Upload
miranda-morton
View
212
Download
0
Embed Size (px)
Citation preview
Introduction To Epilepsy
Semiology diagnosis Treatment
Introduction To Epilepsy
Semiology diagnosis Treatment
M. Scott Perry, M.D.Emory University
April 18, 2007September 18, 2006
M. Scott Perry, M.D.Emory University
April 18, 2007September 18, 2006
QuickTime™ and aDV/DVCPRO - NTSC decompressor
are needed to see this picture.
ObjectivesObjectives•Recognize different types of seizures.
•Discuss workup for new onset seizures
•Learn classification of epilepsy types based on history, seizure type, MRI, and EEG findings
•Review common treatments used in epilepsy
•Learn prognosis based on epilepsy type
•Briefly review some frequently asked questions
•Recognize different types of seizures.
•Discuss workup for new onset seizures
•Learn classification of epilepsy types based on history, seizure type, MRI, and EEG findings
•Review common treatments used in epilepsy
•Learn prognosis based on epilepsy type
•Briefly review some frequently asked questions
SpellsSpells
Seizure EquivalentsSeizure EquivalentsGERDGERD
Breath HoldingBreath HoldingInfantile MasturbationInfantile Masturbation
SyncopeSyncopeBenign Sleep Benign Sleep
MyoclonusMyoclonus
SeizureSeizure
Recurrent Recurrent (Epilepsy)(Epilepsy)
SymptomaticSymptomaticElectrolytesElectrolytes
TraumaTraumaIngestionIngestion
Case 1Case 1
QuickTime™ and aSorenson Video 3 decompressorare needed to see this picture.
QuickTime™ and aSorenson Video 3 decompressorare needed to see this picture.
Seizure ImitatorsSeizure Imitators
•Benign Neonatal Sleep Myoclonus
•Myoclonic jerks are focal, multifocal, unilateral or bilateral
•1-5 hz, distal>proximal
•Begins in first weeks, diminishes by 2nd month, generally gone by 6 months
•Episodes may be exacerbated by benzos
•Benign Neonatal Sleep Myoclonus
•Myoclonic jerks are focal, multifocal, unilateral or bilateral
•1-5 hz, distal>proximal
•Begins in first weeks, diminishes by 2nd month, generally gone by 6 months
•Episodes may be exacerbated by benzos
Seizure ImitatorsBreath Holding Spells
Seizure ImitatorsBreath Holding Spells
• Incidence: 4.6% (population study, N=4980)
• Onset: 6-18 months
• 90% resolve by age 6y
• cyanotic and pallid
• Incidence: 4.6% (population study, N=4980)
• Onset: 6-18 months
• 90% resolve by age 6y
• cyanotic and pallid
CYANOTIC BREATH-HOLDING SPELLS
CYANOTIC BREATH-HOLDING SPELLS
• 60 % are cyanotic
• stimulus triggered (anger, frustration)
• short cry
• breathing interrupted in expiration
• cyanotic, limp, LOC
• +/- sleep
• 60 % are cyanotic
• stimulus triggered (anger, frustration)
• short cry
• breathing interrupted in expiration
• cyanotic, limp, LOC
• +/- sleep
COMPLICATED BREATH-HOLDING
SPELLS
COMPLICATED BREATH-HOLDING
SPELLS• Breath-holding spells + seizure-like
activity
• usually more prolonged
• 15% have complicated features
• clonic activity follows LOC
• stiffening
• Breath-holding spells + seizure-like activity
• usually more prolonged
• 15% have complicated features
• clonic activity follows LOC
• stiffening
Seizures:What information is
useful?
Seizures:What information is
useful?•What was the patient doing when it started? Unresponsive?...are you sure? Asleep or awake?
•Tell us exactly what you saw:
•E.R.B.S.A.O?
•Does it make anatomical sense? Same side, both sides, just arms, etc.
•How long did it last?
•What was the patient doing when it started? Unresponsive?...are you sure? Asleep or awake?
•Tell us exactly what you saw:
•E.R.B.S.A.O?
•Does it make anatomical sense? Same side, both sides, just arms, etc.
•How long did it last?
Clinical Characteristics of Seizures in Neonates (Scher,
et al 1989)
Clinical Characteristics of Seizures in Neonates (Scher,
et al 1989)•No accepted classification for neonatal seizures
•80 neonates with suspicious movements. Only 8 had electrographic seizures.
•Focal/multifocal clonic: 44% epileptic
•“Subtle seizures”-roving eye movements, arrest of behavior, lip smacking, autonomic-30%
•Tonic(focal or generalized) 8%
•Myoclonic 7%
•No accepted classification for neonatal seizures
•80 neonates with suspicious movements. Only 8 had electrographic seizures.
•Focal/multifocal clonic: 44% epileptic
•“Subtle seizures”-roving eye movements, arrest of behavior, lip smacking, autonomic-30%
•Tonic(focal or generalized) 8%
•Myoclonic 7%
Clinical Characteristics of Seizures in Neonates (Scher,
et al. 1993)
Clinical Characteristics of Seizures in Neonates (Scher,
et al. 1993)
•92 neonates with electrographic seizures (345 EEG recordings)
•48% had electroclinical event
•Subtle 71%, clonic 41%, myoclonic 20%, tonic 9%
•34% with only electrographic events
•17/90 (19%) of paralyzed neonates had electrographic events
•92 neonates with electrographic seizures (345 EEG recordings)
•48% had electroclinical event
•Subtle 71%, clonic 41%, myoclonic 20%, tonic 9%
•34% with only electrographic events
•17/90 (19%) of paralyzed neonates had electrographic events
Clinical Seizures in Neonates
Clinical Seizures in Neonates
•Duration- average duration 2.25 minutes. Usually shorter, rarely longer. Intertictal recovery 8 minutes (Clancy and Legido, 1987)
•Status Epilepticus- clinical SE is rare, electrographic may not be
•487 seizures, only 2 SE (Clancy, et al)
•33% FT infants, 9% PT (Scher, et al)
•Duration- average duration 2.25 minutes. Usually shorter, rarely longer. Intertictal recovery 8 minutes (Clancy and Legido, 1987)
•Status Epilepticus- clinical SE is rare, electrographic may not be
•487 seizures, only 2 SE (Clancy, et al)
•33% FT infants, 9% PT (Scher, et al)
•Gen. Tonic Clonic seizures don’t happen in neonates.
•69 infants, 101 seizures, only 4 resembled GTCS, none truly were. (Nordli, et al.)
Seizure Semiology of Neonates
QuickTime™ and aSorenson Video 3 decompressorare needed to see this picture.
Focal/Multifocal ClonicTonic
QuickTime™ and aSorenson Video 3 decompressorare needed to see this picture.
Subtle
QuickTime™ and aSorenson Video 3 decompressorare needed to see this picture.
Tremors
QuickTime™ and aSorenson Video 3 decompressorare needed to see this picture.
Seizure TypesSeizure Types
PartialPartial GeneralizedGeneralized
Simple Partial Simple Partial Complex PartialComplex Partial
Partial SecondarilyPartial Secondarily GeneralizedGeneralized
Simple partialSimple partial
QuickTime™ and aDV/DVCPRO - NTSC decompressor
are needed to see this picture.
•Preserved consciousnessPreserved consciousness•Isolated motor/sensory Isolated motor/sensory •Complex partial involves loss of consciousnessComplex partial involves loss of consciousness
Partial Secondarily Generalized
Partial Secondarily Generalized
QuickTime™ and aYUV420 codec decompressor
are needed to see this picture.
•Starts partial, rapidly spreadsStarts partial, rapidly spreads•You have to ask the questions to get the You have to ask the questions to get the answersanswers
Partial Seizure CluesPartial Seizure Clues
•Contralateral
•Head Deviation, Eye Deviation, Dystonic Posturing, Unilateral Clonic Activity, Postictal Paralysis
•Ipsilateral
•Automatisms, Eye Blinking, Nose Wiping
•Contralateral
•Head Deviation, Eye Deviation, Dystonic Posturing, Unilateral Clonic Activity, Postictal Paralysis
•Ipsilateral
•Automatisms, Eye Blinking, Nose Wiping
Differentiating Seizure Types - Semiology
Differentiating Seizure Types - Semiology
Partial SeizuresPartial Seizures
QuickTime™ and aDV/DVCPRO - NTSC decompressor
are needed to see this picture.
Head and Eye Head and Eye DeviationDeviation
What do you see?What do you see?
QuickTime™ and aDV/DVCPRO - NTSC decompressor
are needed to see this picture.
1. Head 1. Head DeviationDeviation2. Automatism2. Automatism3. Eye Deviation3. Eye Deviation4. Unilateral 4. Unilateral Dystonic/Clonic Dystonic/Clonic ActivityActivity
Seizure Types
PartialPartial GeneralizedGeneralized
Simple Partial Simple Partial Complex PartialComplex Partial
Partial SecondarilyPartial Secondarily GeneralizedGeneralized
Generalized Tonic ClonicGeneralized Tonic ClonicTonicTonicClonicClonicAtonicAtonic
MyoclonicMyoclonicAbsenceAbsence
Generalized Seizure Generalized Seizure MyoclonicMyoclonic
QuickTime™ and aDV/DVCPRO - NTSC decompressor
are needed to see this picture.
• Characterized by quick, Characterized by quick, arrhythmic, and arrhythmic, and symmetric/asymmetric movementssymmetric/asymmetric movements•Often not reported by patients.Often not reported by patients.•Ask about sudden falls or dropping Ask about sudden falls or dropping objectsobjects
See the Difference?See the Difference?
QuickTime™ and aDV/DVCPRO - NTSC decompressor
are needed to see this picture.
Myoclonic-fast, Myoclonic-fast, jerking motionjerking motion
Clonic-rhythmicClonic-rhythmic
QuickTime™ and aDV/DVCPRO - NTSC decompressor
are needed to see this picture.
SemiologySemiologyTypical Absence SeizuresTypical Absence Seizures
•Characterized by brief, abrupt impairment of consciousness associated with EEG demonstrating 3 Hz spike and slow wave complexes with normal interictal background•May also demonstrate:•mild clonic, tonic, or atonic components•automatisms•autonomic components
Panayiotopoulos “The Epilepsies: Seizures,
Syndromes, and Manangement
Generalized Seizure Semiology
Generalized Seizure SemiologyInfantile SpasmsInfantile Spasms
QuickTime™ and aDV/DVCPRO - NTSC decompressor
are needed to see this picture.
Review So FarReview So Far
•Common seizure imitators in pediatrics
•Seizures come in two basic types. You have to ask the right questions to distinguish them
•Now...how do you diagnose epilepsy (i.e. when is EEG/MRI necessary) and why do we care?
•Common seizure imitators in pediatrics
•Seizures come in two basic types. You have to ask the right questions to distinguish them
•Now...how do you diagnose epilepsy (i.e. when is EEG/MRI necessary) and why do we care?
Epilepsy Types
Partial Generalized
IdiopathicBenign Rolandic
EpilepsyBenign Occipital
Epilepsy
Symptomatic
Idiopathic Symptomatic
West SyndromeLennox-Gastaut
Childhood AbsenceJuvenile Absence
Juvenile MyoclonicGrand Mal Upon
Awakening
•Primary = Idiopathic = presumed genetic•Secondary = Symptomatic=underlying cerebral cause (i.e. injury, dyplasia, etc.)
Cryptogenic
Cryptogenic
Idiopathic Partial EpilepsyBenign Rolandic Epilepsy
(Benign Childhood Epilepsy with Centro-Temporal Spikes)
•Onset 1-14 years, 75% between 7-10 years of age
•Prevalence is 15% of children with seizures
•Characterized by infrequent, often single, focal seizures consisting of unilateral facial sensorimotor symptoms, oropharyngolaryngeal manifestations, speech arrest, or hypersalivation lasting 1-2 minutes
•1/3 -2/3 will have secondarily generalized seizures
•75% are nocturnal
•MRI normal
•Typical EEG
Benign Rolandic EpilepsyPrognosis/Treatment
•2-3% school age children have CT spikes with <10% having BRE•Remission usually within 2-4 years from onset and before the age of 16 years•Less than 2% will develop infrequent generalized seizures in adulthood•Treat or not to treat
Benign Occipital EpilepsyGastaut Type
•Onset 3-15 years•Manifest as visual hallucinations, blindness, or both-lasting seconds to <3 minutes•Rarely terminate with hemiconvulsions or generalized convulsion•50% have postictal headache•Similar manifestation to seizures from occipital lesions - MRI needed•Typical EEG
Benign Occipital EpilepsyFixation-Off EEG
Benign Occipital EpilepsyPrognosis/Treatment
•Remission occurs 2-4 years from onset for 50-60% of patients•Dramatic response to carbamazepine in >90%•15% association with celiac disease
Symptomatic Partial Epilepsy
Symptomatic Partial Epilepsy
•Abnormal MRI (stroke, dyplasia, etc.) or abnormal EEG without classic pattern
•History not consistent with primary partial epilepsy
•Prognosis varies
•Abnormal MRI (stroke, dyplasia, etc.) or abnormal EEG without classic pattern
•History not consistent with primary partial epilepsy
•Prognosis varies
Secondary Partial Epilepsy - MRI
Secondary Partial Epilepsy - MRI
HeterotopiaHeterotopia Mesial Temporal SclerosisMesial Temporal Sclerosis
Idiopathic Generalized Epilepsy
Childhood Absence Epilepsy
•Onset 2-10 years, peak 5-6 years•2/3 are females•Abrupt cessation of activity or speech last 4-20 seconds followed by return to baseline •Normal MRI•Typical EEG with 3Hz SW often provoked with HV
Idiopathic Generalized Epilepsy
Childhood Absence Epilepsy
Idiopathic Generalized Epilepsy
Childhood Absence Epilepsy
Prognosis/Treatment•Remission often occurs before 12 years of age•Less than 10% develop infrequent generalized tonic clonic seizures in adolescence or adult life•Rarely will patients continue to have absence seizures as adults•Treatment with valproic acid, ethosuximide, or lamotrigine will control absences in >80%•Possible role for topiramate and levetiracetam
Idiopathic Generalized Epilepsy
Juvenile Absence Epilepsy•Age of onset 9-13 years
•80% suffer from GTCS and 15-25% have Myoclonic seizures with onset 1-10 years after absences•Frequent/severe absences•Absence status in 20%•Prognosis: 70-80% will be controlled, though this is a lifelong disorder•20% may have intractable absences and GTCS
Idiopathic Generalized Epilepsy
Juvenile Myoclonic Epilepsy
•Characterized by myoclonic jerks upon awakening starting in adolescence•GTCS (>90%) may begin a few months later, occasionally earlier•Absence seizures (33%), if present, begin between 5-16 years•M:F equal•Seizure precipitants: Sleep deprivation, alcohol, stress, video games
Idiopathic Generalized Epilepsy
Juvenile Myoclonic Epilepsy•EEG: irregular generalized 3-6hz spike/polyspike-slow
wave discharges and generalized fragments. 33% have photoparoxysmal responses
Idiopathic Generalized Epilepsy
Juvenile Myoclonic Epilepsy
Treatment/Prognosis•Valproic Acid, levetiracetam most commonly used monotherapy treatment•Lamotrigine, clonazepam•Prognosis: Seizures well controlled in up to 90% of patients. Treatment is lifelong, as 80% relapse after drug withdrawal•Carbamazepine, oxcarbazepine, phenytoin, gabapentin, tiagabine, and vigabatrin are contraindicated•Lifestyle management with regards to alcohol use, sleep deprivation, etc.
Symptomatic Generalized Epilepsy
Infantile SpasmsWest Syndrome
“...these bobbings...they come on whether sitting or lying; just before they come on he is
all alive and in motion...and then all of a sudden down goes his head and upwards his knees; he then appears frightened and screams out. --
W.J. West (1841)
Symptomatic Generalized Epilepsy
Infantile SpasmsWest Syndrome•Onset between 3-12 months, peak at 5
months•Incidence: 3-5/10,000•Spasms are flexor, extensor, or combined•Clusters with 20-150 seizures per day, occurring most often on awakening or prior to sleep•Developmental delay preceeds spasms in 2/3•Classified as symptomatic, probably symptomatic, and cryptogenic
Symptomatic Generalized Epilepsy
Infantile SpasmsWest Syndrome•80% symptomatic with most caused
by pre-, peri-, or post-natal insults (i.e. HIE, ICH, dysplasias, trauma)•50% of patients with TS have spasms•3% of patients with Trisomy 21•Aicardi’s syndrome (spasms, agenesis of the corpus callosum, and retinal lacunes•EEG demonstrates hypsarrhythmia•High voltage, chaotic, arrhythmic and asynchronous which becomes more synchronous in NREM sleep•Multifocal independent spike wave discharges•Periods of electrodecrement
Symptomatic Generalized Epilepsy
Infantile SpasmsWest Syndrome
Symptomatic Generalized Epilepsy
Infantile SpasmsPrognosis
•Spasms typically will remit, even without treatment, by 18 months of age•60% of patients develop other seizure types, CPS and Lennox-Gastaut syndrome are most common•90% of patients have developmental delay, 66% are severely cognitively impaired
Symptomatic Generalized Epilepsy
Infantile SpasmsTreatment•ACTH - 50% remission, all or none.
No proven dosing regimen, no clear reason why it works•Topiramate - similar efficacy usually in high doses (25-30mg/kg/d)•Vigabatrin - especially useful in TS (90%), beware of irreversible visual field defects•Pyridoxine, valproate, zonisamide, levetiracetam, lamotrigine, felbatol, keto diet•Surgery
Symptomatic Generalized Epilepsy
Lennox-Gastaut Syndrome•Three criteria•Multiple intractable seizures including tonic (80-100%), atypical absence (66%), and atonic (50%)•cognitive and behavioral abnormalities•Slow (<2.5 Hz) generalized spike wave•Onset 1-7 years, peak 3-5•10-30% develop from West syndrome or other epileptic encephalopathies
Symptomatic Generalized Epilepsy
Lennox-Gastaut Syndrome
Symptomatic Generalized Epilepsy
Lennox-Gastaut SyndromePrognosis/Treatment•5% die, 80-90% have seizures as
adults, and approximately 90% have severely impaired cognition and behavior•Treatment includes almost every AED with polypharmacy common.•Ketogenic diet, VNS, corpus callosotomy
Choosing an AEDChoosing an AED
•Type of epilepsy•Type of epilepsy
Treatment of Epilepsy: AEDs
Treatment of Epilepsy: AEDs
PartialPartial GeneralizedGeneralizedPhenytoinPhenytoin
PhenobarbitalPhenobarbitalValproic AcidValproic Acid
CarbamazepineCarbamazepineOxcarbazepineOxcarbazepine
GabatrilGabatrilGabapentinGabapentinTopiramateTopiramateLamotrigineLamotrigineZonisamideZonisamide
LevetiracetamLevetiracetam
Valproic AcidValproic AcidTopiramateTopiramateZonisamideZonisamideLamotrigineLamotrigine
LevetiracetamLevetiracetamEthosuximideEthosuximide
FelbamateFelbamate
Choosing an AED
•Type of epilepsy
•Type of formulation (IV, capsule, sprinkle, etc.)
Choosing an AEDFormulation
Choosing an AEDFormulation
•IV: Benzos, phenytoin, phenobarbital, valproic acid, levetiracetam
•Sprinkles: valproate, topiramate
•Liquids: carbazepine, oxcarb, levetiracetam, valproate, dilantin. zonegran,lamictal,topiramate will dissolve in H20
•Extended release: valproate, carbamazepine
•IV: Benzos, phenytoin, phenobarbital, valproic acid, levetiracetam
•Sprinkles: valproate, topiramate
•Liquids: carbazepine, oxcarb, levetiracetam, valproate, dilantin. zonegran,lamictal,topiramate will dissolve in H20
•Extended release: valproate, carbamazepine
Choosing an AED
•Type of epilepsy
•Type of formulation (IV, capsule, sprinkle, etc.)
•Time to onset
Choosing an AEDTime To Onset
Choosing an AEDTime To Onset
•Rapid onset: Any IV form
•Onset in 24 hours: Levetiracetam
•Onset in Days: carbamazepine, oxcarb, dilantin, valproate, zarontin.
•Slow titration: Topiramate, zonisamide
•Really slow: Lamictal
•Rapid onset: Any IV form
•Onset in 24 hours: Levetiracetam
•Onset in Days: carbamazepine, oxcarb, dilantin, valproate, zarontin.
•Slow titration: Topiramate, zonisamide
•Really slow: Lamictal
Choosing an AED
•Type of epilepsy
•Type of formulation (IV, capsule, sprinkle, etc.)
•Time to onset
•Side Effects
Choosing An AEDSide Effects
Choosing An AEDSide Effects
SomnolenceSomnolence•AllAll
RashRash•LamictalLamictal•PhenytoinPhenytoin•PhenobarbPhenobarb
Renal StonesRenal Stones•TopiramateTopiramate•ZonisamideZonisamide
HyponatremiaHyponatremia•CarbamazepineCarbamazepine•OxcarbazepineOxcarbazepine
ParasthesiaParasthesia•TopiramateTopiramate•ZonisamideZonisamide
CognitiveCognitive•PhenobarbPhenobarb•TopiramateTopiramate
BehaviorBehavior•LevetiracetamLevetiracetam
Labs drawsLabs draws•CarbamazepineCarbamazepine•Valproic AcidValproic Acid•PhenytoinPhenytoin
LevelsLevels•AllAll
Choosing an AED
•Type of epilepsy
•Type of formulation (IV, capsule, sprinkle, etc.)
•Time to onset
•Side Effects
•Dosing Schedule
Choosing An AEDDosing ScheduleChoosing An AEDDosing Schedule
•QD: Depakote ER, Zonisamide
•TID: Depakene, Neurontin, Tegretol, Phenytoin (neonates)
•BID: Everything else
•QD: Depakote ER, Zonisamide
•TID: Depakene, Neurontin, Tegretol, Phenytoin (neonates)
•BID: Everything else
Febrile SeizureFebrile Seizure•3 types (simple, complex, status)
• NIH consensus: Febrile seizure is an event in infancy or childhood, usually 3m-5 years, associated with fever but without evidence of intracranial infection or defined cause. Seizures with fever in children who have suffered a previous nonfebrile seizure are excluded.
• incidence- 4%: absolute risk increased with family hx (1 relative 10%, 2-32%), daycare (7%), dev delay (10%)
•Risk of recurrence: 1 in 24
• risk of future epilepsy: 2-10%
•workup - MRI/EEG does not predict recurrence
•treatment
•3 types (simple, complex, status)
• NIH consensus: Febrile seizure is an event in infancy or childhood, usually 3m-5 years, associated with fever but without evidence of intracranial infection or defined cause. Seizures with fever in children who have suffered a previous nonfebrile seizure are excluded.
• incidence- 4%: absolute risk increased with family hx (1 relative 10%, 2-32%), daycare (7%), dev delay (10%)
•Risk of recurrence: 1 in 24
• risk of future epilepsy: 2-10%
•workup - MRI/EEG does not predict recurrence
•treatment
Practice ParameterFebrile Seizures
Practice ParameterFebrile Seizures
• Current Recommendations AAP [Pediatrics 97(5), May 1996, 769-71.]
• Age 6-12 months with febrile seizure should strongly consider LP
• Age 12-18 months should consider
• >18 months may use physical exam, associated symptoms to drive need
• Based recommendations on 4 studies reporting 13-15% of children will present with seizures as the initial manifestation of seizures with 30-35% having no meningeal signs.
• More recent reviews have suggested the presence of meningitis in the absence of associated signs is rare (1/200), with a large percentage of such patients with normal CSF at presentation. The introduction of the H.Flu vaccine has significantly altered the epidemiology of infantile bacterial meningitis making present treatment different from that 30 years ago (which the AAP based their recommendations).
• Most physicians would agree that LP in children outside the range of febrile convulsions is necessary, as well as children within the range with sign or symptoms of CNS infection, such as nuchal rigidity, altered mental status, etc.
• Current Recommendations AAP [Pediatrics 97(5), May 1996, 769-71.]
• Age 6-12 months with febrile seizure should strongly consider LP
• Age 12-18 months should consider
• >18 months may use physical exam, associated symptoms to drive need
• Based recommendations on 4 studies reporting 13-15% of children will present with seizures as the initial manifestation of seizures with 30-35% having no meningeal signs.
• More recent reviews have suggested the presence of meningitis in the absence of associated signs is rare (1/200), with a large percentage of such patients with normal CSF at presentation. The introduction of the H.Flu vaccine has significantly altered the epidemiology of infantile bacterial meningitis making present treatment different from that 30 years ago (which the AAP based their recommendations).
• Most physicians would agree that LP in children outside the range of febrile convulsions is necessary, as well as children within the range with sign or symptoms of CNS infection, such as nuchal rigidity, altered mental status, etc.
Practice ParametersFirst Unprovoked Seizure
Practice ParametersFirst Unprovoked Seizure• Laboratory investigations (CBC, CMP, tox screens)
should be considered based on historic and clinical findings
• LP is of limited value in first unprovoked afebrile seizure
• EEG is recommended to dx epilepsy syndromes and provide for prognosis
• MRI is preferred modality and should be considered in children with cognitive/motor impairment that is unexplained, focal onset seizures, or in children < 1y.
• Emergenat imaging should be performed in children with prolonged todd’s, or prolonged (several hours) postictal state.
• Treatment: 46% have recurrence in 10years, 19% > 4 seizures, and 10%>10 seizures
• Laboratory investigations (CBC, CMP, tox screens) should be considered based on historic and clinical findings
• LP is of limited value in first unprovoked afebrile seizure
• EEG is recommended to dx epilepsy syndromes and provide for prognosis
• MRI is preferred modality and should be considered in children with cognitive/motor impairment that is unexplained, focal onset seizures, or in children < 1y.
• Emergenat imaging should be performed in children with prolonged todd’s, or prolonged (several hours) postictal state.
• Treatment: 46% have recurrence in 10years, 19% > 4 seizures, and 10%>10 seizures
FAQ (the ED)FAQ (the ED)•I have a 14 month old with a febrile seizure
and a “raging otitis,” do I need to do a LP?
•(3a.m.) Hey, how are you? I have a kid here with known epilepsy that had a breakthrough seizure (like he does once every 3 months or so), do you want to increase his medicine?
•Do I need to CT this kid?
•I have a patient of Dr. Flamini’s here, how do you want to treat him?
•I have a 14 month old with a febrile seizure and a “raging otitis,” do I need to do a LP?
•(3a.m.) Hey, how are you? I have a kid here with known epilepsy that had a breakthrough seizure (like he does once every 3 months or so), do you want to increase his medicine?
•Do I need to CT this kid?
•I have a patient of Dr. Flamini’s here, how do you want to treat him?
FAQ (the parents)FAQ (the parents)
•Why does my child have seizures?
•Will my child be stupid?
•How long does my child need treatment?
•What do I do when my child has a seizure?
•Why does my child have seizures?
•Will my child be stupid?
•How long does my child need treatment?
•What do I do when my child has a seizure?
CaseCase•16 year old female with first unprovoked
seizure, described as generalized tonic clonic•16 year old female with first unprovoked
seizure, described as generalized tonic clonic
•Focal signs at onset?Focal signs at onset?•Myoclonic or absence type episodes?Myoclonic or absence type episodes?•Time of day?Time of day?•Previous workup?Previous workup?
•Treatment choices: Depakote, Keppra, Treatment choices: Depakote, Keppra, TrileptalTrileptal
•How long will she need medicine?How long will she need medicine?
CaseCase
•8 y/o with frequent episodes of staring, at times associated with lip smacking
•8 y/o with frequent episodes of staring, at times associated with lip smacking
•Focal signs at onset? Can they be stopped?Focal signs at onset? Can they be stopped?•Myoclonic or GTC episodes?Myoclonic or GTC episodes?•Duration?Duration?•Time of day?Time of day?•Previous workup?Previous workup?•Treatment choices: Depakote, Keppra, Treatment choices: Depakote, Keppra, TrileptalTrileptal