may movements from limb to limb), consciousness may be preserved, primarily seen in term infantsbe preserved, primarily seen in term infants

• Myoclonic- sudden flexor movements (lightning-like jerks), may be focal, multifocal or generalized, may occuring singly or in clusters, if due to early myoclonic encephalopathy it carries a poor prognosis. Brief focal or generalized jerks of the extremities or body that tend to involve distal muscle groups

Page 6: I. Neonatal Seizures II. Conditions That Mimic Seizures

Why are seizure patterns in neonates more Why are seizure patterns in neonates more fragmentary than in older children? fragmentary than in older children?

• The cellular organization of the mature and immature brain is different. The neonatal brain has incomplete glial proliferation, w/ continuing migration of neurons, establishing complex axonal & dendritic contacts and myelin deposition.

The electrical discharges therefore spread incompletely and may remain localized to one hemisphere. The electrical discharges are slow to diffuse and bilateral synchronous discharges are rare.

Page 7: I. Neonatal Seizures II. Conditions That Mimic Seizures

Neonatal SeizuresNeonatal SeizuresEEG ClassificationEEG Classification

• Clinical seizure with consistent EEG event– Clinical seizure occurs in relationship to seizure

activity– Includes focal clonic, focal tonic and myoclonic– Responds to antiepileptic drugs

• Clinical seizure with inconsistent EEG event– Clinical seizures with no EEG abnormality– Seen in all generalized tonic and subtle seizures– Seen in patients who are comatose, HIE

Page 8: I. Neonatal Seizures II. Conditions That Mimic Seizures

Neonatal SeizuresNeonatal SeizuresEEG ClassificationEEG Classification

• Electrical seizures with absent clinical seizures– Electrical seizures associated with markedly

abnormal background EEG– Seen in comatose patients

Page 9: I. Neonatal Seizures II. Conditions That Mimic Seizures

Epileptic vs Non-epileptic Epileptic vs Non-epileptic Neonatal PhenomenaNeonatal Phenomena

Clinical Characteristics

Epileptic Non-epileptic

Increases with Sensorystimulation

Rare Common

Suppresses with restraint

- +

Autonomic Accompaniments

+ -

Page 10: I. Neonatal Seizures II. Conditions That Mimic Seizures

Major Causes of Neonatal Seizures In Relation to Time of Major Causes of Neonatal Seizures In Relation to Time of Seizure Onset and Relative FrequencySeizure Onset and Relative Frequency TIME OF ONSETTIME OF ONSET* * RELATIVE FREQUENCYRELATIVE FREQUENCY

Cause 0-3 Days >3 Days Premature Cause 0-3 Days >3 Days Premature Full Term Full Term

Hypoxic-Ischemic encephalopathyHypoxic-Ischemic encephalopathy + +++ ++++ +++ +++

Intracranial hemorrhage + + ++ +Intracranial hemorrhage + + ++ +

Intracranial infection + + ++ ++Intracranial infection + + ++ ++

Developmental defects + + ++ ++Developmental defects + + ++ ++

Hypoglycemia + + +Hypoglycemia + + +

Hypocalcemia + + + Hypocalcemia + + +

Other metabolic + + Other metabolic + +

Epileptic syndromesEpileptic syndromes + + + + + +

Page 11: I. Neonatal Seizures II. Conditions That Mimic Seizures

Neonatal SeizuresNeonatal SeizuresEtiologic diagnosisEtiologic diagnosis

• Hypoxic –ischemic encephalopathy

• Metabolic

• Infections

• Trauma

• Structural abnormalities

• Hemorrhagic and embolic strokes

• Maternal disturbances

Page 12: I. Neonatal Seizures II. Conditions That Mimic Seizures

Causes of neonatal seizuresCauses of neonatal seizuresAges 1 – 4 daysAges 1 – 4 days

• HIE• Drug withdrawal• Dug toxicity

– Lidocaine, penicillin

• Intraventricular hemorrhage• Acute metabolic disorder

– Hypocalcemia– Hypoglycemia– Inborn errors of metabolism

Page 13: I. Neonatal Seizures II. Conditions That Mimic Seizures

Causes of neonatal seizuresCauses of neonatal seizuresAges 4 – 14 daysAges 4 – 14 days

• Infection• Metabolic disorders

– Hypocalcemia– Diet– Hypoglycemia– Inherited disorder of

metabolism such as galactosemia,fructosemia

– Hyperinsulinemic hypoglycemia

– Becwith syndrome– Anterior pituitary hypoplasia

• Drug withdrawal• Benign neonatal

convulsion• Kernicterus,

hyperbilirubenemia

Page 14: I. Neonatal Seizures II. Conditions That Mimic Seizures

Causes of neonatal seizuresCauses of neonatal seizuresAges 2 – 8 weeksAges 2 – 8 weeks

• Infection• Head injury

– Subdural henatoma

• Inherited disorder of metabolism– Aminoacidurias– Urea cycle defects– Organic acidurias– Neonatal ALD

• Malformations of cortical development– Lissencephaly– Focal cortical

dysplasia– Tuberous sclerosis– Sturge weber

syndrome

Page 15: I. Neonatal Seizures II. Conditions That Mimic Seizures

Neonatal SeizuresNeonatal SeizuresEtiologic diagnosisEtiologic diagnosis

• Blood– Glucose, calcium, magnesium, electrolytes, BUN– In hypomagnesemia MgSO4 0.2 ml/kg

• Lumbar puncture– Indicated in all neonates with seizures unless related

to a metabolic disorder• Inborn errors of metabolism

– Inherited as autosomal recessive or X-linked recessive

Page 16: I. Neonatal Seizures II. Conditions That Mimic Seizures

Neonatal SeizuresNeonatal SeizuresEtiologic diagnosisEtiologic diagnosis

• Inborn errors of metabolism– Serum ammonia urea cycle abnormalities– Acidosis + anion gap + hyperammonemia

urine organic acids should be determined

• Unintentional injection of local anesthetic– Supportive measures– Promotion of urine output with IV fluids

Page 17: I. Neonatal Seizures II. Conditions That Mimic Seizures

Idiopathic Syndromes of Clinical Idiopathic Syndromes of Clinical

Seizures in the NewbornSeizures in the Newborn

Epileptic Syndromes Epileptic Syndromes

Benign familial Neonatal SeizuresBenign familial Neonatal Seizures

Benign idiopathic neonatal seizures (fifth-day fits)Benign idiopathic neonatal seizures (fifth-day fits)

Early myoclonic encephalopathy Early myoclonic encephalopathy

Early infantile epileptic encephalopathy (Ohtahara Early infantile epileptic encephalopathy (Ohtahara syndrome)syndrome)

Malignant migrating partial seizuresMalignant migrating partial seizures

Nonepileptic SyndromesNonepileptic Syndromes

Benign neonatal sleep myoclonusBenign neonatal sleep myoclonus

HyperekplexiaHyperekplexia

Page 18: I. Neonatal Seizures II. Conditions That Mimic Seizures

Neonatal SeizuresNeonatal Seizures(Epileptic Syndromes)(Epileptic Syndromes)

• Benign familial neonatal seizures– Begins on the 2nd – 3rd day of life– Seizure frequency : 10 – 20 /day– Patients are normal between seizures– Seizure stops in 1 – 6 months

Page 19: I. Neonatal Seizures II. Conditions That Mimic Seizures

Neonatal SeizuresNeonatal Seizures

Fifth-day fits – • 5th day of life• normal appearing neonates with mulifocal

seizures• Present for less than 24 hours• Good prognosis

Page 20: I. Neonatal Seizures II. Conditions That Mimic Seizures

Neonatal SeizuresNeonatal SeizuresEtiologic diagnosisEtiologic diagnosis

• Pyridoxine dependency– resistant to conventional AED’s– Inherited as autosomal recessive– Tx: Pyridoxine 100 – 200 mg IV– May not have a dramatic effect with IV

pyridoxine thus maintain on oral pyridoxine 10 -20 mg/day x 6 weeks

– Lifelong supplementation : 10 mg/day

Page 21: I. Neonatal Seizures II. Conditions That Mimic Seizures

Neonatal SeizuresNeonatal SeizuresEtiologic diagnosisEtiologic diagnosis

• Drug withdrawal seizures– Barbiturates, benzodiazepenes, heroin and

methadone– Jittery, irritable, lethargic, may show

myoclonus or frank seizures– Serum or urine analysis may identify the

responsible agent

Page 22: I. Neonatal Seizures II. Conditions That Mimic Seizures

Prognosis of Neonatal Seizures:Prognosis of Neonatal Seizures:

Relation to Neurological DiseasesRelation to Neurological Diseases

Neurological Disease* Normal Neurological Disease* Normal DevelopmentDevelopment

Hypoxic-ischemic encephalopathy 50%Hypoxic-ischemic encephalopathy 50%

Intraventricular hemorrhage 10%Intraventricular hemorrhage 10%

Primary subarachnoid hemorrhage 90%Primary subarachnoid hemorrhage 90%

Hypocalcemia Hypocalcemia

Early-onset 50%Early-onset 50%

Later-onset 100%Later-onset 100%

Hypoglycemia 50%Hypoglycemia 50%

Bacterial meningitis 50%Bacterial meningitis 50%

Developmental defect 0%Developmental defect 0%

Page 23: I. Neonatal Seizures II. Conditions That Mimic Seizures

Why should the infant with epileptic Why should the infant with epileptic seizures be treated with AEDseizures be treated with AED

Potential adverse effects of seizure on:• Ventilatory function • Circulation• Cerebral Metabolism • Brain Development

disturbance in cerebral blood flow

energy metabolism

homeostasis of excitotoxic amino acids

neurogenesis and synaptic reorganization

Page 24: I. Neonatal Seizures II. Conditions That Mimic Seizures

Acute Therapy of Neonatal SeizuresAcute Therapy of Neonatal Seizures

With Hypoglycemia --With Hypoglycemia --

Glucose, 10% solution: 2 mL/kg, IVGlucose, 10% solution: 2 mL/kg, IV

No Hypoglycemia No Hypoglycemia

Phenobarbital:Phenobarbital: 20 mg/kg, IV (1-2 mg/kg/min) 20 mg/kg, IV (1-2 mg/kg/min)

If necessary: If necessary:

Additional Additional phenobarbitalphenobarbital: : 5 mg/kg IV to a max. of 40 mg/kg5 mg/kg IV to a max. of 40 mg/kg

(consider omission of this additional phenobarbital (consider omission of this additional phenobarbital

if infant is severely “asphyxiated”)if infant is severely “asphyxiated”)

Phenytoin*:Phenytoin*: 20 mg/kg, IV (0.5-1.0 mg/kg/min) 20 mg/kg, IV (0.5-1.0 mg/kg/min)

(Lorazepam: 0.05-0.10 mg/kg, IV) if available(Lorazepam: 0.05-0.10 mg/kg, IV) if available

Midazolam: 0.2 mg/kg, IV;then,0.1-0.4 mg/kg/hr, IVMidazolam: 0.2 mg/kg, IV;then,0.1-0.4 mg/kg/hr, IV

Page 25: I. Neonatal Seizures II. Conditions That Mimic Seizures

Acute Therapy of Neonatal SeizuresAcute Therapy of Neonatal Seizures

Other (as Indicated)Other (as Indicated)

Calcium gluconate, 5% solution: 4 mL/kg, IVCalcium gluconate, 5% solution: 4 mL/kg, IV

Magnesium sulfate, 50% solution: 0.2 mL/kg, IMMagnesium sulfate, 50% solution: 0.2 mL/kg, IM

Pyridoxine: 50-100 mg, IV; repeat to maximum of 500 mg if Pyridoxine: 50-100 mg, IV; repeat to maximum of 500 mg if neededneeded

Pyridoxal-5-phosphate,30 mg/kg/day, POPyridoxal-5-phosphate,30 mg/kg/day, PO

Folinic Acid, 4 mg/kg/day, POFolinic Acid, 4 mg/kg/day, PO

Page 26: I. Neonatal Seizures II. Conditions That Mimic Seizures

Volpe, Neurology of the Newborn, 5th ed. 2008

Maintenance Therapy of Neonatal SeizuresMaintenance Therapy of Neonatal Seizures

Glucose: Glucose: << 8 mg/kg/, IV 8 mg/kg/, IV

Phenobarbital: 3-4 mg/kg/24 hr, IV, IM, or POPhenobarbital: 3-4 mg/kg/24 hr, IV, IM, or PO

Phenytoin (as fosphenytoin): 3-4 mg/kg/24 hr, IVPhenytoin (as fosphenytoin): 3-4 mg/kg/24 hr, IV

Calcium gluconate: 500 mg/kg/24 hr, PO Calcium gluconate: 500 mg/kg/24 hr, PO

Magnesium sulfate (50%): 0.2 mL/kg/24 hr, IMMagnesium sulfate (50%): 0.2 mL/kg/24 hr, IM

Page 27: I. Neonatal Seizures II. Conditions That Mimic Seizures

Clinical Scenario 1Clinical Scenario 1

F.M. a 36-37 month old baby boy is noted to have blinking of the eyelids with sucking movements of the mouth at 30 hours of life. The extremities are jittery when tactile stimuli is applied.

Maternal history is unremarkable, NSD, G1P1 (1-0-0-1) no hypertension, no infection. Birth weight is 2.5kg. Apgar 8 and 10 at 1 and 5min.

The blinking of the eyes and jittery movements of the extremities recur within the next hour.

Page 28: I. Neonatal Seizures II. Conditions That Mimic Seizures

What is your impression?

What work-ups will you request?

Hgt, CBC, Serum Calcium, Electrolytes

What will be your management?

Na Luminal 20mg/g IV at 1mg/Kg/min infusion, maintain at 3.5 mg/g/day.

Clinical Scenario 1Clinical Scenario 1

Page 29: I. Neonatal Seizures II. Conditions That Mimic Seizures

Management of Neonatal SeizuresManagement of Neonatal Seizures

• Na Luminal 20 mg/kg/day IV bolus

• Rate of infusion—1 mg/kg/min

• Example: Wt is 3 kg, 3 x 20 = 60 mg

• Give 60 mg for 20 mins. IV push

• Maintenance dose of Na luminal—5mg/kg/day

• Example: 3 x 5 = 15 mg

• Give 7.5 mg IV q12 hrs

Page 30: I. Neonatal Seizures II. Conditions That Mimic Seizures

Duration of Anticonvulsant Therapy GuidelinesDuration of Anticonvulsant Therapy Guidelines

Neonatal PeriodNeonatal Period

If neonatal neurological examination becomes normal, discontinue If neonatal neurological examination becomes normal, discontinue

therapytherapy

If neonatal neurological examination is persistently abnormal, consider the If neonatal neurological examination is persistently abnormal, consider the cause and obtain an EEG.cause and obtain an EEG.

In most such cases:In most such cases:

Continue phenobarbital Continue phenobarbital

Discontinue phenytoinDiscontinue phenytoin

Reevaluate in 1 month Reevaluate in 1 month

At 1 Month After DischargeAt 1 Month After Discharge

If neurological examination has become normal, discontinue If neurological examination has become normal, discontinue

phenobarbitalphenobarbital

If neurological examination is persistently abnormal, obtain an EEG.If neurological examination is persistently abnormal, obtain an EEG.

If no seizure activity is noted on the EEG, discontinue phenobarbitaIf no seizure activity is noted on the EEG, discontinue phenobarbita

Volpe, Neurology of the Newborn, 5Volpe, Neurology of the Newborn, 5thth ed. 2008 ed. 2008

Page 31: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic SeizuresConditions that Mimic Seizures• Night terrors

– Common in boys– 5 – 7 years of age– Sudden onset between midnight and 2:00 am

during stage 3 or 4 of sleep or slow-wave sleep– Child screams and appears frightened, dilated

pupils, tachycardia and hyperventilation– Child thrash violently can not be consoled ,

unaware of parents or surroundings

Page 32: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic Conditions that Mimic SeizuresSeizures

• Night terrors– 1/3 will have somnambulism– Emotional disorder should be explored in

patient with prolonged and persistent night terrors

– Short course diazepam maybe considered while the family dynamics is investigated

Page 33: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic SeizuresConditions that Mimic Seizures• Breath holding spells

– Cyanotic spells• Provoked by upsetting or scolding an infant• Brief shrill cry followed by forced expiration and apnea• Rapid onset of generalized cyanosis or loss of consciousness

may be associated with repeated generalized tonic jerks, opisthotonos, bradycardia

• EEG: normal• Rare before 6 months, peak about 2 years & abate by 5 years old• TX: parent counseling

Page 34: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic Conditions that Mimic SeizuresSeizures

• Breath holding spells– Pallid spells

• Initiated by painful experience• Child stops breathing loss of consciousness pale

and hypotonic tonic seizures• Bradycardia with asystole for 2 seconds may be recorded• EEG: normal• TX supportive but may give atrophine sulfate at 0.01

mg/kg/24 hr in divided doses with a maximum dose of 0.4 mg

Page 35: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic SeizuresConditions that Mimic Seizures• Syncope

– Simple syncope• Decreased blood flow loss of consciousness

ischemia influences the higher cortical centers to release inhibiting influence on reticular formation within the brainstem brief tonic contractions of muscles

• Results from vasovagal stimulation precipitated by pain, fear, excitement , prolonged standing particularly in a warm environment

• Age : 10 -12 years old, females

Page 36: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic Conditions that Mimic SeizuresSeizures

• Syncope– Simple syncope

• Tilt test – effective in producing symptoms including hypotension

• Tx: oral B adrenergic blocking agents

Page 37: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic SeizuresConditions that Mimic Seizures• Syncope

– Cough syncope• Most common in asthmatic children• Occurs shortly after sleep and coughing paroxysm

awakens the child• Patients face become plethoric, perspires, agitated,

frightened• Loss of consciousness with generalized muscle flaccidity,

vertical upward gaze and clonic muscle contraction lasting for several minutes

• Urinary incontinence is frequent

Page 38: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic Conditions that Mimic SeizuresSeizures

• Syncope– Cough syncope

• Cough causes an increased intrapleural pressure decreased venous return to the right side of the heart decreased right ventricular output reduction of left ventricular filling rapidly diminished cerebral blood flow cerebral hypoxia loss of consciousness

• Tx: Prevention of bronchoconstriction

Page 39: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic SeizuresConditions that Mimic Seizures• Syncope

– Prolonged QT syndrome• Sudden loss of consciousness during exercise or emotional

and stressful experience• Onset late childhood or adolescence• With cardiac arrhythmias such as ventricular fibrillation• ECG: abnormal lengthening of the QT interval (corrected QT

of 0.46 or more)• May be associated with acquired heart disease (myocarditis,

mitral valve prolapse, electrolyte abnormalities, drug induced) or congenital forms

Page 40: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic SeizuresConditions that Mimic Seizures

• Syncope– Prolonged QT syndrome

• Autosomal recessive trait (Jervell and Lange-Nielsen syndrome) associated with deafness

• Autosomal dominant (Romano-Ward syndrome) mutations in cardiac potassium channel gene linked to chromosome 11p15.5 LQT1

• LQT2 results from mutation to second potassium channel gene linked to chromosome 7q35-36

Page 41: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic SeizuresConditions that Mimic Seizures• Syncope

– Prolonged QT syndrome• LQT3 result in mutation in cardiac sodium channel linked

to 3p21-24• LQT4 linked to chromosome 4q25-27• Testing include supervised exercise test or Holter

monitoring• Tx: B adrenergic antagonist drugs Permanent implantable cardiac pacing or left

thoracic sympathectomy may be considered if drug is not effective Parents shoudls be taught CPR

Page 42: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic SeizuresConditions that Mimic Seizures• Paroxysmal Kinesigenic Choeoathetosis

– Sudden onset of unilateral or occasional bilateral choreoathetosis or dystonic posturing of a leg, arm and facial grimacing and dysarthia

– Precipitated by sudden movements, excitement or stress

– Rare last for more than 1 minute

– Onset between 8 – 14 years

– Attacks may be daily or intermittent

Page 43: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic Conditions that Mimic SeizuresSeizures

• Paroxysmal Kinesigenic Choeoathetosis– NE, MRI and EEG – normal– Autosomal recessive inheritance is suggested– Tx: Phenytoin

Page 44: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic Conditions that Mimic SeizuresSeizures

• Shuddering attacks– Onset at 4 – 6 months of age– Sudden flexion of the head and trunk and

shuddering or shivering movements– May be a precursor to benign essential

tremors

Page 45: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic Conditions that Mimic SeizuresSeizures

• Benign Paroxysmal torticollis of infancy– Recurrent attacks of head tilt with pallor,

agitation and vomiting– Onset : 2 – 8 months– Spontaneous remission at 2 – 3 years of age– Abnormalities in vestibular function– Some patients develop migraine in childhood

Page 46: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic SeizuresConditions that Mimic Seizures• Hereditary Chin trembling

– Repeated episodes of rapid 3/sec chin trembling movements

– Precipitated by stress, anger, frustration– Autosomal dominant– NE and EEG - normal

• Narcolepsy and cataplexy– Narcolepsy begins before adolescence– Attacks of irrepressible daytime sleep with transient

loss of muscle tone (cataplexy)

Page 47: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic Conditions that Mimic SeizuresSeizures

• Narcolepsy and cataplexy– EEG shows recurrent sleep attacks consist of

REM sleep– Patients are easily aroused– Tx for narcolepsy Modafinil acetamide 200

mg/day

Page 48: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic Conditions that Mimic SeizuresSeizures

• Cataplexy– sudden loss of muscle tone and fall to the

floor precipitated by laughter, stress or frightening experience

– Tx: scheduled naps, amphetamines, methyphenidate, tricyclic antidepressant and counselling regarding occupational safety

Page 49: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic Conditions that Mimic SeizuresSeizures

• Rage attacks or episodic dyscontrol syndrome– Sudden and recurrent episodes of violent

behavior with minimal provocation– Seem to be psychotic at the time of the attack– EEG: normal

Page 50: I. Neonatal Seizures II. Conditions That Mimic Seizures

Conditions that Mimic SeizuresConditions that Mimic Seizures

• Pseudoseizures– Occurs typically between 10 – 18 years old– Lack of cyanosis, normal reaction of pupils to

light, no loss of sphincter tone– Normal plantar response– Absence of tongue biting– Can be persuade to have an attack by the

physician– EEG-excessive muscle artifact

Page 51: I. Neonatal Seizures II. Conditions That Mimic Seizures

Febrile SeizuresFebrile Seizures 3 mo – 6 yrs (peak age of onset 14 – 18

mo) Normal Neurological Exam & development

Mapped to Chromosomes 19p and 8q13-21 in some families- Autosomal Dominant pattern

Incidence Rate: 3-4% of young children

Occurs with fever (not due to CNS Infection) Most commonly due to viral URTI, otitis media, Roseola, UTINormal EEG

Page 52: I. Neonatal Seizures II. Conditions That Mimic Seizures

Simple Febrile SeizuresSimple Febrile Seizures• Seizures are Generalized• Lasts a few seconds, not more than 15 min• Occurs only once in 24 hours

Complex Febrile Seizures• Seizures are focal• Lasts more than 15 min• More than 2 seizures on the first day, (recurrent)

Page 53: I. Neonatal Seizures II. Conditions That Mimic Seizures

Factors associated with increased risk of Factors associated with increased risk of recurrencerecurrence

• Age less than 12 mo

• A positive family history of febrile seizures

• Complex features

• Lower temperature before seizure onset

• Febrile seizures are not associated with decreased intellectual performance.

Page 54: I. Neonatal Seizures II. Conditions That Mimic Seizures

Factors associated with an increased risk of Factors associated with an increased risk of developing Epilepsy In Children with FSdeveloping Epilepsy In Children with FS

• Complex type of FS – focal seizures / post ictal neurological sx

• Positive family history of Epilepsy• Onset of FS below 12 years • Delayed milestones / Pre Existing Neurologic

Disorder

Page 55: I. Neonatal Seizures II. Conditions That Mimic Seizures

Management Of Febrile SeizuresManagement Of Febrile Seizures

• In an actively convulsing patient:1. Do not put anything in the mouth

2. Time the event

3. Don’t restrain the patient

4. Don’t give anything to drink to the patient

5. Turn the patient to the side to prevent choking

6. Put something under the patient’s head to prevent injury

Page 56: I. Neonatal Seizures II. Conditions That Mimic Seizures

ManagementManagement of Febrile Seizures of Febrile Seizures

• In a convulsing patient with seizures lasting more than 5 min or with recurrent seizures

Diazepam 0.2- 0.4mg per kg IV

– In a patient with just a history of febrile seizure

– No maintenance anticonvulsant is recommended

Page 57: I. Neonatal Seizures II. Conditions That Mimic Seizures

Management of Febrile SeizuresManagement of Febrile Seizures

• Careful evaluation of the patient to look for the cause of the fever• Antipyretics to lessen discomfort (Have not been

shown to lessen the recurrence of febrile seizures)

• Reassurance and Education of the Parents

• Advise the parents regarding the use of oral diazepam at the onset of febrile illness

• Oral Diazepam 0.3 mg/kg every 8 hours on the first day of illness

Page 58: I. Neonatal Seizures II. Conditions That Mimic Seizures

Use of Maintenance AnticonvulsantsUse of Maintenance Anticonvulsants

2 AEDs can prevent the recurrence of febrile seizures:

Phenobarbital and ValproateHowever routine use as maintenance anticonvulsants are not recommended for Simple Febrile SeizuresPhenobarbital-decreases cognitive function in treated children Valproate – May cause hepatotoxicity in children <2yrs old

Page 59: I. Neonatal Seizures II. Conditions That Mimic Seizures

Use Of AED’S as prophylaxis in Preventing Use Of AED’S as prophylaxis in Preventing Recurrence of Febrile SeizuresRecurrence of Febrile Seizures

• The potential side effects and risks using Phenobarbital and Valproate do not justify its use in a disorder with an excellent prognosis regardless of treatment

(SIMPLE FEBRILE SEIZURES)

• Carbamazepine and Phenytoin do not prevent febrile seizures

Page 60: I. Neonatal Seizures II. Conditions That Mimic Seizures

Clinical Practice Guidelines on the First Clinical Practice Guidelines on the First Simple Febrile SeizureSimple Febrile Seizure

1. Lumbar Puncture should be performed in all children below 18 months for a first simple febrile seizure

2. Neuroimaging studies should not be routinely performed In children for a Simple First FS

3. Antipyretic Drugs are used to lower fever and should not be relied upon to prevent the occurrence of FS

Page 61: I. Neonatal Seizures II. Conditions That Mimic Seizures

Summary of Recommendations First FSSummary of Recommendations First FS

4. The use of continuous anticonvulsants are not recommended in children after a FIRST SIMPLE FEBRILE SEIZURE .Although anticonvulsants can reduce the recurrence of febrile seizures, the adverse side effects of these do not warrant their use in this disorder.

5. The use of intermittent anticonvulsants are not recommended for the prevention of febrile seizures.

Page 62: I. Neonatal Seizures II. Conditions That Mimic Seizures

Clinical Practice Guidelines (Con,t)Clinical Practice Guidelines (Con,t)

6. Electroencephalogram should not be routinely requested in children with a first simple febrile seizure.

Child Neurology Society Philippines and Philippine Pediatric Society, 2000