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Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Epilepsy.Epilepsy.Convulsion.Convulsion.Seizure.Seizure.Fit.Fit.פרכוספרכוסהתכווצותהתכווצותכפיון, מחלה כיפיוניתכפיון, מחלה כיפיונית
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Very common .Very common .Approx 1% .Approx 1% .From first minute until last minute.From first minute until last minute.
A result of abnormal electrical activity of A result of abnormal electrical activity of the brain ( cortex) .the brain ( cortex) .which cause acute change in function.which cause acute change in function.Usually of motor nature.Usually of motor nature.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Epileptic episode.Epileptic episode.Epileptic disorder ( disease).Epileptic disorder ( disease).
Diagnosis is a clinical one.Diagnosis is a clinical one.History,sometimes with hysteriaHistory,sometimes with hysteriaObservation ( duration ,LOC and Observation ( duration ,LOC and Description of the motor phenomena)Description of the motor phenomena)
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Clinical presentation:Clinical presentation:
Motor ( 80%-90%)Motor ( 80%-90%)Sensory.(skin, vision, hearing, Sensory.(skin, vision, hearing, taste, smell)taste, smell)Behavioral .Behavioral .Autonomic.Autonomic.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Neurophysiologic basis.Neurophysiologic basis.
Neuron, dendrites, axon.Neuron, dendrites, axon.Action potentials.Action potentials.Synaptic neurotransmitors Synaptic neurotransmitors Excitators (glutamic , aspartic ac)Excitators (glutamic , aspartic ac)Inhibitors (GABA )Inhibitors (GABA )
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Classification of epilepsy:Classification of epilepsy:
Nature of episode.Nature of episode.Origin.Origin.Electrical Abnormality.Electrical Abnormality.Name of Physician who Name of Physician who describedescribe
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Current classification ofCurrent classification of epilepsy epilepsy since 1989:since 1989:
Partial ( focal ).Partial ( focal ).Generalized .Generalized .Partial with generalizationPartial with generalization
Status Epilepctus . Status Epilepctus .
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Clinical description of motorClinical description of motor seizures :seizures :
Clonic.Clonic.Myoclonic.Myoclonic.Tonic Tonic Atonic ( Akinetic).Atonic ( Akinetic).
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Epileptic episode may include:Epileptic episode may include:
Aura.Aura.
Ictal phase ( ictus).Ictal phase ( ictus).
Post ictal phase. Post ictal phase.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Epileptic episode may be Epileptic episode may be primary or secondary due to…primary or secondary due to…
Primary – genetic or Primary – genetic or idiopathic.idiopathic.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Secondary epileptic episode :Secondary epileptic episode :
C.N.S malformationsC.N.S malformationsMetabolic.( metabolic , primary )Metabolic.( metabolic , primary )Infectious.Infectious.S.O.L.S.O.L.TraumaTraumaToxic ( medications, abuse)Toxic ( medications, abuse)
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Clinical Approach to a child Clinical Approach to a child with with first seizure:first seizure:
In the E.R.:In the E.R.:Treatment , stabilization.Treatment , stabilization.Physical /neuro examination.Physical /neuro examination.Work -upWork -up
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Observation ( patient , Observation ( patient , watch ).watch ).
Position , Oxygen mask.Position , Oxygen mask.
I.V. line. (other 3 options )I.V. line. (other 3 options )
Medications Medications ( Benzodiazepines-( Benzodiazepines-
Diazepam , midazolam)Diazepam , midazolam)
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Heart rate , BP.Heart rate , BP.
Temperature ( c.n.s inf vs Temperature ( c.n.s inf vs febrile seizures )febrile seizures )
Dex .Dex .
Physical exam.( trauma, signs Physical exam.( trauma, signs of recent epileptic episode – of recent epileptic episode – tonge biting,urine tonge biting,urine incontinenceincontinence
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Neurological ExaminationNeurological Examination
Usually not helpful.Usually not helpful.
State of conciseness.State of conciseness.
Cranial nerves ( eye position)Cranial nerves ( eye position)
Muscle tone.Muscle tone.
Reflexes.Reflexes.
Sensory response.Sensory response.
Influenced by : ictus type, Influenced by : ictus type, med’smed’s
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Medical History:Medical History:
PastPast : family ( epilepsy ) : family ( epilepsy )
child. ( preg , child. ( preg , deliverydelivery
p.m.h. , p.m.h. , medications,f.s medications,f.s
Development.Development.
PresentPresent : Detailed : Detailed description description
before episodebefore episode
(illness, trauma , (illness, trauma , medsmeds
activity , sleep )activity , sleep )
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Medical History:Medical History:
Majority of dx are based on Majority of dx are based on hx.hx.
Not always accurate and Not always accurate and reliablereliable
Sometimes young , old Sometimes young , old observer.observer.
Single episode is not an Single episode is not an epilepsy epilepsy
Usually ( exceptions C.P, T.S, Usually ( exceptions C.P, T.S, N.F )N.F )
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Work – up in the E.R.:Work – up in the E.R.:
Two major urgent Two major urgent decisionsdecisions
Neuroimaging.Neuroimaging.
Spinal tap. (open nl fontanella Spinal tap. (open nl fontanella or Neroim. ) or Neroim. )
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Neuroimaging :Neuroimaging :
C.N.S bleeding .C.N.S bleeding .
S.O.L.S.O.L.
Acute hydrocephalus.Acute hydrocephalus.
L.P:L.P:
C.N.S. infection ( bac, viral C.N.S. infection ( bac, viral others )others )
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Hospitalization :Hospitalization :
Observation (recurrent Observation (recurrent seizure).seizure).
Diagnostic evaluation.Diagnostic evaluation.
Parental care and Parental care and explanations . explanations .
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Diagnostic Work–up during Diagnostic Work–up during
Hospitalization:Hospitalization:
EEG. EEG.
Neuroimaging. Neuroimaging.
Others. Others.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
E.E.G.E.E.G.
Recording of electrical activity Recording of electrical activity of brain.of brain.
Non invasive.Non invasive.
Cheap.Cheap.
Available.Available.
Portable , bedside, ( picu, Portable , bedside, ( picu, nicu).nicu).
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
E.E.G.E.E.G.
Complete study includes: Complete study includes:
Alert.Alert.
Sleep, drowsy.(Sleep Sleep, drowsy.(Sleep deprived)deprived)
Photic stimulation.Photic stimulation.
Hyperventilation.Hyperventilation.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
E.E.G.E.E.G.
Regular study.Regular study.
24h ambulatory study24h ambulatory study
Video EEG Study.Video EEG Study.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
E.E.G recording includes:E.E.G recording includes:
Background activity.( alert, Background activity.( alert, sleep, CNS diseases, drugs)sleep, CNS diseases, drugs)
Abnormal overidding activity.Abnormal overidding activity.
Spike , poly spike , slow wave Spike , poly spike , slow wave
Variable complexesVariable complexes
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Abnormal E.E.G is not Abnormal E.E.G is not requiredrequired for the diagnosis of for the diagnosis of Epilepsy.Epilepsy.
A rule with several A rule with several exceptions. exceptions.
The diagnosis of Epilepsy is a The diagnosis of Epilepsy is a
Clinical one based on hx and Clinical one based on hx and or or
Observation.Observation.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
2 Exceptions :2 Exceptions :
Infantile spasms (West synd)Infantile spasms (West synd)
Simple Absence Seizure.Simple Absence Seizure.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Abnormal EEG could be Abnormal EEG could be seen inseen in
CNS infection.CNS infection.
Head trauma.Head trauma.
S.O.L.S.O.L.
Toxic metabolic conditions.Toxic metabolic conditions.
Headache , Migraine.Headache , Migraine.
ADHD , LD.ADHD , LD.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Are all epileptic episodes Are all epileptic episodes required neuroimaging ?required neuroimaging ?
Neuroimaging Modalities:Neuroimaging Modalities:
Ultrasound.Ultrasound.
CT Scan.CT Scan.
MRI.MRI.
SPECT SPECT
PETPET
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Ultrasound of brain.Ultrasound of brain.
Non invasive.( no radiation)Non invasive.( no radiation)
Cheap and available.Cheap and available.
Portable Portable
No need for sedationNo need for sedation
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
CT Scan.CT Scan.
Relatively cheap.Relatively cheap.
Available. Available.
Radiation.Radiation.
Sedation.Sedation.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
MRI.MRI.Expensive.Expensive.Non available.Non available.Sedation. Sedation. No radiationNo radiation
fMRIfMRI
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
The study of choice in The study of choice in the the
work up of a child with work up of a child with
Epilepsy is MRI.Epilepsy is MRI.
In cases of Emergency in In cases of Emergency in
ER , CT Scan is ER , CT Scan is
reliable toolreliable tool
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
SPECT ( single photon SPECT ( single photon
emission computed emission computed tomography)tomography)
Epileptic focus.Epileptic focus.
Focal blood perfusion.Focal blood perfusion.
Not available.Not available.
Only after epileptic episode.Only after epileptic episode.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
PET ( position emission PET ( position emission tomography)tomography)
Demonstrate the content of Demonstrate the content of 0202
And glucose .And glucose .
Epileptic hypermetabolic Epileptic hypermetabolic focus.focus.
Expencsive.Expencsive.
Non available.Non available.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Epileptic Syndromes:Epileptic Syndromes:
Age/sex.Age/sex.
Common clinical expression.Common clinical expression.
Common frequency and Common frequency and durationduration
Family history /genetic .Family history /genetic .
Similar EEG abnormalities.Similar EEG abnormalities.
Common natural hx and Common natural hx and outcome.outcome.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Treatment of Epilepsy.Treatment of Epilepsy.
-Anti epileptic medications.-Anti epileptic medications.
-Other medications( steroids , -Other medications( steroids , vitamines (B complex), vitamines (B complex), diamox)diamox)
-IV IG.-IV IG.
-Ketogenic diet.-Ketogenic diet.
-VNS.-VNS.
-Epileptic surgery.-Epileptic surgery.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Treatment of Epilepsy.Treatment of Epilepsy.
How to select an anti epileptic How to select an anti epileptic drug?drug?
Type of seizure/ syndrome.Type of seizure/ syndrome.
Medical history ( liver , kidney Medical history ( liver , kidney ))
Allergies.Allergies.
Side effects.Side effects.
Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction
Treatment of Epilepsy.Treatment of Epilepsy.
Duration of treatment.Duration of treatment.
Side effects.Side effects.
Follow up (clinical , Follow up (clinical , laboratory)laboratory)
Drug levels. Drug levels.
Recurrent seizures. Recurrent seizures.
Compliance.Compliance.