Which seizure is this? Dr. Andrea Andrade

Assistant Professor of Paediatrics

and Clinical Neurological Science, Western University

Director of the Paediatric Epilepsy Program

Faculty/Presenter Disclosure

• Faculty/Speaker: Dr Andrea V Andrade

• Relationships with commercial interests:

• Grants/Research Support: None

• Speakers Bureau/ Honoraria: None

• Consulting Fee: None

• Other: None

ILAE seizure classification 2017

Case #1

• C.C- 6 year old boy previously well with episodes of staring and blinking since the age of 4 years of age, they have been more noticeable by teachers at school

• Frequency: Multiple times a day

• Duration: 5 to 10 seconds

• Seizure risk factors:

• Family history ++, paternal uncle and paternal grand father with epilepsy NYD

• Developmentally normal

• No trauma, infection , perinatal and neonatal history normal

• No history of febrile seizures

• Neurological exam

• Normal – No focal findings , normal language

Q1. How do you classify

this seizure?

• A) Generalized TC seizure

• B) “Petit Mal”

• C) Day dreaming- non epileptic

• D) Generalized onset seizure –non motor

Q1. How do you classify

this seizure?

• A) Generalized TC seizure

• B) “Petit Mal”

• C) Day dreaming- non epileptic

• D) Generalized onset seizure –non motor

Q2. To confirm your diagnosis

you do the following ?

• 1) EEG and MRI due to concern of a structural brain abnormality

• 2) Ask the school to test for ADHD

• 3) EKG to rule out arrhythmias

• 4) EEG with hyperventilation to provoke 3 Hz generalized spike and wave

Q2. To confirm your diagnosis you order the

following : (Choose best

answer)

• 1) EEG and MRI due to concern of a structural brain abnormality

• 2) Ask the school to test for ADHD

• 3) EKG to rule out arrhythmias

• 4) EEG with hyperventilation to provoke 3 Hz generalized spike and wave

Q3. The best treatment

option and most likely

outcomes are: (Choose the

best answer)

• 1) Start Carbamazepine and evaluate for epilepsy surgery , this type of seizures likely become drug resistant

• 2) Start stimulants and request for an IEP in school

• 3) This is a benign type of focal epilepsy, no need to treat unless seizures are longer than five minutes. He will likely outgrow the epilepsy by late teens

• 4) Start Ethosuximide , outcome is good when childhood onset

Q3. The best treatment

option and most likely

outcomes are: (Choose the

best answer)

• 1) Start Carbamazepine and evaluate for epilepsy surgery , this type of seizures likely become drug resistant

• 2) Start stimulants and request for an IEP in school

• 3) This is a benign type of focal epilepsy, no need to treat unless seizures are longer than five minutes. He will likely outgrow the epilepsy by late teens

• 4) Start Ethosuximide , outcome is good when childhood onset

What type of seizure is this according to the new classification ?

Why is generalized ? • Because the EEG shows bi-hemispheric activity when the seizure

happens

BOTH CEREBRAL HEMISPHERESDISCHARGE AT THE SAME TIME

Case 2.

• C.C- 7 month old girl with episodes of “motionless” noted since she is 6 months of age

• Frequency: 2 a week

• Duration: 30 to 60 seconds

• Seizure risk factors:

• Family history None

• Developmentally – she is slightly behind in gross motor milestones

• No trauma, infection , no perinatal history

• Had one “big seizure” a month back due to a febrile infection

• Neurological exam

• Normal CN, does not sit yet , rest of the exam unremarkable

Q4. What is the best

classification for this event?

• Focal onset seizure non motor

• Generalized onset seizure non motor

• Infantile Spasms

• Breath holding spells

Q4. What is the best

classification for this event?

• Focal onset seizure non motor

• Generalized onset seizure non motor

• Infantile Spasms

• Breath holding spells

Q5. The best next steps

are?

• 1)EEG only and start Ethosuximide

• 2)EEG and MRI, start Carbamazepine

• 3)ECG and reassuring the family

• 4)EEG, genetic testing and start Vigabatrin

Q.5 The best next steps are?

• 1)EEG only and start Ethosuximide

• 2)EEG and MRI, start Carbamazepine

• 3)ECG and reassuring the family

• 4)EEG, genetic testing and start Vigabatrin

HOW DO YOU CLASSIFY THIS SEIZURE ??????

FOCAL ONSET SEIZURE

BUT HOW CAN WE DIFFERENTIATE CLINICALLY FROM FOCAL NON MOTOR SEIZURES VS GENERALIZED NON MOTOR SEIZURES ?

GEN NON MOTOR (ABSENCE ) FOCAL NON MOTOR

AGE OF ONSET School age/Teens Any age , but suspect if seizures started during infancy

Frequency Too many to count a day with a clear “onset and off set”

Less frequent , in older children can have an ”aura” = warning sign

Additional ictal features Fast blinking Automatism , focal findings (lateral eye deviation, asymetric postures of the limbs), manual and oral automatisms

Postictal Never Usually yes , except in frontal lobe originated ones

Duration Seconds Minutes

What about in terms of risk factors for epilepsy…

GEN NON MOTOR FOCAL NON MOTOR

Family Hx Usually yes Usually no

Febrile seizures No Usually yes

Perinatal abnormalities No Potentially yes

Developmental history Normal Mildly abnormal , or slightly behind in any area including motor (specially focal – hemiparesis) or language delays

Neurological Exam Normal Look for focal deficits – hemiplegic CP, subtle asymetries in rapid alternating movements , or asymetric DTRs

EEG 3 Hz spike and wave generalized Focal spikes

MRI Not indicated Indictaed

Response to medication Good Usually refractory to AEDs

FRONTAL LOBE SEIZURES-MOTOR, NOCTURNAL, ASYMETRICTONIC, HYPERMOTOR BIZARRE FEATURES

PARIETAL LOBE SEIZURESSomatosensory: “tingling”,”pins and needles”, numbness

FRONTAL LOBE MESIAL AREA , WE CALL THIS SEIZURE FOCAL ONSET TONIC ASYMMETRIC

HYPERMOTOR SEIZURE = FRONTAL LOBE, BASAL:DO NOT CONFUSE WITH CONVERSION DISORDER

TEMPORAL LOBE SEIZURE:-Epigastric aura, focal unawareNon motor

OCCIPITAL LOBE SEIZURES:-Visual phenomena, illusions-Ocular phenomena: nystagmus

Temporal lobe seizure (focal non motor)

A B C

D

E F G

Case 3

• 4 year old boy previously well . Events onset – 4 weeks ago,

• Description- child is usually sleep when he developed mouth twitching and mouth pulling towards one side, at times he wakes up and he goes to parents bedroom very upset

• Duration – 1 to 2 minutes

• Frequency a total of 3 events

• Risk factors for epilepsy- None

• Exam- Normal

Q6.This event is best

classified as ?

• 1)Psychogenic non epileptic seizure (PNES)

• 2)Generalized onset seizure –motor –clonic

• 3) Focal onset seizure-preserved awarenes –motor

• 4) Tic disorder

Q6. This event is best

classified as ?

• 1)Psychogenic non epileptic seizure (PNES)

• 2)Generalized onset seizure –motor –clonic

• 3) Focal onset seizure-preserved awarenes –motor

• 4) Tic disorder

•

Q7.This seizure type is

a predominant

feature of which epilepsy

syndrome of childhood?

• 1) Childhood Absence Epilepsy

• 2) Juvenile Myoclonic epilepsy

• 3) Lennox Gastaut Syndrome

• 4) Benign Rolandic epilepsy

Q7.This seizure type is

a predominant

feature of which epilepsy

syndrome of childhood?

• 1) Childhood Absence Epilepsy

• 2) Juvenile Myoclonic epilepsy

• 3) Lennox Gastaut Syndrome

• 4) Benign Rolandic epilepsy

HOW DO YOU CLASSIFY THIS SEIZURE ??????

Case 5.

• 6 month old baby with new onset body jerks. Mom describes that she “bends forward” as she would be upset of her stomach, treated for infant colic but the events still happening

• Frequency – every day , more common when awaking from naps.

• Duration- second, but several can follow one and other for 10 to 15 minutes, the time between one and other can be 30 second to 3 minutes

• Epilepsy risk factors- development has arrested since the events happened, she used to sit up and its not happening anymore. Dad has epilepsy and intellectual disability

• Exam- hypopigmented skin marks throughout her body

Q.8 Which one best

describes the events

• 1)Myoclonic seizures

• 2)Infant shuddering

• 3)Infantile spasms

• 4)Motor tics

Q.8 Which one best

describes the events

• 1)Myoclonic seizures

• 2)Infant shuddering

• 3)Infantile spasms

• 4)Motor tics

INFANTILE SPASMS/WEST

SYNDROME (CAN BE

FOCAL OR GENERALIZED)

• AGE OF ONSET- FROM 1 MONTH TO 3 YEARS ~ 6 TO 8 MONTHS

• SEIZURE TYPE ; INFANTILE SPASMS … TYPICAL COME IN CLUSTERS

• FLEXOR

• EXTENSOR

• MIXED

• EEG: HYPSARRHYTHMIA

• DEVELOPMENTAL- ABNORMAL/DELAYED

• CAN BECOME DRUG RESISTANT

• TX- STEROIDS, VGB

TUBEROUS SCLEROSIS

REMOTE STROKE

Take home message

• Recognition and proper classification of seizure type, can lead to a an accurate diagnosis and therefore good outcomes

• Pediatricians and family doctors must be familiar with seizure types and classification given they are the first line diagnosing and referring children with epilepsy

• The appropriate diagnosis of a child with epilepsy is not only related tp seizure freedom but also to protect the developing brain from the negative effects of epileptic seizures