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Rosalina Q. De Sagun,M.D.

Maria Antonia Aurora Moral - Valencia,


M.D.

Seizure: is an abnormal excessive


neuronal discharge arising from the
brain capable of causing alteration in
function and/ or behavior.

Convulsion: is a type of seizure with a


motor component.

Epilepsy: Recurrent unprovoked seizures


(operational definition more than two).

Everyone is entitled to a diagnosis for


prognosis and management to be specific
and precise.

The diagnostic label epilepsy is


unsatisfactory for both physician and
patient because epilepsy is not a single
disease entity .

First: Are these epileptic seizures?

Second: What is their cause and what is the


epileptic syndrome?

Breath-Holding Spells
Benign Paroxysmal vertigo
Night terrors
Syncope
Shuddering attacks
Paroxysmal torticollis
Rage attacks
Masturbation
Hereditary chin trembling
Narcolepsy/Cataplexy
Paroxysmal Kinesigenic choreoathetosis
Pseudoseizures

Paroxysmal disorder
Altered neurological function (motor,
sensory, psychic, autonomic)
Abnormal cortical electrical discharge
Beginning and an end (sudden and
transitory)
Involuntary

History with an exact description of the event


Physical and Neurological Examination
Age of onset
Precipitating events: possible prenatal or
postnatal insults to the CNS such as trauma
and infections. Possible etiology of seizures.
Occurrence of prior seizures ( non-convulsive)
Classify the seizure
Family history of seizures

Look for physical and neurological signs


that may suggest a possible etiology.

Any signs of trauma, dysmorphic features,


signs of increased ICP or metabolic
disorders.

Serum glucose determination


Electrolytes
Drug screens
BUN and creatinine
Thyroid function tests

If the seizure is clearly related to a


metabolic disturbance an EEG is
unnecessary.

Treatment with antiepileptic drugs may be


needed to control seizures until the
underlying pathology responsible for the
acute encephalopathy has been corrected.

Classification of the seizure

Provide additional clues in making an


etiologic diagnosis

A normal EEG is of limited value and does


not rule out the fact that a seizure episode
has occurred

I. Partial seizure
A.
Simple partial seizure (consciousness
nintact)
B.
Complex partial seizure (with impairment of
consciousness)
C.
Partial secondarily generalized
II. Generalized seizures (bilaterally symmetrical and
without
local onset)
A.
Absence seizures
B.
Myoclonic seizures
C.
Clonic seizures
D.
Tonic seizures
E.
Tonic-clonic seizures
F.
Atonic seizures (astatic)
III.Unclassified epileptic seizures (inadequate or
incomplete data)

Consciousness is preserved
May have motor, sensory, somatosensory
or special sensory, autonomic or psychic
symptomatology.
No post-ictal confusion

Characterized by impairment of
consciousness and purposeless behaviors or
automatisms.
Warning signs or auras may occur

Simple evolving to GTC


Complex evolving to GTC
Simple evolving to complex evolving to GTC

Begin throughout both hemispheres,


more or less simultaneously
Do not have localized onset
Reflect generalized disturbance of
cortical function

Absence
Myoclonic seizures

Myoclonic jerks, single or multiple

Tonic-clonic seizures
Clonic seizures
Tonic seizures
Atonic seizures (astatic)

Brief ( less than 30 seconds)


With impairment of consciousness
No aura
No post-ictal symptoms
Typical EEG: generalized 3-4 Hz slow spike
and wave discharges
Fundamentally and pharmacologically
unique from other seizures

Brief jerks of whole body or individual


muscle groups, usually without
impairment of consciousness
Shock-like contractions are commonly
precipitated by the patients falling asleep
or awakening.
May evolve into a tonic-clonic seizure

Most common and most dramatic


Generalized stiffening followed by clonic
movements of the extremities
At the end of the seizure the patient
frequently falls into deep sleep.

Sudden loss or diminution of muscle tone


without apparent preceding myoclonic or
tonic events, lasting for 1-2 seconds
involving the head, trunk, jaw or limb
musculature.

History of event (witnesses and personal


recall)
Medical history Risks for epileptogenesis
General physical examination
Neurologic examination
Blood tests (toxicology)
Electroencephalography (EEG)
Video Telemetry
Brain scanning (MRI, CT-scan)
Other investigations

No Routine Laboratory requests

EEG
Neuroimaging: MRI > CT
Others for specific indications
CSF, head-up tilt table test and/or other
cardiologic work-up
endocrinological, metabolic, genetic work-up
neuropsychological investigations

Diffrential Diagnosis for other Paroxysmal


events
Differentiate Partial from Generalized
Seizures
Identification of certain Epilepsy Syndromes

Abnormal epileptiform activities


- absent in 10-40 % of epileptic patients
- present in 1-5 % of non epileptic people

Partial onset seizures especially in adults


Findings suggest of progressive
neurologic disease
Intractable seizures
Seizures increasing in frequency and
intensity despite adequate treatment.

MRI- has higher sensitivity than CT


Scan for structural epileptogenic foci.

Classification of epilepsies and epileptic


syndromes based on clusters of signs and
symptoms
Predominant seizure type (EEG and clinical)
Age of onset
Family history
Anatomic correlation
Precipitating factors
Severity
Chronicity
Prognosis

Age specific epileptic disorder


Occurs between 3-12 months, peaking at 4-7
months
Triad: Infantile spasm, mental retardation and
hypsarrythmia on EEG
Spasms are brief but recurrent
Flexor, extensor or mixed
Most are associated with perinatal injury

Triad of seizure disorder, mental retardation and


stypical petitmal on EEG
Seizure types are variable and mixed
Tonic seizures are the most frequent
Forms a continuum with Infantile spasm.
Seizures are usually resistant to treatment.

Common between 3- 13 years of age, peak at 910 years


Male preponderance
Occur more frequently in sleep
May begin as focal siezures 2-3 hours after falling
asleep and may generalize
Affected children are otherwise normal
Complete remission bt 15-16 years of age
EEG : characteristic centro-temporal spikes

Onset between 6-7 years


3 times more common in girls
Simple or complex
Simple: blank stares
Complex- associated with automatisms, clonic
jerks or change in tone.
Triggered by hyperventilation for no less than 3
minutes

Antiepileptic

Drugs (AEDs)
Avoidance of Predisposing Factors
Vagus nerve stimulation
Epilepsy Surgery

A seizure in association with a febrile illness


with a temperature greater than 38.4 C
( although the fever may not be evident until
after the seizure).
Without evidence of any causative disease
such as CNS infection, metabolic abnormality,
intoxication, etc., in children older than 1 month
of age without prior afebrile seizures.

Simple:
Short
Generalized
Occurs only once in a febrile illness.
Complex:
Prolonged (>15mins)
Focal
Recurrent within a 24 hour period.

About 2-3 % children worldwide will


experience at least 1 febrile seizure.

1/3 of them will have a second attack.

of those who have had a second attack will


have a third episode.

< 9 % altogether will experience more than 3


episodes.

More than 3 is already considered atypical


and requires further investigation.

Complex febrile seizures

Child is neurologically impaired ( e.x. CP or


has developmental delay.

Multiple risk factors: highest risk of


recurrence.
- > 2 risk factors : > 30 % risk of
recurrence
- 3 or more risk factors: > 60 % risk

Family history for febrile seizures.


Age younger than 18 months
The lower the maximum temperature at
occurrence the higher the risk.
The shorter duration or recognized fever
the higher the risk.

American Academy of Pediatrics recommendations


for Lumbar Puncture:
A must for children under 12 months.
Strongly recommended for children between 1218 months.
Not necessary in a child > 18 months.
First complex febrile seizures and or persistent
lethargy.
Strongly recommended for children who have
received prior antibiotic therapy.

Medications have been found effective in


preventing recurrences: Diazepam,
Phenobarbital and Valproic acid
Most

recommended: Intermittent diazepam


treatment at 0.5 mg/k per rectum every 12
hours or 0.2 mg/k per orem every 8 hours
during the febrile illness.

Most children however require no


treatment considering the benign nature
of the disease.
More important is educating and
counselling parents and caregivers of
children with FS.
Control fever which is the trigger for the
seizure

The risk of death , mental retardation and cerebral


palsy ( motor deficits) is no different from that of
the general population who do not experience
febrile seizures.
No difference were seen in the IQ scores and
performance on the Wide range Achievement
Tests between children with and without febrile
seizures.

Risk of epilepsy ranges from 2- 10% in the presence of


the following risk factors:
1. The child is neurologically impaired prior to the
seizure.
2. Positive family history for epilepsy.
3. Complex febrile seizures.
Risk of epilepsy after a first febrile seizure however is
no different from that of the general population.