PEDIATRIC SEIZURES

TAKING A SEIZURE HISTORY: SEMIOLOGY

• Response to tactile stimulation
• Eye (fluttering, deviation)
• Head (forced flexion)
• Mouth (chewing, lip smacking)
• Facial (twitching)

TAKING A SEIZURE HISTORY: SEMIOLOGY

• Hand (repetitive reaching)
• Limbs (arm/leg freezing)
• Incontinence
• Color change
• Length, post-ictal phase

OTHER IMPORTANT PARTS OF A SEIZURE HX

• Mimics: GERD, ADHD, Sleep Disorders
• Family Hx of Epilepsy
• Diarrhea, Rickets (electrolyte disturbances)
• Medications (Buspirone)
• Presence of fever

FEBRILE SEIZURES

FEBRILE SEIZURES

• Seizure in >1mo febrile pt, not d/t CNS infection
• Usually occur 6-60 months, peak at 18months
• Incidence 3-8% in kids
• 25-40% have + family hx
• 9-22% have +sibling hx

SIMPLE VS. COMPLEX

• Simple: Generalized,
• Complex: Focal, >15min, multiple seizures in 24hrs

FEBRILE SEIZURES: RISK FACTORS

• Febrile seizure in 1st degree relative
• Neurodevelopmental delays
• Increased exposure to HHV6
• Recent Vaccination: MMR, DTaP, Flu
• *High incidence of sodium channelopathies

MANAGEMENT OF FEBRILE SEIZURES

• LP:
• CT: Complex, neuro deficits, prolonged post-ictal, high ICP
• EEG: Febrile Status Epilepticus
• Rectal Diazepam: Prolonged, Risk factors for recurrence
• AEDs Lowers risk of FS recurrence but not development of epilepsy

FEBRILE SEIZURES: RECURRENCE RISK

• Younger age of onset
• Low temperature threshold
• First degree relative
• Brief duration between fever onset & seizure
• Risk of recurrence is 60% after initial FS

FEBRILE SEIZURES: RISK OF EPILEPSY

• 2-7% risk of developing epilepsy
• Family Hx of Epilepsy
• Complex FS
• Neurodevelopmental abnormalities
• 40% w/ complex & status develop mesial temp lobe epil.

FEBRILE SEIZURES: ANTICIPATORY GUIDANCE

• Recurrence risk
• Epilepsy development risk
• No assoc. with later developmental delay
• No assoc. with SIDS
• Antipyretics do not reduce risk of recurrence

EPILEPSY

EPILEPSY DEFINED

• 2 or more unprovoked afebrile seizures
• AEDs are recommended after 2nd episode
• Chances of recurrence after single, unprovoked seizure: 60%
• AEDs prescribed based on: Semiology (clinical findings) and EEG findings
• Also consider: Mood stability, Abx use, comorbidities (obesity)

SEIZURE TYPES: 2 BROAD CATEGORIES

• Partial (most common type of seizure in childhood)
• Generalized

TYPES OF PARTIAL SEIZURES

• Simple (no LOC, focal jerking or sensory loss)
• Complex (+LOC, +/-aura) aka "Psychomotor Seizures"
• Partial complex may develop secondary generalization
• Focal slowing or epileptiform activity on EEG
• DOC: Levitiracetam or Oxcarbazepine

SEIZURES IN ADOLESCENCE

• As children get older, seizures usually become:
• Generalized (GTCs), although teens may have partial seizures
• Epileptiform discharges originate from frontal or centrofrontal lobe

TYPES OF GENERALIZED SEIZURES

• Tonic clonic (GTC)
• Absence
• Atypical absence
• Myoclonic tonic
• Atonic, Tonic

GENERALIZED TONIC CLONIC

• Generalized epileptiform activity on EEG
• DOC: Lamotrigine, Valproic Acid, Topirimate
• a.k.a. Grand Mal

ABSENCE SEIZURES (CAE)

• 2nd most common type of epilepsy
• Lapse in consciousness, motionless stare
• Usually 10-15 seconds, back to baseline at 30secs
• EEG: 3Hz generalized spike wave
• DOC: Ethosuximide, Valproic acid, Lamotrigine

ATYPICAL ABSENCE SEIZURES

• Similar presentation as CAE, but duration is longer (15-60sec)
• Onset and cessation is less clear
• DOC: Valproic Acid

MYOCLONIC TONIC

• Rapid, rhythmic jerks in the upper ext>lower ext
• EEG: 4-6Hz polyspikes
• DOC: Valproic Acid, Levetiracetam
• Relatively rare outside of Juvenile Myoclonic Epilepsy

TONIC SEIZURES

• Tonic spasms of face, chest, trunk
• Tonic flexion of upper ext
• Flexion or extension of lower ext
• May have tachycardia, cyanosis, pupillary dilatation
• EEG: Low amplitude, very fast activity

ATONIC SEIZURES

• Also called drop attacks
• Sudden loss in postural tone
• Tonic and Atonic are on a continuum, so treatment is same:
• Lamotrigine, Topiramate, rufinamide, clobazam, felbamate
• Corpus callostomy may be effective, some pts need permanent helmet

THINGS TO KNOW WHEN USING AEDS

• Valproic Acid: Monitor PLTs and LFTs, avoided in
• Lamotrigine: SJS
• Levitiracetam can exacerbate behavioral problems, treat w/ B6
• Oxcarbazepine (monitor CBC and BMP--leukopenia & hyponatremia)
• AEDs continued till at least 2 yrs of seizure freedom

EPILEPSIES TO BE FAMILIAR WITH

• Benign Rolandic Epilepsy
• Infantile Spasms
• Juvenile Myoclonic Epilepsy
• Lennox-Gastaut
• Pediatric Pseudoseizures

BENIGN ROLANDIC EPILEPSY

• Most common epilepsy syndrome in childhood
• Unilateral facial sensory-motor & oropharyngo-gutteral symptoms
• Hypersalivation and speech arrest, fully aware, GTCs can occur
• EEG: Biphasic, focal centrotemporal spikes and slow waves
• AEDs given after 3rd episode, but usually remit by age 16

INFANTILE SPASMS (WEST SYNDROME)

• 200 known causes (HIE, TORCH, Downs, viral, etc.)
• Presents as spasm-like seizures in pts 3-9 months
• DOC: Adrenocorticotropic therapy x2 weeks, w/taper
• Neurological prognosis is poor, but Downs babies respond best
• Vigabatrin is used in pts who have IS d/t Tuberous Sclerosis

PEDIATRIC PSEUDOSEIZURES

• Psychogenic, often due to stressors
• Accounts for 5% of events in Pediatric epilepsy monitoring
• No changes on EEG

LENNOX-GASTAUT

• Presents between age 2-6 w/ seizures & psychomotor retardation
• Tonic seizures in 90% but can also have Myoclonic & Atonic, GTCs
• May develop from West Syndrome
• Lamotrigine, topiramate, rufinamide, clobazam, felbamate

JUVENILE MYOCLONIC EPILEPSY

• Begins at age 5-15
• Myoclonic jerks upon waking
• May develop GTCs, Absence

BEHAVIORAL ISSUES IN EPILEPSY

• Children with new onset seizures have high rates of:
• Anxiety disorders (35%)
• Depressive disorders (22%)
• ADHD (26%)

STATUS EPILEPTICUS

• Repeated seizures w/o return of consciousness for 30min
• Causes: CNS infection, toxins, ingestion, drug withdrawal
• May cause: hypoperfusion of brain, electrolyte disturb., etc.
• Treat: Rectal diazepam till EMS arrives.
• Ativan-Ativan-Fosphenytoin-Phenobarb, correct electrolytes

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