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Hints for effective listening
1. Stop talking2. Be interested3. Remove distractions4. Be patient5. Mind your temper6. Avoid criticism & arguments7. Ask questions8. Paraphrase9. Stop talking
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PAEDIATRIC SEIZURES & EPILEPTIC SYNDROMES
DR. MOHAMMAD AL NASSERConsultant Pediatric Neurologist
Department of PediatricsKing Saud University
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OBJECTIVES
Seizures (ZT’s) a symptom NOT a diseaseClinical observation crucial for Dx, classification,
and Rx.R/O other paroxysmal, non-epileptic disorders.Acute management & prevention of recurrence.Thoughtful & rational patient work-upOptimum use of anti-epileptic drugs (AED’s)Comprehensive patient (not SZ’s) management.
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DEFINITIONS & TERMS
A seizure = abnormal electrical cerebral cortical discharge clinical alteration (in function and in behavior).
Epilepsy = two or more unprovoked seizures.Status epilepticus= a seizure lasting more than
30 mins. or repeated seizures with NO regain in consciousness (convulsive or non-convulsive).
Aura, ictus, postical….interictal.
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AETIOLOGY OF SZ’
Primary (idiopathic)
- extensive w/u unyielding
- genetic vulnerability
Secondary (symptomatic-provoked)
- congenital (e.g. anomalies, infections)
- acquired (e.g. P-HIE, metabolic…etc.)
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Normal SZ’s thresholdStrong provoking factor
Low SZ’s thresholdNo provoking factor
Seizure
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International Classification Old Terms
General Seizures Absence Petit mal - Typical - Atypical Myoclonic Minor motor Clonic seizures Grand mal Tonic seizures Grand mal Tonic-clonic seizures Grand mal Atonic seizures Akinetic, drop
attacks, minor motor
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International Classification
Old terms
General Seizures Absence Petit mal Myoclonic Minor motor Clonic seizures Grand mal Tonic seizures Grand mal Tonic-clonic seizures Grand mal Atonic seizures Akinetic, drop attacks,
minor motor
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International Classification
Old terms
Partial seizures
P. simple seizures
(consciousness not impaired)
Focal or local seizures
With motor symptoms Focal motor
Jacksonian seizures With somatosensory
symptoms
Focal sensory
With automatic symptoms
With psychic symptoms
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International Classification Old terms
Partial Seizures (cont.)
P. Complex seizures Psychomotor seizures
(consciousness impaired) Temporal lobe seizures
Simple partial onset With impairment
consciousness at onset Partial seizures that
secondarily generalize10
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APPROACH TO DIAGNOSIS
What is the problem? (clinical)
Where is the problem? (anatomy)
Why is the problem? (pathology)
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DIAGNOSTIC PROCESS
Questions to be answered:
Was it a seizure (see DDx of SZ’s)?
Was it provoked (e.g. hunger, T.V., fever…)?
How was the onset (focal generalized)?
Precise description of the event (eye-witness)?
Prior neuro-developmental status?
Findings on neurolofic & G. physical exam…..?
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LABORATORY INVESTIGATIONS
R/O treatable conditions: - CBC, platelets, smear AED’s serum
levels
- Glucose, Ca, PO4
- BUN, electrolytes, Cr and CO2
- Liver function
- (+/- CSF & CT scan head)
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LABORATORY INVESTIGATIONS
Neurophysiology:
- EEG (regular, sleep-deprived, videotape)
Neuro-imaging:
- Ultrasound, SXR, CT scan, MRI
(anatomic) PET & SPECT (functional)
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ACUTE MANAGEMENT OF A SEIZURE ATTACK
ABC’s:
- suction
- O2
- position What if:
- can not get I.V. access?
- SZ is refractory?
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ACUTE MANAGEMENT OF A SEIZURE ATTACK (cont.)
I.V. line:
- Get blood
- Give anticonvulsant
a. glucose, Ca
b. benzodiazepine to abort
c. long acting AED to prevent recurrence
What aetiologic diagnosis & manage accordingly.
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LONG TERM PROPHYLAXISTreat or not to treat?Choose drug of choice for type of SZ’s.Single AED & not polypharmacy. Increase till response or side effects.Wait 5 x t ½ after each increment.Add another AED similarly → +/- withdraw 1st one.Monitor drug levels (& evidence of side effects)
timely & appropriately.Consider withdrawing AED/s carefully and rationally.Patient & parent continued education is crucial.? Epilepsy surgery?
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QUESTIONS & ISSUES TO BE
CLARIFIED Do seizures damage the brain?
Why there is no cure for epilepsy?
Is patient going to outgrow this?
Can epileptics function normally?
Do AES’s have long-term side effects?
For how long Rx will be continued?18
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FEBRILE CONVULSION
Seizure with fever:
- Seizure (not shivering [rigors])
- Fever, documented, source
outside CNS
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FEBRILE CONVULSION
Simple (typical) FC:
- GTC’s
- less than 15 mins
- no recurrence within 24 hrs.
- no postical abnormality
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FEBRILE CONVULSION
Complex (atypical) FC:
- Mostly focal
- More than 15 mins.
- Recur within 24 hrs.
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FEBRILE CONVULSION
Investigations:
- Like any seizures disorder
- R/O intracranial infection
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FEBRILE CONVULSION
Treatment:
- Abort the attack
- Prophylaxis
- No treatment
- Daily treatment x 2 yrs. (P.B/VPA)
- PRN treatment (Rectal diazepam)
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FEBRILE CONVULSION
Treatment:
40% recurrence of FC- young age at onset- family predisposition- complex-type SZ’s- day nursery
10% atypical SZ’s → non-febrile SZ’s (epilepsy)
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INFANTILE SPASMS
Myclonic spasms: - mixed → flexor → extensor
Hypoarrhythmias on EEG Mental retardation Typically:
- Onset at 3-7/12 of age. - In cluster on awakening - Missed as infantile “colic”
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INFANTILE SPASMS
Aetiology:
• Idiopathic (10-40%):- normal prior development- no brain pathology
• Symptomatic:- brain malformations;- tuberous sclerosis- others
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INFANTILE SPASMS
Investigations:
As other types of SZ’s
Treatment:
Steroids, benzodiazepines, valproate, pyridoxine.
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INFANTILE SPASMS
Prognosis: - ? Underlying cause - Good in 40% if:
- idiopathic - normal development- early treatment
- Bad in 60% if:- symptomatic- develop other SZ’s e.g. Lennox-Gastaut. S.
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PAROXYSMAL DISORDERS MIMICKING SZ’s
Decrease cerebral blood flow (CBF)
Sleep disorders.
Movement disorders
Psychologic disorders
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SIMPLE FAINTING (SYNCOPE)
Mostly in school age children.
Usually non-convulsive.
R/O cardiac dysrhythmias.
Precipitant → vasovagal response → venous
pooling → decrease CBF.
Rx….. Avoid precipitants
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CYANOTIC BREATH-HOLDING ATTACKS
3% of children Few months – 4 years Fright or pain → cry → hold breath in
expiration May show few jerks Slow EEG intra attack but NOT epileptic Rx……?
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REFLEX ANOXIC SEIZURES
“Pallid breath-holding” attacks. Minor trauma → minimal crying → stiff, pale +/-
jerks. Decrease threshold to vagal cardiac inhibitory
reflex → a systole. In 1% of children, mostly 12-18/12 of age. May co-exist with the cyanotic breath-holding. ECG should be done. Rx…..? (transdermal anticholinergic)
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CARDIAC DYSRHYTHMIAS
Consider if: - Syncope:
→ tonic/clonic movements→ prolonged confusion
- Exercise-induced “seizures” - Relatives (“epileptic” or sudden deaths)
Prolonged Q-T int. & sick sinus syndromes. Extensive cardiac investigation is mandatory.
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SLEEP DISORDERS
Nigthmares & night terrors
Narcolepsy & cataplexy
Somnambulish & somniloquy
Sleep apnea
Bruxism, noct, enuresis, noct, myoclonus
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PSYCHOLOGIC DISORDERS
panic attacks
day dreaming
conversion reactions
fictitious epilepsy
hyperventilation syndrome
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