An 18 m. old baby is admitted to the hospital B/C he is suffering from fever and convulsion . In the P.H : he was doing well until 4 days of his admission when he had fever, running nose & dry cough. His mother brought him to PHC where the family physician diagnosed him as acute URTI and he prescribed antibiotic, cough syrup and paracetamole. But the fever didn’n subside & in the 4 th day he developed convulsion . F.H : his brother developed fever & convulsion when he was 3 y old .
Transcript
An 18 m. old baby is admitted to the hospital B/C he is suffering
from fever and convulsion.In the P.H : he was doing well until 4 days of his admission when he had fever, running nose & dry cough. His mother brought him to PHC where the family physician diagnosed him as acute URTI and he prescribed antibiotic, cough syrup and paracetamole. But the fever didn’n subside & in the 4th day he developed convulsion.F.H : his brother developed fever & convulsion when he was 3 y old.
Supervised by: Dr.amaniDone by :Eman Al-otibiDarin Al –radadiDina Al-amamEbtehal Al-yami
DEFINITIONS
Seizures: Are transient disturbances in brain function
manifesting as episodic impairments in consciousness in association with abnormal autonomic activity.
Epilepsy:
Is a group of neurologic conditions , the common and fundamental
characteristic of which is the liability to recurrent, usually
unprovoked epileptic seizures.NB:
A persone with a single or recurrent seizures due to correctable circumstances dose not necessarily have epilepsy
Immature nervous systemCannot sustain organized seizuresPoorly developed connections
Less capable of repetitive high-frequency firing
20 X
Partial SeizuresStart by activation of group of neuron in one part of one hemisphereThree main types
1)Simple partial Seizures. motor, sensory, behavioral, or autonomic)
2)Complex partial seizures.
3)Partial Seizures evolving to generalized. 2nd generalized
SIMPLE PARTIAL SEIZURES:
Consciousness is preserved Simple partial seizures arise from a specific anatomic focus. Clinical symptoms include Motor : Location and direction of spread of the seizure focus determine the clinical symptoms.
Sensory : tingling or parasthesia on the face or lomp , visual , aoditory, olfactory disturbance. Psychic ( behavioral ) : DEJA, JAMIAS.Autonomic abnormalities : sweating or flusing .
Complex partial seizures are similar, but in addition, consciousness is impaired.
Commonly origenated from temporal lope.It is associated with alterned consiousness without the pt. collapsed to the ground . The pt. stop what he is doing & stares blinkly, often macking rhythmic smacking
movment of lips or pickling at their cloth .
Usually arise from temporal lobe.When partial seizures spread to involve
the whole brain and produce a generalized tonic-clonic seizure, they show secondary generalization ("jacksonian" seizures).
Generalized seizer
GENERALIZED SEIZER: It starts by activation of
neurones in large area of both hemisphere.
GENERALIZED SEIZER: It consists of:
1-Generalized--Tonic
--Clonic,- and Tonic-Clonic Seizures (grandmal).
2-Absence Seizures ( petit mal ).3-Myoclonic.
4-Atonic seizure
TONIC-CLONIC SEIZURES (GRANDMAL)
Phases of TCS:Prodromal phase : houres or days before
attack. Aura : specific feeling or occurance of seizure.
e.g olfactory hallusination, epi. Discomfort .
Consciousness and control of posture are lost followed by:Tonic phase :Rapid discharg of motor cortix cell causing tonic contraction of muscle ( stiffness )children do not breath and become cyanosed Upward deviation of the eyes.Pooling of secretion , pupillary dilation ,diaphoresis, hypertension , and
piloerection . Clonic phase :
Less rapid, gradually & slowing of discharge of cortical cells causes alternating contraction and relaxation ( Jerking of limbs). Irregular breathing & cyanosis persists, saliva may accumulate in mouth, tongue bitting and incontinence . Last for 2 – 3 min.
Typical absence seizure :*(Disorder of childhood (Usually begin
between 4 and 6 y Characterized : Brief loss of enviromental awareness
accompanied by eye fluttering or simple automatisms ,such as head bobbing and lip smacking .
The attack lasts for a few second (15-30 sec)
Induced by hyperventilation . TYPICAL EEG >>>> 3 hz. SPIK AND
WIEVES .
MYOCLONIC SEIZURES: It consist of single or multiple myoclonic jerk
involving one part of the body or entire.Not proceded by aura.
Atonic Seizures
-Sudden loss of postural tone, with sagging of the head or falling.
-Rarely loose consciousness.
EPILEPTIC SYNDROMES
Epilepsy : Is a group of neurologic conditions, the common and fundamental characteristic of which is : the liability to recurrent , unprovoked seizures.
Benign focal epilepsy, also known as rolandic epilepsy
-usually begins between ages 5 and 10 years.In the central sulcus.Good prognosis.They are usually focal motor seizures involving the face and arm and tend to occur only during sleep or on awakening in more than half of patients .
Symptoms commonly include abnormal movement or sensation around the face and mouth with drooling and a rhythmic guttural sound .Speech and swallowing are impaired .
A family history of similar seizures is found in 13% of patients.
The disorder is called benign because 1 -seizures usually respond promptly to
anticonvulsant therapy;2 -intellectual outcome and brain imaging
are normal, and epilepsy resolves after puberty. Continued treatment is not needed.EEG : centrotemporal spike
INFANTILE SPASMS (WEST SYNDROME)
INFANTILE SPASMS (WEST SYNDROME)
are brief contractions of the neck, trunk, and arm muscles, followed by a phase of sustained musclecontraction lasting 2 to 10 seconds 3 patterns :
1. Extensor : extension of trunk and extrimities . least common .
2. Flexor : flexion of neck , arm and leg onto the trunk .
3. Mixed : most common . May occur during sleep or waking .
Classified in to : 1-Cryptogenic : unknown cause .
-10-20% . -Good prognosis .
2-Symptomatic : -related to prenatal or perinatal or pos natal causes .-Prognosis 80_90 % mantal retardation , but the nature of
the disease determine the outcomes. Tuberous sclerosis is the most common recognized
cause.
The EEG during the waking state,
hypsarrhythmia ,Treatment of infantile spasms includes adrenocorticotropic hormone, oral corticosteroids ,benzodiazepines ,
and valproic acid
JUVENILE MYOCLONIC EPILEPSY
occurs in adolescence and is an autosomal dominant disorder The patient may have absence, generalized tonic or clonic, and myoclonic seizures .
The hallmark is morning myoclonus occurring predominantly within 90 minutes of awakening .
Seizures usually resolve promptly with therapy with valproic acid, but therapy must be maintained for life .
Benign neonatal convultions Outosomal dominant Generalized clonic seizures occur toward the end of first week of life.
Lennox gastaut syndrome multiple seizure types Poorly response to treatment
Acqured epliptic aphasia (landau-kleffner syndrome )Characterized by the abrupt loss of previously acqured language in young childrin
SummaryseizureAbsent seizure
Characterized :
Brief loss of enviromental awareness accompanied by eye fluttering or simple automatisms ,such as head bobbing and lip smacking .
Induced by hyperventilation. TYPICAL EEG >>>> 3 hz. SPIK AND WIEVES .
Epileptic Syndromesrolandic epilepsy
EEG : centrotemporal spike
Infantile spasms (West syndrome)
are brief contractions of the neck, trunk, and arm muscles, followed by a phase of sustained muscle
The EEG during the waking state,hypsarrhythmia ,
FEBRILE CONVULSIONS Seizures associated with sudden onset of high fever in
absence of other causes of seizures & not due to intracranial infections )should be extra cranial infection).
Viral infection of the URT , roseola infantum , shigellosis (most important 2 infections)´ otitis media are most frequently the causes of Febrile convulsion
Affect 4-6% of children. Commonest seizure in childhood. Genetic predisposition. Strong family history “1st degree relative” Gastroenteritis may cause febrile convulsion especially with
campylobacter Giovanni
TYPES Typical (simple): Occur in 1st 24 h of fever. Age group (6 ms – 6 ys) More than half occur between ages 1
and 2 years (mean age 22 months). Single. No neurological or developmental
abnormality. Negative family history of epilepsy. Generalized tonic clonic. Persist < 15 min.
CONT.…Atypical (complex): Occur after 1st 24 h of fever. Age group (<6 ms & >6 ys) Multiple Focal convulsion . Persist > 15 min. Repeated convulsion for several hours or days
in the febrile illness. Neurodevelopmental abnormality may be
present Positive family history of epilepsy may be
present 4-10% of these cases may develop epilepsy
later .
INVESTIGATION Lumbar puncture should be done at
first time of diagnosis. Glucose level CBC EEG Urine analysis
TREATMENT ABC Left lateral position O2 i.v or rectal diazepam Antipyretic & cold compressor Search for the cause and treat it . We should exclude meningitis and encephalitis before treatment. But in general no need treatment. Prophylaxis: During attack of fever give oral or rectal diazepam
3 times daily.Advise family to keep paracetamol at home.
Phenobarbital not given b\c lead to ADHD except in neonatal convulsion.
PROGNOSIS Good prognosis. Risk of recurrence:
50% first febrile seizure at younger than 1 year of age .
30% first seizure at older than 1 year of age 10% have three or more recurrence . 7% with complex having complicated
febrile seizure.Intellectual achievements are normal.
Simple febrile seizures do not cause brain damage.
Risk of epilepsy development:is 2% if one risk factor present,Presence of more than one risk increase to 10%:
1. +ve family history2. Atypical febrile convulsion3. Neurological abnormalities4. Developmental
3-Progression movement:Swimming movements of the arms, bicycling or pedaling movements of the legs.Also , there alteration in the respiratory rate including apnea. And change in color.
EEG CLASSIFICATION OF NEONATAL SEIZURESA-Clinical seizures with a consistent
EEG event.clinical seizure occures in relashionship to
seizure activity recorded on EEG (focal clonic , focal tonic, some myoclonic) respond to anticonvulsants
B-Clinical seizures with inconsistent EEG event.
(tonic , subtle , some myoclonic)C-Electrical seizures with absent
clinical seizure.comatosed pts who are not on anticonvulsants
ETIOLOGY OF NEONATAL SEIZURESAge 1-4 days:
-hypoxic-ischemic encephalopathy -drug withdrawal,maternal drug use of
narcotics or barbiturates.-drug toxicity,lidocaine,penicilline.
*subdural haemorrhage , child abuse.-inherited disorder of metabolism.
-malformation of cortical development.*focal cortical dysplasia.
-tuberous sclerosis.-sturge – weber syndrome.
BENIGN FAMILIAL NEONATAL SIEZURE
-Autosomal dominant , begin on 2nd -3rd day of life with a seizure frequency of 10-20/day.Patients are normal between seizures.Which stop in 1-6 months .
Fifth day fits occur (4-6) days in small appearing neonatesSizure are multifocal. Present for less than 24 hours. Prognosis is good.
DIAGNOSTIC EVALUATIONCareful neorologic examinationsFamily history of IEMExamination of retina.(chorioretinitis
seuggsets TORCH ).Inspection of skin (hypopigmented lesions
:tuberus sclerosis)An unusual body odor :inborn error of
metabolism.
Blood ..lower serum Ca associated +birth trauma or a CNS insult in the perinatal period
hypomagmesemia+Hypocalcemia occur in infants of malnourished mothers ( Im magnesium)
Serum ammonia : urea cycle abnormalities (orinthine transcarbamylase ) present with increasing lethargy progression to coma,vomiting.
CSF : infections , blood.
TREATMENT The treatment is specific such as treatment of meningitis or the correction of hypoglycemia,hypocalcemia, hypomagnesemia.Therapy should involve anticonvulsant agent:
Phenobarbital 20to40 mg/kg or 10 to 20mg/kg phynetoin or diazepam.
STATUS EPILEPTICS Neurological emergency which defined as
ongoing seizure activity for greater than 20 min or repetitive seizures without return of consciousness for greater than 30 min.
50% of this group ,status is triggered by fever. 25% have acute brain injury.(meningitis m
INVESTIGATIONSBlood glucose.Blood calcium and magnesium.CBC.Electrolytes.ABG.CSF analysis.Blood and CSF cultures.EEG: not diagnostic, and it is normal in about
one-third of cases .Transfontanellar ultrasound for hemorrhage.CT scan: to diagnose cerebral malformations and
hemorrhage.
TREATMENT Goal : stop seizures as soon as possible.At onset : ABC & O21: IV line with NS.2: Lorazepam )best chose) ,)0.1 mg/kg ) or diazepam ) 0.2
mg/kg ) over 2 minutes via second IV line.3: Phenytoin 20 mg/kg IV.
4:EEG monitoring unless status ended and patient waking up.
5: Phenobarbital 20mg/kg.
If persist : artificial ventilation. Muscle relaxant.
EVALUATION full Carful History:
Take care about:(onset ,duration ,head injury,
previous attack, medication , neck stiffness , fever , family history , history of neurologic or developmental disorder) Physical examination:
Exclude any suspected cause , vital sign , meningitis test, neurologic & mental status
evaluation
Laboratory investigation : CBC , full blood chemistry , blood or
urine toxicology screening , analysis of CSF , blood ammonia , urine and stool culture
imaging MRI superior to CT in showing brain
pathology, but in emergency department setting ,CT may be desirable because it can be performed rapidly and shows acute intracranial hemorrhage more clearly than MRI
EEG
There is no special examination or tests to diagnose & evaluate seizure & epilepsy
The only way is by exclusion & interpretation of history , physical examination , imaging , laboratory tests , EEG
MANAGEMENT
Education .
Avoid RF.
Correct the underlying cause.
If there is no clear cause for the first seizure, wait before starting anticonvulsant.
Single drug therapy (minimum dose) is used where possible.
Sometimes, two or more anticonvulsants are required.
Most commonly used anticonvulsants: valproate, carbamazepine, lamotrigine.
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CHOICE OF ANTIEPILEPTIC 1Seizure type Drug of choice Alternatives
Condition mimic seizure:1-breath holding attack2-benign paroxysmal vertigo3- Night terrors4- Syncope 5-peudosizure 6- prolonged QT interval 7- narcolepsy and cataplexy
BREATH HOLDING SPELLS
Occur in some toddler when they are upset . The child cries ,holds his breath and goes blue ,sometimes children briefly loss consciousness but rapidly recover fully.
- Cyanotic spells: predictable and provoked by upsetting and scolding. rare before 6 months and abate by 5 yrs
- Heralded by brief shrill cry followed by forced expiration and apnea ,followed by loss of consciousness & may be a.e repeated generalized clonic jerks, episotonous .
- Pallid spells :painful experiences such as falling & striking the head.the child stops breathing, loses consciousness, become hypotonic may have atonic seizure .in refractory cases oral atropine
● Drug therapy….. is unhelpful
● Attacks ….resolve spontaneously
BENIGN PAROXYSMAL VERTIGO
ToddlersSudden + ataxiaHorizontal nystygmus Consciousness not disturbedRotational sensation
