APPROACH TO CHILD SEIZURE

AND
USE OF ANTIEPILEPTIC DRUGS
Rishi k kafle

2nd year Resident, pediatrics

KMC-TH
 Definition
SEIZURES
seizure is a transient occurrence of signs and /or symptoms
resulting from abnormal excessive or synchronous neuronal
activity in the brain.

EPILEPSY
• It is a disorder of brain characterized by an enduring
predisposition to generate seizures and by the neurobiologic ,
cognitive , psychologic, and social consequences of this
condition .
• 2 or more unprovoked afebrile seizures
 Seizure disorder
A term that is usually used to include any 1 of
several disorders, including :
• Epilepsy
• Febrile seizure
• Single seizures and symptomatic seizures
secondary to metabolic, infectious, or other
etiologies.( e.g- hypocalcemia, meningitis)
 History
• Clinical diagnosis is made by history
It is important to get a detailed account of the
event or spell from a witness in order to
answer the three questions
1.Was the spell in question a seizure?
2.What type of seizure?
3.Cause of seizure?
 Pre ictal Manifestations

• Was there any warning before the spell? If so, what was
the warning?
• Did the child complain of abdominal discomfort, fear or
any other unpleasant sensations before the spell?
• What was the child doing before the spell?
• sleep or awake prior to the event?
sleep deprived prior to the spell?
• Were there any triggers for the spell?
• Was there a fever or illness?
 Ictal manifestaions

• Was the child responding during the spell or not?

• Did the child remember anything that occurred during the spell?
• Were there any repetitive behaviors during the episode, such as lip
smacking, pulling at clothing, and constant rubbing of objects.
• Did any body movements occur?
• Was there any perioral cyanosis?
• What was the child’s skin colour during the event?
• Did the patient lose continence during the spell?
• How long did the spell last?
• How many episodes has the child experienced?
• How often do the spells occur?
 Post-ictal manifestations

• How did the patient feel after the spell?

• Did the child seem confused and tired after
the spell?
• How long did it take for the child to get back
to baseline condition?
• Did the child suffer from a headache after the
spell?
• Has the child ever had any seizures before? Febrile
seizures?

• Ask about past medical history, developmental

history and current medications to rule out a
symptomatic seizure.

• Is there any family history of seizures?

 Diagnosis
Clinical categorization 2 questions
1.Is the seizure primary or secondary?
primary seizure -
secondary seizure -
2. Is the seizure partial or generalized?

• Partial seizure - involves a focal area of the brain and therefore affects a
specific portion of the body. The clinical presentation of the partial
seizure at onset indicates the location of the epileptic focus in the brain.

• Generalized seizure - affects the whole body and involves the entire
cerebral cortex.
Simple partial seizure
Partial seizures
Complex partial seizure Partial with 2◦
generalization

•Focal in onset Focal in onset Focal in onset

No impairment of
consciousness Usually
short lived, rarely longer
than 10 to 20 seconds
•Associated with either
motor,somatosensory/spec
ial sensory, autonomic or
psychic (dysphasic,
dysmnesic, cognitive,
affective, illusions,
structured hallucinations)
symptoms.
Characteristic EEG
demonstrates unilateral
spikes or sharp waves in
anterior temporal region,
but discharges may be
bilateral or multifocal
occasion.
but then
Impairment of consciousness either spreads
from onset or simple partial throughout
developing into complex partial cortex causing a
seizure. generalized
seizure.
Average duration of seizure is 1 to 2
minutes, which is significantly longer
than simple partial or absence
seizures.
Aura common, signals seizure onset in
30% children, who typically complain
of epigastric discomfort, fear, or an
unpleasant feeling. Auras occur
before impairment of consciousness.
 Complex seizures
Absence seizures:
•Seizures typically start around age 5 to 6 years.
•Characterized by short (5 to 20 second) lapses in consciousness, speech or motor activity.
•No aura
•No postictal drowsiness
• Automatisms may be present during the seizure and usually involve eye blinking or lip
smacking.
•Often provoked by hyperventilation for 3 to 4 minutes.
• EEG demonstrates 3 cycles per second generalized spike and wave activity.
• Atypical absence seizures may involve myoclonic movements of the face or body and may
result in loss of body tone causing the patient to fall. Furthermore, the onset and cessation
of the seizure may not be abrupt as in typical absence seizure.
• EEG in atypical absence seizures often reveals either 2 to 2.5 or 3.5 to 4.5 cycles per second
generalize spike and wave activity.
 Tonic clonic seizures

• Characterized by sudden loss of consciousness and tonic-clonic, tonic

or clonic contractions.
• Tonic contraction is an intense, generalized muscle contraction.
• Clonic contractions are rhythmic, often symmetric muscle contractions.
• Tonic-clonic contractions start with a tonic contraction and then
produce clonic contractions.
• Perioral cyanosis may be present.
• Loss of bladder may occur.
• Seizure is often followed by 30 to 60 minute deep sleep and postictal
headache.
• Tonic seizure: Involve intense muscle contraction only.
• Clonic seizure: Involve rhythmic, often symmetric muscle contractions only.

• Myoclonic seizure: refers to the spasm of a muscle or a group of muscles.

These seizures occur either in isolation or in connection with other seizure
types.
Clinically characterized by brief, repetitive, symmetric muscle contractions.

• Atonic seizure: Sudden loss of postural tone causes child to fall.

May be difficult to differentiate from other seizure types
 Seizure mimics
• Syncope
– Syncopal seizures may have tonic stiffening, clonic jerking
and/or post-ictal confusion
• Parasomnias
– Sleepwalking, night terrors
• Stereotypies/Tics
• Breath holding spells
• Staring spells
• Benign paroxysmal vertigo
• Pseudoseizures
• Narcolepsy
 Febrile Seizure
• Occur between the age of 6 and 60 month

• Temperature of 38C (100.4F) or higher

• Are not the result of CNS infection or any metabolic

imbalance

• Occur in the absence of a history of prior afebrile

seizure.
• Simple febrile seizure is a primary generalized, usually
tonic-clonic ,attack associated with fever, lasting for
maximum of 15min and not recurrent within a 24 hr
period. Short postictal state .

• A Complex febrile seizure is more prolonged ( >15min)

is focal, and/ or reoccur within 24 hr.

• Febrile status epilepticus is a febrile seizure lasting

longer than 30 min .
• Recur in approximatley 30% of those
experiencing a first episode

• 50% after 2 or more episodes

• 50% of infants younger than 1 year old at

febrile seizure onset.
Risk factors for recurrence of febrile seizures
Risk factor for occurrence of epilepsy after a
febrile seizure
• Simple febrile seizure • 1%
• Recurrent febrile seizure
• 4%
• Complex febrile seizure
(>15min or recurrent • 6%
within 24hr)
• Fever <1hr before febrile
seizure • 11%
• Family history of epilepsy
• Complex febrile seizure • 18%
(focal) • 29%
• Neurodevelopmental
abnormlaities • 33%
 Common pediatric seizure syndrome

• Lennox-Gastaut syndrome-
• Juvenile myoclonic epilepsy
• West syndrome
• Dravet’s syndrome.
 Common pediatric seizure syndrome
West syndrome/ infantile spasm
• Age of onset 2 and 12 month
• Triad of
 infantile epileptic spasms
 developmental regression
 typical EEG picture called hypsarrhythmia

• Lennox-Gastaut syndrome
• Age of onset 2 and 10 yr
• Triad of :
 Developmental delay
 Multiple seizure types that as a rule include atypical absences, myoclonic, astatic, and
tonic seizures
 EEG findings : 1-2 Hz spike–and– slow waves, polyspike bursts in sleep, and a slow
background in wakefulness.
Dravet syndrome :
• Most severe of the phenotypic spectrum of febrile seizure-
associated epilepsies.
• Its onset is characterized by febrile and afebrile unilateral
clonic seizures recurring every 1 or 2 month.
• These early seizures are typically induced by fever, but they
differ from the usual febrile convulsions in that they are more
prolonged, are more frequent, are focal and come in clusters.
• Seizures subsequently start to occur with lower fevers and
then without fever.
 Etiology of seizure:

1CNS Infection
- Meningitis
- Encephalitis
-Brain Abscess
-cerebral malaria
2CNS Trauma
- Acute trauma
- Previous trauma may lead to scar tissue formation
3Cerebrovascular
- Infarction
- Hemorrhage
- Arteriovenous malformation
- Venous thrombosis
4Hypoxic
- Hypoxic ischemic encephalopathy
• Metabolic - Hypoglycemia - Electrolyte disturbances
• Drug withdrawal - Alcohol - Alcohol withdrawal -
Lead poisoning

• Tumour Congenital CNS malformations - Cortical

dysplasia - Lissencephaly
• Neurocutaneous syndromes (e.g. tuberous
sclerosis)
• Fever – febrile seizures
 Physical Examination
• All children who present with a possible seizure should have a complete
pediatric exam. Pay particular attention to the following elements of the physical
exam:
• a) Vitals, including temperature
• b) Height, weight and head circumference - plot on a growth chart to determine
percentiles
• c) Developmental stage of child in gross motor, fine motor, language and social
domains.
• A delay indicates a cerebral insult.
• The insult may be remote (e.g. cerebral palsy), chronic ongoing (e.g. brain
tumour), or may be secondary to another disease. Furthermore, developmental
delay may occur in infantile spasms, an idiopathic epilepsy syndrome .
• d) Signs of trauma. Direct trauma to the brain can be a cause or consequence of
seizures.
• e) Signs of increased intracranial pressure
• f)Skin lesions – may suggest a neurocutaneous diseases
underlying seizure activity.
• g) Special tests: Fundoscopy – look for papilledema -
suggests an increase in intracranial pressure.
• H)Neurologic exam - looking for focal deficits - indicates
symptomatic seizure.
• Include components: - Mental status - Cranial nerves - Motor
- Reflexes - Sensory - Coordination and gait Brudzinski’s test
and a Kernig’s test – positive test suggest meningitis
 INVESTIGATIONS
The particular investigations for each patient
depend on the differential generated after the
history and physical examination.
• Therefore all children should have the following
tests performed:
• CBC and differential
• Electrolytes
• Calcium, phosphorus, magnesium
• Blood glucose level
• Additional tests need to be considered when investigating
the possibility of the following specific conditions:
• Hemorrhagic basis – INR, PTT
• Toxic basis – blood levels of suspected drugs and
metabolites
• Genetic disease – possible karyotype and other tests
specific to illness
• Metabolic disease – tests specific to disease, may include: -
Ammonia - Lactate - Pyruvate - Amino acids - Urine organic
acids
Lumbar puncture
• All infants younger than 6 month of age who
present with fever and seizure.
• If the child is ill appearing or at any age if there is
any clinical sign and symptoms of concern.
• 6-12 month of age who is deficient in H.influenza
type b or Streptococuus pneumonie
immunization or if immunization status not
known.
 Investigations contd
• Electroencephalogram
– Occasionally useful for determining nature of a clinical
symptom (absence seizures, tics or other frequent
movements)
– Helpful in predicting recurrence of seizures.
– A normal EEG does not exclude a diagnosis of seizure

Videotelemetry
-Simultaneous recording of EEG and video of patient.
– Can be done as a day procedure or as inpatient
– Episodes must occur with some frequency
Neuroimaging:

• CT or MRI ( not recommneded in evaluating the child

after a first simple febrile seizure)

• Complex febrile seizure ( EEG+ Neuroimaging )

• 11% children with febrile seizure may show unilateral

swelling of their hippocampus , followed by longterm
hippocampal atrophy.
Choice of drugs
 Newer Drugs
• Ezogabine
• Perampanel
• Lacosamide
• Rufinamide
• Zonisamide
Management of febrile seizure
 Prophylaxis of febrile seizure
• Prolonged anticonvulsant prophylaxis for preventing recurrent
febrile convulsions is controversial and no longer recommended.

• Oral diazepam, 0.3mg/kg q8h (1mg/kg/24hr), is administered

for the duration of the illness ( usually 2-3days.)

• Rectal diazepam in case of recurrence lasting >5min.

• Other therapies have included continuous phenobarbital (4-5

mg/kg/day in 1 or 2 divided doses), and continuous valproate
(20-30 mg/kg/day in 2 or 3 divided doses).
 Status epilepticus
• Status epilepticus- more than 5 minutes of continuous seizure activity, or
recurrent seizures without the recovery of consciousness.
• ILAE definition 2015
• The proposed new definition, published in Epilepsia, is conceptual, with two
operational dimensions. The first, time point 1 (t1), indicates the earliest time
when treatment should be started. The second, time point 2 (t2), indicates when
long-term consequences, such as neuronal injury, neuronal death, alteration of
neuronal networks, and functional deficits, are increasingly likely.
• For example, in the case of convulsive (tonic-clonic) SE, time point 1 is at 5
minutes and time point 2 is at 30 minutes.
• Both these time points are based on animal experiments and clinical research
but should be considered best estimates as the evidence is still incomplete and
there is considerable variation, according to the authors.

• In past it was defined as > 30 min duration .

Refractory status epilepticus
• It is status epilepticus that has failed to respond to therapy,
usually with at least 2 (although some have specified 3
medications.)

New-onset refractory status epilepticus (NORSE)

• Distinct entity that can be caused by almost any of the causes of
status epilepticus in a patient without prior epilepsy.
• It also is often of unknown etiology,
• presumed to be encephalitic or postencephalitic.
• Poor prognosis.
USE OF ANTIEPILEPTIC DRUGS
 AEDS for non epileptic condition
Evidence for their benefit in these nonepileptic conditions varies
widely among different drugs, but there is, in general, a paucity of
published multicenterrandomized double-blind trials.
Variable levels of evidence
• suggest that lamotrigine and the vagal nerve stimulator have
antidepressant properties.
• Carbamazepine, valproate, lam_x0002_otrigine, and oxcarbazepine
appear to have mood stabilizing properties
• while gabapentin, pregabalin, and tiagabine have anxiolytic benefits.
• Pregabalin, gabapentin, carbamazepine, and oxcarbazepine have
been used to treat neuropathic pain such as postherpetic neuralgia,
and diabetic polyneuropathy
• Topiramate and valporate sodium have utility
in the prophylaxis or acute treatment of
migraine.
• THANK YOU