Prepared by: Nurul Syazwani Ramli

SEIZURE

A sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioral manifestations.

FEBRILE SEIZURE
Febrile fits, febrile seizure and febrile convulsions are synonymous terms. Febrile fits (F.C.) are defined as fits occurring in association with fever in children between 6 months and 6 years of age, in whom there is no evidence of intracranial pathology or metabolic derangement that could be the cause of the fit.

Epidemiology
There is no comprehensive local epidemiological data. 3-4% of children < 5 years experiencing febrile fits (Western Europe) Higher figures of up to 8% in Japan. The single most common problem in paediatric neurology

Types of Febrile Fits

Simple Febrile Fits
Duration short (< 15 minutes) Generalised fits do not recur during febrile episode
Duration prolonged (> 15 minutes) Focal features > 1 seizure during the febrile episode Residual neurological deficit postictally, such as Todds paralysis

Complex Febrile Fits

Diagnosis

Diagnosis of febrile seizures is based on history.

Also ask about possible ingestions of drug or

toxins

Physical examination to rule out of meningitis or encephalitis

Investigation
Blood counts, blood glucose, lumbar puncture, urinalysis, chest x-ray, blood culture etc depend on clinical assessment of the individual case. Lumbar punctare must be done (unless contraindicated) Measurement of serum calcium and electrolytes are rarely necessary. EEG is not indicated even if multiple recurrences or complex febrile convulsions.

Management Need for admission. Not all children with febrile fits need to be admitted. The main reasons for admission are: To exclude intracranial pathology especially infection

Fear of recurrent fits

To investigate and treat the cause of fever besides

meningitis or encephalitis. To allay parental anxiety, especially if they are staying far from the hospital.

Management

if in a convulsive state:
Loosen clothing around neck Wipe off vomitus Diazepham (0.5mg/kg)

If not in a convulsive state (control fever):

Tepid sponging Anti-pyretic (PCM rectal or syrup- 15

mg/kg/6hourly) Look for cause if initial infection

Prognosis
Benign events with excellent prognosis 3-4% of population have FC 30% recurrence after 1st attack 48% recurrence after 2nd attack 2-7% develop afebrile seizure or epilepsy No evidence of permanent neurological deficit. No deaths reported from simple FC

Epilepsy
* A neurological condition characterised by recurrent unprovoked epileptic seizures. An epileptic seizure is the clinical manifestation of an abnormal and excessive discharge of a set of neurons in the brain An epileptic syndrome are complex signs and symptoms that define a unique epilepsy condition.
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Epidemiology

5 per 1000 school aged children

10% are severely affected.

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Causes

Perinatal Conditions:

Infections:
Encephalitis
Meningitis Brain abscess

Cerebral malformation Intrauterine infection Hypoxic-ischemic Trauma Hemorrhage

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Causes

Metabolic Conditions

Poisoning

Hypoglycemia Hypocalcaemia Hypomagnesaemia Hyponatremia Hypernatremia Storage diseases Reye syndrome Degenerative disorders Porphyria Pyridoxine dependency and deficiency

Lead Cocaine Drug toxicity Drug withdrawal

Neurocutaneous Syndromes

Tuberous sclerosis Neurofibromatosis Sturge-Weber syndrome Klippel-TrenaunayWeber syndrome Linear sebaceous nevus Incontinentia pigmenti

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Causes

Systemic Disorders
Vasculitis (CNS or

Other
Trauma
Tumor Febrile Idiopathic

systemic) SLE Hypertensive encephalopathy Renal failure Hepatic encephalopathy

Familial

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Classification of Seizures
Seizure Classification Partial
seizure activity starts in one area of the brain

Generalized
seizure involves whole brain & consciousness is affected

Simple
Retains awareness

Complex
Altered awareness and behavior

Secondary generalization
(spreading from one area to the whole brain) "jacksonian" seizure

Tonic Clonic
grand-mal or convulsion Loss of consciousness, stiffening of body then jerking of limbs

Absence
petit mal or starting fit or trance like state

Tonic or Atonic
drop attack Abrupt fall, either with stiffening (tonic) or with loss of muscle tone (atonic or astatic attacks)

Myoclonic
Sudden muscle jerks

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Generalized vs. Partial

Generalized Seizures

Always loss of consciousness No warning Symmetrical seizure Bilateral synchronous seizure discharge on EEG

Partial Seizure Begins in a relatively small group of

dysfunctional neurons in one of the cerebral hemispheres. May have an aura which reflects site of origin May/not- change in consciousness or more generalized motor jerking
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Partial Seizures

Simple Partial Seizures

The child will retain awareness with

consciousness unimpaired

Complex Partial Seizures

Altered conscious state or confusion due to the

abnormal electrical discharge spreading from the originating site

Partial Seizures with Secondary Generalisation

Focal seizure manifests clinically or on an ictal

EEG followed by a generalized Tonic-Clonic Seizure

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Generalised Epilepsies

Absence seizures
Transient loss of consciousness, with an abrupt

onset and termination, unaccompanied by motor phenomena except for some flickering of the eyelids and minor alteration in muscle tone. Onset 4-12 years old. Absences may be typical (petit mal) or atypical can often be precepitated by hyperventilation. Occurs for a few seconds (< 30s) Child does not recall seizure. EEG would not a 3Hz Spike and wave activity with frontal accentuation.
A bsence Seizure.flv

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EEG

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Generalised Epilepsies

Myoclonic epilepsy (Juvenile Myoclonic Epilepsy)

Brief often repeatitive, jerking movement of

the limbs, neck and trunk. 10-20years old, (Females: Males = 2:1) Myoclonic predominates but absences and tonic-clonic seizures also occur

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Generalised Epilepsies

Tonic-Clonic Seizure
Rhythmical contraction of muscle groups following

the tonic phase In the rigid tonic phase, children may fall to the ground, sometimes injuring themselves. Do not breath and become cyanosed. Followed by the clonic phase, with jerking of the limbs. Breathing is irregular, cyanosis persists and saliva may accumulate in the mouth May be biting of the tongue and incontinence of urine. Lasts a few seconds to minutes, followed by unconscious or deep sleep for several hours.
Tonic C lonic Seizure.flv

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Generalised Epilepsies

Atonic Seizures
Often combined with a myoclonic jerk

followed by a transient loss of muscle tone causing a sudden fall to the floor or drop of the head. 1-2 years old, last 1-4seconds Most frequent during awakening of falling asleep. Often have Mental Retardation or underlying brain abnormalities
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Generalised Epilepsies

Infantile Spasms (West Syndrome)

4-6months Violent flexor spasms of head, trunk and limbs,

followed by extension of the arms (Salaam Spasms) Last 1-2s, bursts of 20-30spasms, usually on waking 2/3 children are neurologically abnormal before onset of seizures- development process further arrested EEG- hypsarrthymia, a chaotic background of high voltage dysrhymic slow-wave activity with sharp components. 30-40% respond well to treatment Loss of skills and later learning disability or epilepsy.

Infantile spasms.flv

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Other epilepsies

Lennox-Gaustaut
1-3 years old
Multiple seizure types:

Benign rolandic epilepsy of childhood

Common (5-10 yo) Sleep: generalized

Myoclonic single jerk, atonic drop attacks or atypical absences. Developmental arrest or regression & behaviour disorder. Poor prognosis

tonic-clonic Day: distortion of face and arm on one side + abnormal feeling of tounge Seizure stop by midteens & may not require treatment
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Differential Diagnosis

Neonates and infants

Jitteriness Benign myoclonus Apnoea

Young children
Breath holding spells
Reflex anoxic seizures Parasomnia Benign paroxysmal

Gastro-Oespophageal

reflux Shuddering attacks Benign paroxymal torticollis Hyperekplexia

vertigo Paroxysmal choreoathertosis Tics and ritualistic movements Rage attacks

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Differential Diagnosis

Childhood and Adolescents

Vasovagal syncope Migraine Narcolepsy

Any Age
Drug-Induced

dystonia Cardiac Dysrhythmias

Panic attacks
pseudoseizures

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Investigations

EEG
- if normal, try barbiturate induced sleep,

sleep deprivation recording or 24 hour monitoring.

CT or MRI of brain indicated (< 5 years) Blood electrolyte analysis

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Treatment for epilepsy

Medications Surgery

Ketogenic Diet
Vagus Nerve Stimulation

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Medication

>2 episode Attempt to classify the seizure type(s), monotheraphy is recommended. Increase dose gradually until the desired effect is achieved Add 2nd drug if 1st has failed, optimize second drug and try to withdraw 1st drug. Rational combination (2/3 with different mechanisms) Monitor drug levels to check compliance Withdrawal after 2 years of being seizure free

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Surgical
Lobectomy and Cortical Resection Hemispherectomy

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Ketogenic Diet
Primarily used in childhood epilepsy. Mechanism- unknown. The high-fat, low-protein, nocarbohydrate diet mimics some effects of starvation that seem to inhibit seizures. The diet is very rigid and carefully controlled and must be supervised by a physician -- sometimes in a hospital setting.

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Vagus Nerve Stimulation

Approved to treat partial seizures in patients 12 years of age or older stimulator is surgically implanted under the skin in the chest. The device is attached to a wire that is tunneled under the skin and attached to the vagus nerve, which is located in the left side of the neck adjusted to automatically stimulate the vagus nerve from every few seconds to every few minutes.

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Status Epilepticus
Prolonged episode of seizure activity (>30 minutes) or an extended period of recurrent seizures between which the patient does not return to consciousness. Its a medical emergency !!

Can lead to hypoxia, brain damage and death

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Management of Status Epilepticus

ABCs ECG monitoring Oxygen and pulse oximetry IV access Immediate laboratory tests (electrolytes, glucose..) a rapid infusion of 5 mL/kg of 10% dextrose Antiepileptic drug levels Toxicologies

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