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Dr. Judy Pipo-Deveza American Mission Hospital July 2012
History and Neuro PE Seizures, Epilepsy Headache Neurodiagnostics Increased ICP Neurodevelopmental disorders CNS Infections Neuromuscular disorders CNS tumors, SOL Immune mediated neurologic disorders Neurometabolic diseases Neurologic manifestations of systemic diseases
Epilepsy refers to occurrence of two or more “unprovoked” seizures. “Unprovoked” – seizures not precipitated by entities such as fever, electrolyte imbalance, CNS infection, trauma, etc
• Facilitate communication among professionals • Facilitate communication between physician and patient • Aid diagnosis • Rational prescribing of AEDs based on accurate diagnosis of seizure type • Prognosis
Simplified Classification of Epileptic Seizures
• Partial seizures
– Simple – preservation of awareness – Complex – impairment of consciousness – Secondary generalized
• Generalized seizures
– – – – – Absence Myoclonic Tonic-clonic Tonic Atonic
With psychic symptoms B. With impairment of consciousness at the onset . With somatosensory or special sensory symptoms 3. With autonomic symptoms 4. Partial Seizures (Focal Seizures) A. Complex partial seizures 1. With motor signs 2. Simple partial seizures 1.International Classification of Epileptic Seizures I. Simple partial onset followed by impairment of consciousness 2.
Simple partial seizures evolving to complex partial seizures evolving to generalized seizures . Complex partial seizures evolving to generalized seizures 3.International Classification of Epileptic Seizures I. C. Simple partial seizures evolving to generalized seizures 2. Partial seizures evolving to secondarily generalized seizures 1.
Clonic seizures D. Tonic seizures E.International Classification of Epileptic Seizures II. 1. Unclassified Epileptic Seizures IV. Tonic-clonic seizures (grand mal) F. Atypical B. 22: 489-501 . Atonic seizures III. Myoclonic seizures C. Status Epilepticus Epilepsia 1981. Generalized Seizures (Convulsive or Nonconvulsive) A. Typical absence seizures (petit mal) 2.
Videos • GTC video • Absence sz video • Tonic video • Simple partial Sz video • Complex partial Sz video • Infantile spasm • Chorea video .
Epilepsy syndromes • • • • • • • • Severe Myoclonic Epilepsy of Infancy Infantile spasms Lennox-Gastaut Syndrome Childhood Absence Epilepsy Benign Rolandic Epilepsy Benign Occipital Epilepsy of Childhood Juvenile Absence Juvenile Myoclonic Epilepsy .
Cellular basis of epileptogenesis Cellular basis of epileptogenesis Astrocyte GABAergic interneuron Glutamine synthase Glutamate Transporter GABA-T Ca++ channel Na+ channel Glutamate NMDA receptor GABA receptor Non-NMDA receptor Presynapse Postsynapse .
Treatment Issues • The goal is to prevent the recurrence of seizures while avoiding side effects of the drug • Type of seizure • Age of child • Male or female • Issues of compliances .
HISTORY of Antiepileptics 1857 1912 Bromides Phenobarbital Ethosuximide 1937 50ies 1960 70ies Phenytoin Carbamazepine 1989 Vigabatrin Zonisamide 1990 Oxcarbazepine 1991 Lamotrigine Felbamate Benzodiazepine Valproate 1993 1995 1996 1999 Gabapentin Topiramate Tiagabine Levetiracetam .
driving benefits Risks Potential drug interactions Cost Potential drug side effects (short.& long-term) Inconvenience . employment.Factors Influencing Decision to Treat Benefits Freedom from (or lower rate of) seizures Reduced risk of potential injury or death Psychological & social benefits of more security from seizures Educational.
Mechanisms of Action and Indications of AEDs Mechanism Of Action Sodium channel drugs Drug Carbamazepine Phenytoin Oxcarbazepine Gabapentin Tiagabine Vigabatrin Effective for Localization related epilepsy GABA enhancement drugs Localization related epilepsy .
Mechanisms of Action and Indications of AEDs Mechanism Of Action Mixed mechanism (excitatory amino acid. Lamotrigine Felbamate . Na channel. Clonazepam. Valproate. GABA) Drug Effective for Valproate Lamotrigine Localization related epilepsy & juvenile myoclonic epilepsy Lennox-Gastaut syndrome Topiramate.
Na channel.Mechanisms of Action and Indications of AEDs Mechanism Of Action Mixed mechanism (excitatory amino acid. GABA) Drug Effective for Valproate Phenobarbital Generalized epilepsies Topiramate Lamotrigine Tiagabine .
Number 2.Clinical Practice Guideline—Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure From the American Academy of Pediatrics PEDIATRICS Volume 127. February 2011 AAAMjjduyusayd FROM THE AMERICAN ACADEMY OF PEDIATRICSFROM THE AMERICAN ACADEMY OF PEDIATRICS .
that occurs in infants and children 6 through 60 months of age. without central nervous system infection. Simple febrile seizures – – primary generalized seizures lasting for less than 15 minutes – – does not recur within 24 hours. were defined as focal Complex febrile seizures – – prolonged ( 15 minutes) and/or recurrent within 24 hours .Clinical Practice Guideline—Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure Febrile seizure is a seizure accompanied by fever (temperature 100.4°F or 38°C2 by any method).
. a lumbar puncture is an option when the child is considered deficient in Haemophilus influenzae 3. neck stiffness. 2. Kernig and/or Brudzinski signs) or in any child whose history or examination suggests the presence of meningitis or intracranial infection. A lumbar puncture is an option in the child who presents with a seizure and fever and is pretreated with antibiotics. In any infant between 6 and 12 months of age who presents with a seizure and fever. because antibiotic treatment can mask the signs and symptoms of meningitis.Clinical Practice Guideline—Febrile Seizures: RECOMMENDATIONS: 1. A lumbar puncture should be performed in any child who presents with a seizure and a fever and has meningeal signs and symptoms (eg.
Clinical Practice Guideline—Febrile Seizures: RECOMMENDATIONS: An electroencephalogram (EEG) should not be performed in the evaluation of a neurologically healthy child with a simple febrile seizure. . phosphorus. or blood glucose or complete blood cell count. The following tests should not be performed routinely for the sole purpose of identifying the cause of a simple febrile seizure: measurement of serum electrolytes. magnesium. Neuroimaging should not be performed in the routine evaluation of the child with a simple febrile seizure. calcium.
Head Injuries .
possibly invasive.CT scan Plain and contrast studies There are both benefits and risks associated with the use of CT Risks : Abnormal test results ---. follow-up tests that may present additional risks increased possibility of cancer induction from x-ray radiation exposure.or a benign or incidental finding. . leading to unneeded.
0 2.I.0 7.4 days 0. urogram Upper G.3 2.5 days 158 days 304 days 1.V.3 years 243 days .02 2. exam Barium enema CT head Typical Effective Dose (mSv) Number of Chest X rays (PA film) for Equivalent Effective Dose 1 Time Period for Equivalent Effective Dose from Natural Background Radiation 0.Radiation Dose Comparison Diagnostic Procedure Chest x ray (PA film) Skull x ray Lumbar spine I.07 1.0 4 65 125 150 350 100 8.5 3.0 year 2.
bruise.CT scan in head injuries National Institute for Health and Clinical Excellence (NICE) Scottish Intercollegiate Guidelines Network (SIGN) Selection of children (under 16 years) for CT Scan Urgent scan if any of the following: Witnessed loss of consciousness >5 minutes Amnesia (antegrade or retrograde) >5 minutes Abnormal drowsiness ≥3 Discrete episodes of vomiting Clinical suspicion of nonaccidental injury Post-traumatic seizure (no PMH of epilepsy) GCS <14 in emergency room Suspected open or depressed skull fracture or tense fontanelle Signs of base of skull fracture* Focal neurological deficit Aged <1 . high-speed projectile) . fall from >3 m. swelling or laceration on head >5 cm Dangerous mechanism of injury (high-speed RTA.
A CT scan is also recommended (within 8 hours of injury) if there is either: More than 30 minutes of amnesia of events before impact Or any amnesia or loss of consciousness since injury if: Aged ≥65 years Coagulopathy or on warfarin Dangerous mechanism of injury Road traffic accident (RTA) as a pedestrian RTA .ejected from car Fall >1 m or >5 stairs .
Blood is hyperdense (white area) .Subdural hemorrhage on Non contrast CT scan.
When is cranial CT scan warranted ? CT scan or MRI or ultrasound ? .
Advantages of CT scan over MRI Faster. shorter duration Bone. pacemakers Patients who are claustrophobic cheaper . metallic fragments. blood Surgical clips. calcium deposits.
MS Superior in the post fossa and Can change plane without moving the patient Contrast dye (gadolinium) is safer than iodine parasellar regions . epilepsy.Advantages of MRI over CT scan No radiation Better detail for soft tissues Tumor dtection.
temporal bone) Screening and follow ups Limitation for posterior fossa structures .Ultrasound Needs a window (AF.
change in attack frequency . weight loss) N : Neurologic symptoms (confusion.> 50 years old P : Previous headache history – first headache.sudden. lateralizing signs.Worrisome Headache “SNOOP” S : Systemic symptoms (fever. new onset. progressive O : Older . impaired consciousness) O : Onset .
9 years for girls .2 years for boys and 10.Migraine in Children Relatively common in children their frequency increases through adolescence The mean age of onset is 7.
Greater than or equal to five attacks fulfilling features B-D B. Headache attack lasting one to 72 hours C. Headache has at least two of the following four features: • • • • •At Either bilateral or unilateral (frontal/temporal) location Pulsating quality Moderate to severe intensity Aggravated by routine physical activities Nausea and/or vomiting Photophobia and phonophobia (may be inferred from their behavior) least one of the following accompanies headache: • • 2004 classification of headache disorders .International Headache Society Criteria for Pediatric migraine without aura: A.
Management of Headache Diagnosis Acute treatment Preventive treatment .
MD. D. MD. MD. Hirtz. S. Yonker.63:2215-2225 . Hershey. S.Practice Parameter: Pharmacological Treatment of migraine headache in children and adolescents Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society D. MD Published in Neurology 2004. Silberstein. Ashwal. M. Lewis. MD. MD. A.
63:2215-2225 . (Class I. Level A) Acetaminophen is probably effective and should be considered for the acute treatment of migraine in children. Level B) Neurology 2004.Recommendations Practice Parameter: Pharmacological Treatment of migraine headache in children and adolescents Ibuprofen is effective and should be considered for the acute treatment of migraine in children. (Class I.
Level U) There is inadequate data to make a judgement on the efficacy of subcutaneous sumatriptan. Level U) .Recommendations Sumatriptan nasal spray is effective and should be considered for the acute treatment of migraine in adolescents. (Class IV. (Class IV. Level A) There is no supporting data for the use of any oral “triptan” preparations in children or adolescents. (Class I.
abscess) Toxin (cocaine. Arnold-Chiari) Infections (meningitis. epidural) Endocrine (hypoglycemia) Neoplasm (brain tumor. amphetamine) Trauma (subdural.Secondary Headaches by Category C I T T E N D V M Congenital anomalies (HCP. leukemia) Degenerative disorder (Alexander’s disease) Vascular (aneurysm. fever) . AVM. dehydration. coagulation disorder) Metabolic (hypoxia.
Neurologic causes for headache in children Variables that predict the presence of SOL : 1. Absence of family history of migraine 3. Presence of seizures Practice parameter : Evaluation of children and adolescents with recurrent headache. Neurology 2002. Abnormal neurologic functions on PE 4. Gait abnormalities 5. headache of less than 1 month 2. 59 : 490-498 .
Epilepsy • Can present as headache .
Congenital malformations • • • Congenital Hydrocephalus Arnold Chiari malformation Congenital infection .
Increased Intracranial Pressure The brain occupies a rigid cranial container with a fixed volume with 3 components: Brain CSF 80 % 10 % Blood - 10 % .
not more than 20 mm Hg Beyond 20 mm Hg = cerebral perfusion pressure falls leading to ischemia Cerebral perfusion pressure.Increased Intracranial Pressure Normal intracranial pressure : 0-10 mm Hg.ICP = 50 -150 mm Hg .defined as mean arterial pressure minus ICP CPP = MAP .
25 to 1.Management of Increased Intracranial Pressure (ICP) Mannitol .5 minutes with a duration of action of 2-3 hours .0 g/kg body weight of a 20% solution Two Effects: 1) Direct Osmotic Effect 2) Decreases blood viscosity .6 -carbon sugar similar to glucose Dose: 0.increases CBF and cerebral oxygenation Onset of Mannitol: within 1.
Furosemide • Furosemide has a synergistic effect to mannitol in decreasing free water. .
– caution : too much hyperventilation can cause cerebral ischemia .Hyperventilation • CO2 is a potent cerebral vasodilator • Hyperventilation lowers cerebral vascular CO2 and causes rapid vasoconstriction leading to a decreased intracranial blood volume.
induced ischemia in areas of uninjured brain thus poorer outcome .Hyperventilation • Maintain PaCO2 at 33+2 mm Hg (30-35) • Aggressive hyperventilation with of PaCO2 <25mmHg can lead to abrupt vasoconstriction and a reduction in cerebral blood flow • PaCo2 <30 mm Hg : can lead to vasoconstriction .
Positioning of the Neck Head elevated at 30 degrees .
can precipitate a fluid shift into brain and exacerbate edema • Use plain LR or normal saline for resuscitation and maintain with 5% dextrose with NSS.Fluid & Electrolyte Management • CVP line if indicated • Indwelling catheter for urine output • Avoid Hypotonic solutions . half saline or Ringer’s lactate • Do not use D5 water .
• Treat the cause of increase ICP! .
Developmental Delays Pervasive Development Disorders ADHD Autism GDD Isolated speech delay .
Shukran !! .
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