Seizures

A seizure is a clinical event in which there is a sudden disturbance of

neurological function caused by an a bnormal or excessive neuronal
. discharge
A febrile convulsion is a seizure associated with fever in absence of
another cause and not due to intracranial infection from meningitis or
.encephalitis
Epilepsy is recurrent seizures other than febrile convulsions in the
.absence of an acute cerebral insult
The causes of seizures
Epilepsy
idiopathic
Secondary
cerebral dysgenesis/malformation-
cerebral vascular occlusion-
cerebral damage,e.g congenital infection,hypoxic ischaemic-
encephalopathy,intraventricular hemorrhage/ischaemia
Cerebral tumor
Neurodegenrative disorders
Neurocutaneous syndromes
Non-epiletic
Febrile convulsions
Metabolic
Hypoglyceamia
Hypocalcaemia/hypomagnesemia
Hypo/hypernatraemia
Head trauma
Meningitis/encephalitis
Poisons/toxins

(Febrile seizures( febrile convulsions

:Incidence
these occur in 3% of children , between the ages of 6 months and 5
. years
:etiology
there is a genetic predisposition , with a 10% risk if the child has first-
degree relative with febrile seizures
the seizure usually occurs early in a virla infection when the
. temperature is rising rapidly
clinical picture
the seizures are usually brief , and are generalized tonic-clonic seizures
thirty to forty percent will have further febrile seizures
 this more likely the younger the child , the shorter the duration of illness
before the seizure, the lower the temperature at the time of seizure and if
.there is a positive family history
:Types
Simple febrile seizures
Do not cause brain damage
The child's subsequent intellectual performance is the same as children who
do not experience a febrile seizures
There is a 1-2% chance of developing epilepsy similar to the riskfor all children
Complex febrile seizures i.e
Those which are focal , prolonged , or repeated in the same illness, have an
.increased risk of 4-12% of subsequent epilepsy

Management
Examination should focus on the cause of fever which is usually , which is
usually a viral illness but a bacterial infection including meningitis should
always be considered
The classical features of meningitis such as neck stiffness and photophobia
may not be as apparent in children less than 18 months of age , so an infection
.screen (including blood cultures,urine culture & LP for CSF)may be necessary
In the unconscious child (GCS <8) LP is contraindicated and antibiotics should
be started empirically

Treatment
Parents need reassurance and information
Advice sheets are usually givento parents on temperature control using
.antipyritic and tepid sponging
.The family should be taught the first aid management of seizure
If there is a history of prolonged seizure(>5 minutes) rescue therapy with
rectal diazepam or buccal midazolam can be supplied
Oral prophylactic antiepileptic drugs are not used as they do not reduce the
.recurrence rate of seizures or the risk of epilepsy
An EEG is not indicated as it does not serve as a guide for treatment nor does
.it predict seizure recurrence
Summary
Febrile seizure
affect 3% of children, have a genetic pridection #
occur between 6 months and 6 years of age #
are usually brief , generaly tonic-clonic seizures occuring with a rapid rise in #
fever
if a bacterial infection , especilly menigitis, is present , it needs to be #
identified and treated
advise the family about fever control , management of seizures , consider #
rescue therapy
If simple- does not affect intellectual performance or risk of developing #
epilepsy
 Paroxsmal disorders ( funny turns) and epilepsy
There is a broad differential diagnosis for children with paroxsmal disorders
Epilepsy is a clinical diagnosis based on the history from eyewitnesses and the
child own account
If available videos of the seizure or suspected seizures can be of great helps
The diagnostic question is whether the paroxysmal events are that of an
. epilepsyof childhood or one of the many conditions which mimic it
Causes of funny turns
(Breath holding spells (temper
Occur in some toddlers when they are upset.the child cries, hold his breath
and goes blue
.Sometimes children will briefly lose concentration but rapidly recover fully
Drug therapy is unhelpful
Attacks resolve spotaneously but behavior modification therapy , with
.avoidance of confrontation , may help
Reflex anoxic seizures
Head trauma –cold food –fright-fever
Occur in infants or toddler
Many have a first degree relative with a history of faint
Commonest triggers are pain or discomfort particularly from minor head
.trauma, cold food (such as ice- cream or cold drinks) and fright
Fever is another trigger
Some children with febrile convulsions may have experinced this phenomenon
After the triggering event , the child becomes very pale and falls to the floor
The hypoxia may induce a generalized tonic-clonic seizure
The episode is due to cardiac a systol from vagal inhibition
.The seizure is brief and the child rapidly recovers
Ocular compression under controlled conditions often leads to asystole and a
.paroxysmal slow-wave discharge on the EEG
Syncope
Children may faint if in a hot and stuffy environment, on standing for long
.periods, or from fear
Clonic movements may occur
Migraine
May sometimes lea to paroxysmal headache involving unsteadiness or light-
headedness as well as the more common visual or GIT disturbance
.In some young people these episodes occur without headache
Benign paroxysmal vertigo
 This is characterized by by recurrent attacks of vertigo , lasting from one to
.several minutes , associated with nystagmus, unsteadiness or even falling
It is thought to be due to a viral labryinthitis
(Other causes (prolonged QT interval
Cardic arrhythmia – prolonged QT interval may rarely cause collapse or cardiac
. syncope which may be related to exercise
Tics , daydreaming,night terrors
Self-gratification- young children may stimulate their genitalia in order to
.achieve a feeling of comfort rather than sexual gratification
(Non – epileptic attack disorder (NEAD
Pseudoseizures-when children feign by parent
Induced illness( non-accidental injury)-e.g.seizure, from hypoglcemia from an
.adult deliberatly injecting insulin
Summary
Breath holding and reflex anoxic seizures
:In toddlers
Breath holding attacks –toddler, precipitated by anger, holds breath goes
.blue , then limp, rapid recovery
Reflex anoxic seizures –toddler , precipitated by pain, stops breathing,goes
. pale , brief seizure sometimes, rapid recovery
Other non-epileptic paroxysmal disorders
comments Seizure pattern Age Name
Many causes, two- Violent flexor spasms of 4-6 Generalized
thirds have the head , trunk and limbs months epilesies
underlying followed b extension of
.neurological cause the arms (so-called Infantile spasms
.(''salaam spasms
The EEG show
hypsarrhythmia , a Flexor spasms lasts 1-2
chaotic pattern of seconds often multiple
high-voltage slow bursts of 20-30 spasms,
waves, and multifocal often on walking , but may
sharp wave .occur many times a day
.discharges
May be misinterpreted as
TTT is with colic
vigabatrin or
Social interaction often
, corticosteroids
deteriorate-a usful marker
Good response in 30- . in the history
40% but side effects
are common
Most will
subsequently lose
skills and develop
learning disability or
.epilepsy
 Often other complex Multiple seizure types , 1-3 Lennox-gastaut
neurological problems but mostly drop attacks years syndrome
or history of infantile (astatic seizures), tonic
spasms seizures and atypical
.absences
Prognosis is poor
Also neurodevelopmental
arrest or regression
.behavior disorder
Two-third are female Stare momentarily and 4-12 Typical(petit
stop moving may twitch years (mal
The episodes can be
their eyelids or a hand
induced by Absence seizures
minimally
hyperventilation,the
child being asked to Lasts only only a few
blow on a piece of seconds and certainly not
paper or a windmill longer than 30 seconds
for 2-3 minutes a child has no recall except
useful test in the realizes they have missed
outpatient clinic something and may look
puzzled or say pardon on
The EEG generalized 3
regaining consciousness
per seconds spikes
and a wave discharge Developmentally normal
wich is bilaterally but can interfere with
synchronous during . schooling
and sometimes
Accounts for 2% of
between the attacks
childhood epilepsy
Prognosis is good
with 95% remission in
adolescene
may develop 5-10%
tonic-clonic seizures
.in adult life
Characteristic EEG Myoclonic seizures but Adolesce Juvenile
generalized tonic-cloic nce myoclonic
Respose to TTT is
seizures and abscences -adultho epilepsy
usually good but
may occur, mostly shortly od
lifelong
after waking
A genentic linkage
A typical history is
has been identified
throwinga drinksor
cornflakes about in the
morning as myoclonus
occurs at this time
Learning is unimpaired
Comprises 15% of all Tonic-clonic seizures in 4-10 Focal epilepsies
childhood epilepsies sleep, or simple partial years
Benign rolandic
seizures with awareness
EEG shows focal sharp epilepsy, also
abnormal feelings in the
waves from the known as benign
tongue and distortion of
rolandic or childhood
the face (supplied by
centrotemporal area epilepsy with
(rolandic area of the brain
centrotempral
 Important to (spikes (BCCTS
recognise as it is
benign and does not
always require TTT
Almost all remit in
adolescence
Uncommon Younger children –periods 1-14 Benign occiptal
of unresponsiveness , eye years epilepsy
EEG shows occipital
deviation vomiting and
.discharges
autonomic features
.Remit in childhood
Older children – headache
and visual disturbance
including distortion of
images and hallucinations
 The epilepsies of childhood
Incidence
Epilepsy has incidence of about .05%(after the first year of life when it is more
( common
a prevalence of .5% .this means that most large secondary schools will have &
a bout six children with an epilepsy of childhood or adolescence
Most epilepsy is idiopathic but other causes of seizures are listed in the box
Classification of epilepsy
An international classification of epilepsy is used
: This broadly classify seizures as either
Generalized – discharge arises fro both hemispheres, or
Focal (also known as localization-related or partial)-where seizures arise from
. one or part of one hemisphere
:Generalized seizures may be
Absence
Myoclonic
Tonic
Tonic-clonic
Astatic
The Manifestations of focal seizures will depend on the part of the brain where
:the discharge originate
: Frontal seizures
Involve the motor cortex
(May lead to clonic movements which may travel proximally(jacksonian march
Asymmetrical tonic seizures can be seen , which may be bizarre and
.hyperkinetic and can be mistakenly dismissed as non epileptic events
:Temporal lobe seizures
The most common of all the epilepsies
May result in strange warning feelings or aura with smell or taste
abnormalities and distortions of sound and shape
Lip-smacking , plucking at one's clothing , and walking in a no purposeful
manner (automatisms) may be seen
.following spread to the pre-motor cortex ,
Déjà-vu and jamais-vu are described (intense feeling of having been , or never
(having been, in the same situation before
Consciousness can be impaired and the length of the event is longer than
atypical absence
Occipital seizures – can cause distortion of vision
 Parietal lobe seizures – cause contralateral dysaethesias (altered sensation),
distorted body image

:Focal seizures are also delineated according to level of consciousness

Simple partial focal seizures – consciousness is retained
Complex partial focal seizures –consciousness is lost
Children with comlex partial seizures may, however, retain some memory
of the event
partial focal seizures with secondary generalization-focal seizures followed by
generalized tonic-clonic seizures