OCCASIONAL SEIZURES

(ACUTE SYMPTOMATIC SEIZURES)

PROF. DR. SANDA MAGUREANU
DR. DIANA BRC
PEDIATRIC NEUROLOGY DEPARTMENT,
AL. OBREGIA CLINICAL HOSPITAL

Humanity has but three

great enemies: fever, famine
and war; of these by far
the greatest, by far the
most terrible is fever.
William Osler, 1897

OCCASIONAL (ACUTE SYMPTOMATIC) SEIZURES

DEFINITION

Epileptic seizures occurring at any age especially in infants and
toddlers as an answer of the CNS to an acute insult ( alteration
of homeostatic constants temperature, glycemia, acid-base
equilibrium, phospho-calcemia, etc), in the absence of any
epileptogenic lesion.

frequently due to extracerebral changes, rather than to
intracerebral ones

OCCASIONAL (ACUTE SYMPTOMATIC) SEIZURES

CLASSIFICATION
1. OCCASIONAL SEIZURES DUE TO EXTRACEREBRAL INSULTS :


Febrile seizures;


Hypocalcemic seizures;


Hypoglycemic seizures;


Acute dehydration -induced seizures;


Acute poisoning ( intoxication) induced seizures;


Pyridoxine-deficiency induced seizures;
2. OCCASIONAL SEIZURES DUE TO INTRACEREBRAL INSULTS:

Acute cerebral infections;

Seizures in brain tumors;
Seizures in brain trauma;
Seizures in stroke;

FEBRILE SEIZURES (FS)

 DEFINITION:

Sz occuring in childhood after 1 month of age,

associated with febrile illness, not caused by an
infection of the CNS, without previous neonatal
seizures or a previous unprovoked seizure, and not
meeting the criteria for other acute symptomatic
seizures .

ILAE

FEBRILE SEIZURES (FS)

 EPIDEMIOLOGY:

strongly age-dependent - 3 mo 5-6yrs:

 4% before 6 mo
 90% within first 3 yrs
 6% after age 3;

produced in association with fever;

without any proved central nervous system infection
(encephalitis, meningitis);
the most frequent convulsions in infants
2-7% children < 5 yrs: at least 1 FS;
> ;

FEBRILE SEIZURES


ETIOPATHOGENESIS:
- insufficiently known;
- various factors with impact on cortical excitability:
1. Fever ;
2. Age ;
3. Inheritance ;

FEBRILE SEIZURES
1.

FEVER
etiology: upper respiratory airways infections, eruptive
disease, urinary infections, gastroenteritis;
FS occur at sudden body core temperature rising;

75% at >39,5 C;

FEBRILE SEIZURES
2.

AGE:

very important;
rarely < 6 mo & > 4-5 yrs;

Due to * brain maturation

* diminishing of infections incidence;

FEBRILE SEIZURES
3. HEREDITARY FACTORS:
-

AD transmission, with incomplete penetrance and age-related

expression - incompletely clarified;

+ Family history for epilepsy: 10-50%;

+ Family history for FS: 33%;

FEBRILE SEIZURES
 CLASSIFICATION:
 SIMPLE FEBRILE SEIZURES (SFS)
 COMPLEX ( COMPLICATED) FEBRILE
SEIZURES (CFS)

SIMPLE FEBRILE SEIZURES

95% of total FS; 6 mo 5 yrs;

unique episode in first 24 hours of a febrile episode ( body ext temp > 38C );

occur at sudden raise of the fever > 38C;

!! fever must be present at least immediately after the sz

( may not be detected before sz);

short < 15 min;

generalized ( tonic, hypotonic, tonic-clonic );

in children without neurologic deficits ( no pre-, peri- or postnatal brain damage, normal
psychomotor development, no afebrile seizure previously );

FEBRILE COMPLEX SEIZURES

Rare - 4-5% of FS;

Age at onset < 1yr;

multiple;

focal;

prolonged > de 15 min;

postictal abnormalities frequent postictal palsy

DIAGNOSIS OF FS

Rigorous history;

LUMBAR PUNCTURE:
PUNCTURE
 + meningeal signs
 patients < 6 mo (obligatory);
 patients under antibiotic therapy
 patients < 18 mo (recommended);
 strong suspicion of CNS infection
 in CFS.

meningitis may be masked

DIAGNOSIS OF FS

EEG:
- limited value
- in CFS: high dg value in viral encephalitis !
- epileptiform abn may be expression of genetic
predisposition (not future epilepsy indicator).

Blood chemical tests (glycemia, calcemia) and other
investigations if the clinical picture is suggestive!!

NEUROIMAGING: CT & MRI - not routinely.

DIFFERENTIAL DIAGNOSTIC :

CNS infections meningitis, encephalitis (40% cases
do not have meningeal signs);

anoxic seizures ( cerebral syncope) may be triggered
by fever, fear, emotion, heart pathology;

Shuddering, dystonic seizures

Breath holding spells

FEBRILE SEIZURES
TREATMENT

1. ACUTE INTERVENTION;

SFS > 3 min

CFS
2. PREVENTION AND RECURRENCE RISK ;

1. ACUTE INTERVENTION

Supportive measures: lateral decubitus position, removal of airway
obstruction, venous access, O2.

iv Diazepam: 0,5 mg/kg;

antipyretics: acetaminophen, ibuprofen, lukewarm baths DO NOT !!!
use cold packs or ice. May cause shivering, increasing temperature

etiological treatment if the case;

Calm the scared, anxious parents
CALM, DO NOT PANIC

2. PROPHYLACTIC TREATMENT:
a. Intermittent treatment various regimes:
1. classical : at temp > 38C: antipyretics, Diazepam, 0,2-0,5
mg/kg/day per os during the febrile illness and 2 more days
after fever resolution
2. if the FS recurs the family will administrate Diazepam ir
0,4-0,5mg/kgc , repeated 1 more time if there is still fever > 8
hours, max x3/24 hrs

2. PROPHYLACTIC TREATMENT:
b. Continuous treatment:
- does not prevent epilepsy
- ! side-effects of the AEDs (irritability, lethargy,
cognitive impairment, liver/ pancreatic insufficiency )
some may be permanent
- Phenobarbital 3-5mg/kg/day,
- Valproate 20-30 mg/kg/day;

2. PROPHYLACTIC TREATMENT

When? :
- children with high risk ( 3FS in 6 mo, 4 in 1yr),
- duration FS>15 min,
- FS requiring pharmacological intervention to be stopped
- frequent recurrences,
- abnormal psychomotor development
- frighten, anxious parents

OUTCOME

Mortality very low

PREDICTORS OF RECURRENCE (33-40%):
- familial history + for FS (Ist degree relatives) ;
- short duration of fever prior to FS;
- overall duration;
- low temperature;
- lateralized seizure;
- age at onset : < 15 mo: 50-65%;
- 50-75% recurrences in the Ist year;
- infancy associates multiple recurrences (x3);

> 3 risk factors + : 50-100% cases - recurrence

OUTCOME

Risks of neurological/ cognitive impairment :
- low in previously normal, healthy chidren;
- after some CFS: hemiplegia, diplegia, coreoatetosis
- frequent:
- minor neurologic signs,
- behaviour disorders (hyperkinetic sdr);
- learning disabilities;

OUTCOME

PREDICTORS FOR EPILEPSY :





FS > 15 min;
More FS in 24 ore;
Familial history + for epilepsy
Neurologic abnormalities;

FS & EPILEPSY

Approximate history of FS in specific epileptic
sindromes:







BRE - 8%
BOE 15%
CAE 15%
JME 8%
Myoclonic-astatic epilepsy 28%
Febrile seizures plus 90%
Current Opinion in Neurology, 1998


From pathogenic point of

view, FS are considered a
sudden reaction to a high
fever, in a child with
genetic predisposition, at
the age of low convulsive
threshold of the
immature brain. (Moshe,
1989)