Seizure Disorders in Children

1. Seizure Disorders in Children Maura B. Price MD FRCPC FAAP February 2010 mprice@maine.rr.com

2. Seizure Facts • 2 % of ER visits • 40% will have a recurrence after first seizure • Incidence 1/1000

3. Seizures Diagnosis • Abrupt loss of responsiveness • Rhythmic clonic movements • Sustained changes in posture or tone • Simple automatic movements • Staring without change in tone • Changes in cerebral electrical activity

4. Seizure Questions • Where was child, what were they doing? • Loss of consciousness? • Any warning signs? • Stiffness, jerking? • What did eyes do, color change, saliva, tongue, urine or bowel control? • How long did it last? • Post ictal phase? • Has the child been well? • PMH for meningitis, head injury, brain damage? • Child’s development? • Family history?

5. Seizure Mimics • Psychogenic seizures • Syncope • Migraine • Breath-holding spell • Sleep disturbances • Tics • Shuddering attacks • Gastroesophageal reflux • Cardiac conduction abnormalities • Self-stimulating behaviors • Hyperexplexia • Benign tonic upgaze of infancy • Paroxysmal dystonia

6. Paroxysmal Event

7. Febrile Seizures • Age 6 month to 6 years • Acute febrile illness • Non focal, brief (< 15 minutes) • Minimal work-up • Treat fever and infection if required • No AED required • Reassure

8. Risk Factors for First Simple Febrile Seizure • Family history of febrile seizures • Neonatal discharge > 28 days • Delayed development • Child care attendance • Low serum sodium • Very high fever

9. Risk Factors for Recurrence of Febrile Seizure • Young age < 18 months • Family history of febrile or non-febrile • Short duration of fever before initial seizure • Relatively lower fever at onset • Developmental delay

10. Febrile seizure talking points • Most children do well and the risk of epilepsy is low • The earlier the age of the first febrile the more likely a recurrence • Diagnostic tests should never be routine • Meningitis should be ruled out • Treatment does not reduce development of epilepsy and has side effects

11. Trauma • Apparent from history and physical • Attention to clues for non-accidental trauma • Persistence of post-ictal phase • Careful ophthalmologic exam • CT • Admitted for observation • +/- AEDs and usually less than a year

12. Fluids and Lytes • Most commonly hypoglycemia or hyperglycemia, sodium and calcium • Less Mg, Cl, Ph • Prior diagnosis? Gastroenteritis • Treat underlying disorder • No AEDs

13. CNS Infection • Must differentiate from first febrile • LP if < 1 year (12-18 months) • Strongly consider LP if prolonged, atypical, focal or prolonged post-ictal

14. Remote symptomatic • Etiology is remote from event • Perinatal hypoxic injury, congenital stroke, progressive neurodegenerative disease and prior meningitis • Previous diagnosis of developmental delay or cerebral palsy • EEG then brain imaging (MRI) • AEDs used • Neurology usually involved to some extent

15. Risk Factors for the Development of Epilepsy • Suspect or abnormal development • Family history of afebrile seizures • First febrile seizure - complex • Three or more febrile seizures • Duration of recognized fever less than 1 hour

16. Epilepsy • Generalized begins simultaneously in both cerebral hemispheres • Generalized include absence, atypical absence, myoclonic, clonic, tonic, atonic, and tonic-clonic • Partial seizures begin in a localized area of the cerebral cortex • Partial further subdivided into simple where consciousness isn’t impaired or complex partial where have LOC and partial evolving into generalized

17. Epilepsy talking points • Precise classification is important for treatment and prognosis • Anticonvulsants are rarely used after first seizure if normal development, negative EEG and negative family history • A history of aura epigastric discomfort, frightened) indicates focal onset • If seizure free for 2 years on meds and normal neurologically >75% remain seizure free

18. Idiopathic • No underlying neurologic disorder • Clearly defined syndromes with fairly clear prognosis and treatment • Genetically inherited although sometimes it’s just the EEG abn inherited

19. Benign Rolandic Epilepsy • Starts age 5-15 • Primarily nocturnal seizures after falling asleep or just before wakening • Generalized convulsions or slurring • EEG: bilateral independent temporal and central spikes • Outgrown by early adolescence. • No AEDs

20. Childhood Absence and Juvenile Absence • Starring spells with or without automatisms (mouthing, eye blinking, head jerking) • Hyperventilate in office • EEG: 3 Hz spike wave discharges • Rx VPA, Lamotragine, Ethosuximide • Childhood absence outgrown by adolescence, in juvenile absence less common but usual remittance

21. Juvenile Myoclonic Epilepsy • Age 10-15 years • Morning myoclonic jerks, starring spells generalized convulsions • EEG: 3 to 4 Hz generalized spike and poly spike • Rarely outgrow • AEDs VPA, lamotrigine, leviteracitam

22. Benign Occipital Epilepsy • Prolonged poor but maintained responsiveness, starring and occasional ictal vomiting and headache • Confused with migraine • Rarely occipital lesion - do MRI • EEG: bi-occipital spikes • Outgrown by adolescence • AEDs low dose variable drug

23. Treatment of Status Epileptius • Stabilize the patient first including ABC’s • Oxygen and antipyretics and +/- glucose • Draw labs if necessary • IV Lorazepam or rectal diazepam gel