Pediatric SeizuresPediatric Seizures

An OverviewAn Overview

Childhood SeizuresChildhood Seizures

EvaluationEvaluation ClassificationClassification DiagnosisDiagnosis TreatmentTreatment MimicsMimics

EvaluationEvaluation

Frequency: 4-6/1,000Frequency: 4-6/1,000 HistoryHistory

Focal or GeneralizedFocal or Generalized Duration, State of Consciousness, TriggersDuration, State of Consciousness, Triggers Aura, Behavior, Posture, Post-ictal StateAura, Behavior, Posture, Post-ictal State

ExaminationExamination Vitals, HC, HSM, abnormal Neuro examVitals, HC, HSM, abnormal Neuro exam Skin exam, Retinal exam, hyperventilationSkin exam, Retinal exam, hyperventilation

Classification-Febrile SeizuresClassification-Febrile Seizures

3-4% of population3-4% of population Most common Most common Excellent prognosisExcellent prognosis 9 months to 5 years; peak 14-18 months9 months to 5 years; peak 14-18 months Strong family history of febrile seizuresStrong family history of febrile seizures Rapid rising temp, >38 degrees CelsiusRapid rising temp, >38 degrees Celsius Generalized Tonic/Clonic; <10 minutesGeneralized Tonic/Clonic; <10 minutes If exam is normal, No further Work-upIf exam is normal, No further Work-up Rectal Diazepam for recurrenceRectal Diazepam for recurrence

Febrile Seizures (2)Febrile Seizures (2)

Work up is necessary if:Work up is necessary if: More than one febrile seizure in 24 hoursMore than one febrile seizure in 24 hours Seizure last for more than 10 minutesSeizure last for more than 10 minutes Focal seizure characteristicsFocal seizure characteristics Positive physical exam suggestive of infectious, Positive physical exam suggestive of infectious,

structural, neurologic, congenital pathologystructural, neurologic, congenital pathology

Classification-Partial SeizuresClassification-Partial Seizures

Simple Partial SeizuresSimple Partial Seizures Maintained ConsciousnessMaintained Consciousness Motor activity: Versive SeizuresMotor activity: Versive Seizures Sensory: auraSensory: aura AutonomicAutonomic No automatisms, No tics (can be suppressed)No automatisms, No tics (can be suppressed) EEG: spikes, sharp waves in a unilateral or EEG: spikes, sharp waves in a unilateral or

bilateral or multifocal patternbilateral or multifocal pattern Duration: 10-20 secondsDuration: 10-20 seconds

Partial Seizures (2)Partial Seizures (2)

Complex Partial Seizures (impaired LOC)Complex Partial Seizures (impaired LOC) Simple partial seizure followed by LOCSimple partial seizure followed by LOC Consciousness impaired at onset of seizureConsciousness impaired at onset of seizure Aura: 1/3 of patients with PSAura: 1/3 of patients with PS Automatisms: ¾ of patients with CPSAutomatisms: ¾ of patients with CPS

Following LOC into postictal phase, not recalledFollowing LOC into postictal phase, not recalled Infant: alimentary; Child: gestural, unplannedInfant: alimentary; Child: gestural, unplanned

PS (3): CPS (cont’d)PS (3): CPS (cont’d)

Spreading of discharge throughout brain can lead to Spreading of discharge throughout brain can lead to secondary generalization (tonic-clonic)secondary generalization (tonic-clonic)

EEG: Anterior temporal lobe sharp waves, focal EEG: Anterior temporal lobe sharp waves, focal spikes or multifocal spikesspikes or multifocal spikes

Normal EEG in 20%; must use sleep deprived, Normal EEG in 20%; must use sleep deprived, prolonged techniquesprolonged techniques

Duration: 1-2 minutesDuration: 1-2 minutes Needs CT or MRI to rule out structural causesNeeds CT or MRI to rule out structural causes

PS (4): BPECPS (4): BPEC

Benign Partial Epilepsy with Centrotemporal Benign Partial Epilepsy with Centrotemporal Spikes (Rolandic Epilepsy)Spikes (Rolandic Epilepsy) Excellent PrognosisExcellent Prognosis Ages: 2 – 14; peak onset at 9 – 10 years oldAges: 2 – 14; peak onset at 9 – 10 years old Facial tonic-clonic symptomsFacial tonic-clonic symptoms Normal exam, possible positive FamHxNormal exam, possible positive FamHx One seizure: 20%; Repeated clusters: 25%One seizure: 20%; Repeated clusters: 25% Occurs during sleep: 75%Occurs during sleep: 75% EEG: repetitive spike in rolandic area, o/w nl.EEG: repetitive spike in rolandic area, o/w nl.

Classification: Generalized Classification: Generalized

AbsenceAbsence Simple: Cessation of activity with blank facial Simple: Cessation of activity with blank facial

expression, flickering of eyelidsexpression, flickering of eyelids Usually after age 5, F>M, hyperventilationUsually after age 5, F>M, hyperventilation No aura, no postictal state, duration <30 secondsNo aura, no postictal state, duration <30 seconds 3/sec spike, generalized wave discharge3/sec spike, generalized wave discharge

Complex: Associated motor symptomsComplex: Associated motor symptoms Myoclonic movements of face, fingers, extremitiesMyoclonic movements of face, fingers, extremities May have loss of body toneMay have loss of body tone 2-2.5/sec spike and wave discharge2-2.5/sec spike and wave discharge

Generalized (2)Generalized (2)

Generalized Tonic Clonic Generalized Tonic Clonic Focal Onset or De NovoFocal Onset or De Novo

Aura can suggest originAura can suggest origin Tonic ContractionsTonic Contractions

LOC, eyes roll back, cyanosis, apneaLOC, eyes roll back, cyanosis, apnea Clonic ContractionsClonic Contractions

Rhythmic contraction/relaxation, loss of sphincterRhythmic contraction/relaxation, loss of sphincter Post-ictal: 30 minutes to 2 hoursPost-ictal: 30 minutes to 2 hours

Truncal ataxia, hyperactive DTRs, Babinski’sTruncal ataxia, hyperactive DTRs, Babinski’s Vomiting, intense bifrontal headacheVomiting, intense bifrontal headache

Generalized (3); T/C (2)Generalized (3); T/C (2)

TriggersTriggers Low grade feverLow grade fever FatigueFatigue StressStress Drugs: Methylphenidate, psychotropics, etc…Drugs: Methylphenidate, psychotropics, etc…

Duration: Few minutesDuration: Few minutes IdiopathicIdiopathic

Generalized (4)Generalized (4)

Myoclonic Epilepsies of ChildhoodMyoclonic Epilepsies of Childhood Repetitive seizuresRepetitive seizures Brief, symmetrical contractionsBrief, symmetrical contractions Loss of body tone—falling, slumping forwardLoss of body tone—falling, slumping forward

Benign Myoclonus of InfancyBenign Myoclonus of Infancy Myoclonic Epilepsy of Early ChildhoodMyoclonic Epilepsy of Early Childhood Complex Myoclonic EpilepsyComplex Myoclonic Epilepsy Juvenile Myoclonic EpilepsyJuvenile Myoclonic Epilepsy

Generalized (5); MEC (2)Generalized (5); MEC (2)

InfancyInfancy Neck, trunk, extremitiesNeck, trunk, extremities Normal EEG, Ends by 2 years, no medsNormal EEG, Ends by 2 years, no meds

Early ChildhoodEarly Childhood 6 months – 4 years6 months – 4 years Favorable outcome, 50% seizure freeFavorable outcome, 50% seizure free MR, social problems in the minorityMR, social problems in the minority Positive EEG, possible genetic backgroundPositive EEG, possible genetic background May have concurrent tonic/clonic or febrile seizuresMay have concurrent tonic/clonic or febrile seizures

Generalized (6); MEC (3)Generalized (6); MEC (3)

ComplexComplex Poor prognosisPoor prognosis Focal or generalized seizures <1 year of ageFocal or generalized seizures <1 year of age History: hypoxic-ischemic encephalopathy, History: hypoxic-ischemic encephalopathy,

microcephalymicrocephaly Positive EEG, less prominent FamHxPositive EEG, less prominent FamHx Refractory to medsRefractory to meds MR, behavioral problems in 75%MR, behavioral problems in 75% Lennox Gastaut syndromeLennox Gastaut syndrome

Generalized (7); MEC (4)Generalized (7); MEC (4)

JuvenileJuvenile Between ages 12 – 16Between ages 12 – 16 5% of all epilepsies5% of all epilepsies Initial: Morning myoclonic jerksInitial: Morning myoclonic jerks Later: Morning Generalized Tonic Clonic szsLater: Morning Generalized Tonic Clonic szs Positive EEG: 4-6/sec irregular spike Positive EEG: 4-6/sec irregular spike Enhanced with photic stimulationEnhanced with photic stimulation Normal exam, lifelong meds (Valproic Acid)Normal exam, lifelong meds (Valproic Acid)

Generalized (8)Generalized (8)

Infantile SpasmsInfantile Spasms Between 4 – 8 monthsBetween 4 – 8 months Flexor, Extensor, or Mixed spasmsFlexor, Extensor, or Mixed spasms Cryptogenic: 10-20%, normal work-upCryptogenic: 10-20%, normal work-up

Good prognosisGood prognosis Symptomatic: 80-90%, underlying pathologySymptomatic: 80-90%, underlying pathology

Prenatal and Perinatal etiologiesPrenatal and Perinatal etiologies MR 80-90%MR 80-90%

Positive EEG: hypsarrhythmia patternPositive EEG: hypsarrhythmia pattern

DiagnosisDiagnosis

MinimumMinimum Blood glucose, calcium, mag, lytes, EEGBlood glucose, calcium, mag, lytes, EEG

EEG techniques: 40% of EEGs are normalEEG techniques: 40% of EEGs are normal Sleep deprived, prolonged (72 hrs), photicSleep deprived, prolonged (72 hrs), photic

CSFCSF Infectious etiology suspectedInfectious etiology suspected

Radiologic: CT or MRIRadiologic: CT or MRI1

Prolonged or intractable szs, neuro deficit, increased ICPProlonged or intractable szs, neuro deficit, increased ICP High risk: Predisposing factors, focal sz <33 monthsHigh risk: Predisposing factors, focal sz <33 months

TreatmentTreatment

Treat after the first uncomplicated seizure with Treat after the first uncomplicated seizure with a negative work up—80% will NOT have a negative work up—80% will NOT have another seizureanother seizure2

Educate patient and family of possible long Educate patient and family of possible long term use and side effectsterm use and side effects

May terminate meds after 2 seizure free yearsMay terminate meds after 2 seizure free years

Wean over 3-6 months due to possible recurrence Wean over 3-6 months due to possible recurrence or status.or status.

Treatment (2)Treatment (2)

Carbamazepine or TegretolCarbamazepine or Tegretol Gen T/C, partial; watch leukopenia, LFTsGen T/C, partial; watch leukopenia, LFTs

Phenytoin or DilantinPhenytoin or Dilantin Gen T/C, partial; watch SJS, rashes, lupus-likeGen T/C, partial; watch SJS, rashes, lupus-like

PhenobarbitalPhenobarbital Gen T/C; watch behavioral changesGen T/C; watch behavioral changes

Sodium Valproate or Valproic AcidSodium Valproate or Valproic Acid Gen T/C, absence, myoclonic; watch LFTs, ReyesGen T/C, absence, myoclonic; watch LFTs, Reyes

ACTHACTH Infantile spasms; watch glucose, BP, lytesInfantile spasms; watch glucose, BP, lytes

Treatment (3)Treatment (3)

Ketogenic DietKetogenic Diet Increases GABA inhibition of seizure activityIncreases GABA inhibition of seizure activity Recalcitrant seizuresRecalcitrant seizures Complex myoclonic epilepsyComplex myoclonic epilepsy Fat diet, restriction of CHO and proteinFat diet, restriction of CHO and protein

Surgical OptionsSurgical Options Vagal Nerve StimulatorVagal Nerve Stimulator3

Ablation therapyAblation therapy Intractable seizuresIntractable seizures

MimicsMimics

BPVBPV Night TerrorsNight Terrors Breath Holding SpellsBreath Holding Spells Simple SyncopeSimple Syncope Cough SyncopeCough Syncope Shuddering AttacksShuddering Attacks PseudoseizurePseudoseizure Benign Paroxysmal Torticollis of InfancyBenign Paroxysmal Torticollis of Infancy

BibliographyBibliography

1Sharma, et. al, “Role of Emergent Sharma, et. al, “Role of Emergent Neuroimaging…,” Neuroimaging…,” PediatricsPediatrics, Vol 111, , Vol 111, January, 2003.January, 2003.

2Shinnar, et. al, “Risk of Seizure Shinnar, et. al, “Risk of Seizure Recurrence…,” Recurrence…,” PediatricsPediatrics, Vol 98, August, , Vol 98, August, 1996.1996.

3Parker, et. al, “VNS in Epileptic Parker, et. al, “VNS in Epileptic Encephalopathies,” Encephalopathies,” PediatricsPediatrics, Vol 103, April, , Vol 103, April, 1999.1999.