Seizure disorders

STUDENT : MAHAD ABDULLAHI

SUPERVISOR : DR.CHEBET MARTIN
 Seizure
Seizure
(Latin sacire, “to take possession of”)

 A transient occurrence of signs and/or

symptoms resulting from abnormal
excessive or synchronous neuronal
activity in the brain.
Seizures
Epileptic Non epileptic
Convulsion
A convulsion is any seizure (not
necessarily epileptic) characterized by
excessive, abnormal muscle contractions,
which are usually bilateral.
Epilepsy
Epilepsy is a disease of the brain defined by
any of the following:
1. A least two unprovoked (or reflex) seizures
occurring >24 h apart
2. One unprovoked (or reflex) seizure and a
probability of further seizures similar to the
general recurrence risk (at least 60%) after
two unprovoked seizures, occurring over the
next 10 years
3. Diagnosis of an epilepsy syndrome
Status Epilepsy
Clinical Definition New

Recurrent epileptic seizures continuing for more than 30

minutes without full recovery of consciousness before the next
seizure begins, or continuous clinical and/or electrical seizure
activity lasting for more than 30 minutes whether or not
consciousness is impaired’

Operational Definition (children > 5 yrs)

“Greaterthan or equal to 5 minutes of continuous seizures or

two or more discrete seizures between which there is
incomplete recovery of consciousness.”
Seizure vs Epilepsy

A seizure is the event

Epilepsy is the disease associated with

spontaneously recurring seizures
Epidemiology
Febrile seizures are the most common
seizure disorder and most common
neurological disorder in childhood
Febrile seizures are seen in 3 % of
children aged 6 months to 5 years (rarely,
3 months and 6 years)
Epilepsy is predisposition to recurrent
seizures
Epilepsy is seen in 5 per 1000 children
Cont…
The incidence of SE ranges between 10 and
60 per 100,000 population in various studies.
SE is most common in children younger
than 5 yr of age, with an incidence in this
age-group of > 100 per 100,000 children.
Approximately 30% of patients presenting
with SE are having their first seizure, and
approximately 40% of these later develop
epilepsy.
Some terminology
 Acute Symptomatic Seizure
 A seizure occurring within a week of an acute brain insult
(trauma, infection, toxic, metabolic or vascular insult).
Future risk of unprovoked seizures is only 3-10%
 Unprovoked seizure
 One that is not an acute symptomatic seizure.
 Remote symptomatic seizure
 Secondary to a distant brain injury, such as an old stroke.
 Reflex seizures
 Precipitated by a sensory stimulus such as flashing lights
Secondarily generalized seizures
 partial-onset seizures that spread and
generalize.
Secondary generalized epilepsy
 a constellation of any number of
generalized onset seizure types
Epilepsy Resolved
 Epilepsy is considered to be resolved for
individuals who had an age-dependent epilepsy
syndrome but are now past the applicable age or
those who have remained seizure-free for the last
10 years, with no seizure medicines for the last 5
years.
Epileptic syndrome
 A disorder that manifests one or more specific
seizure types and has a specific age of onset and a
specific prognosis
 CLASSIFICATIONs

Seizures
Focal
Generalized
The first clinical and
The first clinical and
electroencephalographic
EEG changes indicate
(EEG) changes suggest
synchronous
initial activation of a
involvement of all of
system of neurons limited
both hemispheres
to part of one cerebral
hemisphere
Etiology
Etiology
of Acute Symptomatic Seizures/
NON Epileptic Seizure

Febrile Seizuress (age 6 months to 5 years)

CNS infections (Meningitis / Encephalitis /
Cerebral malaria)
Intracranial hemorrhage
Hypoglycemia / Electrolyte imbalance
(Na,Ca,Mg)
Cont… Etiology

Drugs / Chemical Poisoning /

Encephalopathy
Trauma
Hypoxia
PNES (Psychological Non-epileptic
Seizures)
Tetanus (spasms not seizures)
Cont… Etiology
Etiology - Recurrent Seizures/ Epileptic Seizure

Epilepsy

Idiopathic Epilepsy in children has a genetic basis

Epilepsy in children may be associated with:

Hypoxic-ischemic injury to Brain
Cerebral Malformations
Degenerative Brain diseases
Cont… Etiology
Epilepsy in children may be secondary to:

Cerebral palsy
Encephalopathy
Cerebral vascular occlusion
Cerebral tumour
Neurodegenerative disorders
Neurocutaneous syndromes
Intellectual disability / Mental handicap
Cont…Etiology-Neonatal Period
Birth asphyxia or trauma
Intracranial hemorrhage
Hypoglycemia
Hypocalcaemia or hypomagnesemia
Infections: meningitis, septicemia, tetanus
neonatorum
Inborne errors of metabolism
Pyridoxin dependent seizures
Maternal withdrawal of medications
Accidental inj of local anaesthetic into fetal scalp
Mechanisms which Underlie Seizure
Generation
Abnormalities at the cell membrane level (ion
channels and receptors) and in neuronal
circuits
Three main classes of voltage gated ion
channels have been described: Na+, Ca2+ and
K+.
Sodium currents are involved in the generation
of action potentials.
Potassium currents cause hyperpolarization
and hence stabilize the neuronal membrane.
Cont…
Both calcium and sodium currents are involved
in the generation of burst discharges, generated
by certain classes of neurones when excited.
Gamma amino butyric acid (GABA) and glycine
are inhibitory neurotransmitters while glutamate
and aspartate are excitatory neurotransmitters.
A useful, though simplistic model of epilepsy is
that it involves an imbalance of excitatory and
inhibitory neurotransmitter systems within the
CNS.
Seizures in Children Evaluation
History:
Seizures – Onset, Frequency, Duration, Progression
Seizure – Description, Video evaluation, Type
Present illness – other symptoms of disease • Past
History – seizures
Development history – milestones Family History –
epilepsy
Physical Examination:
General Physical Examination – all systems of body
Neurological Examination – abnormal findings
Seizures in Children Clinical Diagnosis

Description of Seizures
Video evaluation
Detect and Look for important signs of
seizure activity:
Impaired conscious level
Tonic spasms, clonic jerky movements
Froth at mouth, facial movements
Passage of urine or stool
Post-ictal sleep
Seizures in Children Differential
Diagnosis
Breath – Holding Spells
PNES (Psychological Non-epileptic
Seizures, Pseudoseizures)
Parasomnias (sleep disorders)
Syncope
Tics
Movement disorders
Gratification disorder
Seizures in Children Investigations
CBC, CRP, ICT malaria, X-ray Chest
(infection)
Serum glucose, electrolytes, calcium, and
BUN (metabolic)
CSF examination and microbiology
(meningitis)
Neuroimaging - CT / MRI Brain
(neurological disease)
EEG – electroencephalography (epilepsy)
Seizures in Children Acute Management

General Management:
Airway – Breathing – Circulation
Oxygen by mask / nasal prongs
Monitoring – GCS, Vitals, SaO2,
Seizure Management:
Rectal diazepam (at home)
IV diazepam or IV midazolam
(benzodiazepines)
 IV Leviteracetam (if needed)
Seizures in Children Acute
Complications
Hypoxia and Hypercapnia
Hypoglycemia
Hyperpyrexia
Aspiration pneumonia
Shock
Raised ICP (Intracranial Pressure)
Physical injuries
Status epilepticus
Febrile Seizures
Febrile Seizures
Nelson Text Book Definition:
Febrile seizures are seizures that occur
between the ages of 6 and 60 mo (peak
12-18 mo) with a temperature of 38°C
(100.4°F) or higher, that are not the result
of CNS infection or any metabolic
imbalance, and that occur in the absence
of a history of prior afebrile seizures
Cont…
ILAE Definition:
FS is a seizure occurring in childhood
after one month of age, associated with a
febrile illness that is not caused by an
infection of the central nervous system
Febrile Seizures Epidemiology
Febrile seizures are the most common
seizure disorder and most common
neurological disorder in childhood
Febrile seizures are seen in children aged
6 months to 5 years (rarely, 3 months and
6 years)
Febrile seizures are seen in 3 % of
children
 CLASSIFICATIONs

Simple Complex
Primary generalized, Focal
usually tonic–clonic, Prolonged (>15
attack associated with min)
fever Reoccurs within 24
Lasting for a maximum hours
of 15 min
Not recurrent within a
24-hr period
Types - Febrile Seizures
Febrile status epilepticus
 ... is defined as one lasting over 30
minutes.
Febrile seizure plus
 When the febrile seizures continue after
age 5 or other types of seizure develop.
FS+ usually end in early adolescence....
Cont…
 Febrile infection-related epilepsy
(FIRES):
 In children >5 yr) usually male children
and associated with an encephalitis-like
illness but without an identifiable
infectious agent. Children with FIRES
were previously normal but subsequently
develop difficult-to-treat epilepsy.
Cont…
Generalised epilepsy with febrile seizures
plus (GEFS+):
 Children may go on to have febrile
seizures well beyond 6 yrs age, even into
adult life. They may also develop other
seizure types not associated with a high
temperature. An epileptic syndrome
Etiology and Pathogenesis
The exact underlying mechanism of febrile
seizures is unknown
The increased activity of neurons during rapid
brain development may predispose to seizures
in younger children
Inflammatory mediators, and cytokines,
released during a fever may contribute to the
pathogenesis of febrile seizures
There is a genetic basis to febrile seizures
which are more common in families
Etiology and Pathogenesis
Due to temporary impairment of the balance
between convulsant and anticonvulsant
system of brain 17
Studies done in children suggest that the
cytokine network is activated and may have
a role in the pathogenesis of febrile seizures
Threshold level of anticonvulsant system in
these genetically predisposed children is
lower
Febrile Seizures Clinical Features - Fever

Febrile seizures are associated with an abrupt

rise of fever in genetically-predisposed
children
Fever is usually more than 102 F (39 C)
Most febrile seizures will occur during the
first 24 hours of developing a fever
In many children, parents may not have
noticed the fever till the seizure occurs
The cause of fever is usually a viral infection
Febrile Seizures Clinical Features -
Seizure
Febrile Seizures are usually brief, lasting less than 5
minutes
Most commonly, it is a generalized tonic-clonic
seizure.
Child rapidly loses consciousness with open
deviated eyes, irregular breathing, increased
secretions, and pallor
Bilateral jerky movements occur
Child may vomit or become incontinent
After the seizure is over, child rapidly regains
consciousness, within an hour
Cont…
Other suggestions
Endogenous pyrogens such as IL-1
increase neuronal excitability & cause
seizures
Hyperthermia induced alkalosis
Diagnostic criteria
Age

Peak14 – 24 months
6 months – 60 months (5yrs)

Temperature

Usually >= 38C with rapidly rising temp.,

within 24hrs of onset of fever 12
Cont…
Should not last > 10min
Generalized, not focal
 No residual weakness of limb or
disability except a brief period of
drowsiness
No evidence of CNS infections.
(meningitis, encephalitis, abscess….)
Cont…
Extracranial infection may be there.
( URTI, tonsillitis, otitis media…)

No Hx of previous afebrile seizure

No acute systemic metabolic abnormality

Cont…
past history of Febrile seizures often
present in the child or siblings
child regains consciousness quickly
child is neurologically normal after the
seizure
Investigations
Usually not needed in simple febrile
convulsion
Complex form may need,
Blood glucose, serum electrolytes
LP and CSF analysis
Neuro-imaging (CT, MRI)
EEG
Cont…
Lumbar puncture is strongly
recommended

Hx of irritability, reduced feeding or

lethargy
Clinical signs of meningitis/encephalitis
Systemically ill
After pretreatment with antibiotics
 Inthese situations,
LP must be undertaken to check for,

protein
sugar organisms

CSF
Cont…
Neuroimaging is considered If,

Micro/ macrocephaly
Neurocutaneous syndrome
Pre-existing neurological defect
Recurrent complex febrile seizures
Cont…
EEG

Not a guide for treatment

Does not predict recurrence
So not usually indicated
Febrile Seizures Acute Management
General Management:
Airway – Breathing – Circulation
Oxygen by mask / nasal prongs
Monitoring – GCS, Vitals, SaO2,
Seizure Management:
Rectal diazepam (at home)
IV diazepam or IV midazolam (benzodiazepines)
 IV Leviteracetam (if needed)
Fever Management:
IV Paracetamol
Sponging with water
Febrile Seizures Long Term Management

Control of Fever :
Oral Paracetamol or Oral Ibuprofen (keep fever
low)
Sponging with water
Seizure Management at home:
Rectal diazepam
Oral Midazolam
Prevention of Seizures:
Oral diazepam during febrile episodes
Oral Phenobarbitone daily till 5 years of age
Febrile Seizures Complications
Acute complications:
Hypoxia
Hypoglycemia
Hyperpyrexia
Aspiration pneumonia
Status epilepticus
Chronic complications:
Recurrence – further Febrile Seizures
Epilepsy
Epilepsies of
children
Definition
Epilepsy Chronic neurological disorder
characterized by recurrent unprovoked
seizures, associated with abnormal,
excessive or synchronous neuronal
activity in brain
Pathogenesis
 Sudden, excessive, disorderly
discharging neurons
 failure of desensitization of AMPA
glutamate receptors, thus causing
the persistence of increased excitability, and
Increased GLUTAMATE levels &
decreased GABA levels
Classification
Generalized
Discharges from both hemispheres
Absence
Generalized seizures
Myoclonic
There is,
Tonic Always LOC
Tonic-clonic No warning
Symmetrical
Atonic
B/L synchronous discharge
on EEG
Cont…
Focal
Arise from one or part of one hemisphere
 Frontal seizures
Temporal lobe seizures Focal seizures
Occipital seizures Begin in one
hemisphere
Parietal lobe seizures
May herald by an aura
May or may not have
change in
consciousness
Diagnosis
Primarily by detailed Hx
Child & eye witnesses
Skin markers of Neurocutaneous syn. Or
neurological abnormalities
Investigations
EEG
Indicated whenever suspected
To detect structural abnormalities
Neuronal hyperexcitability
Sharp waves
Spike-wave complexes
Cont…
Many children with epilepsy Normal initial
EEG
Many children never had epilepsy
Abnormal initial EEG

Additional techniques
Sleep deprived record
24h ambulatory EEG
Subdural electrodes (prior to surgery
Cont…
Imaging studies
Structural scans
CT brain
MRI
Can identify
Vascular lesions
Tumours
Sclerotic areas
Cont…
General Management:
Airway – Breathing – Circulation
Oxygen by mask / nasal prongs
Monitoring – GCS, Vitals, SaO2,
protecting the patient from injury.
Seizure Management
Rectal diazepam (at home)
IV diazepam or IV midazolam
(benzodiazepines)
 IV Leviteracetam (if needed)
THANK YOU