Febrile Seizures

Stirred, Not Shaken

Getting Comfortable with Neurology Amy Kao, MD 2005-2006 Division of Pediatric Neurology Oregon Health & Science University

Learning Objectives
Review basic definitions and classification of seizures Discuss the specific epilepsy syndrome of febrile seizures Review the neurologic exam in the context of the concept of anatomical localization of neurologic symptoms and deficits

The Basics
Definition of a Seizure sudden event caused by abrupt, uncontrolled, hypersynchronous discharges of neurons

More Definitions
Epilepsy condition characterized by the tendency for recurrent seizures that are unprovoked by an immediate cause Status epilepticus > 30 minutes long OR Back-to-back without return to baseline

SeizuresDifferential Dx
Loss of tone or consciousness
Abnormal heart rhythm Vasovagal syncope (classic fainting) Attention deficit disorder

Disorders of breathing
Breathholding spells Hyperventilation

Other medical disorders

Hypoglycemia Gastroesophageal reflux

SeizuresDifferential Dx (2)
Unusual movements

Benign sleep myoclonus Shuddering attacks Migraine (torticollis, ataxia, confusional) Tics Pseudoseizures
Night terrors Sleep walking Rocking Head banging Infantile masturbation

Behavioral or Self-stimulation

SeizuresEtiology
V(ascular): AVM, stroke, hemorrhage, HTN I(nfectious): meningitis, encephalitis T(raumatic) A(utoimmune): SLE, vasculitis, ADEM M(etabolic/toxic): electrolyte imbalance, tox I(diopathic): idiopathic epilepsy N(eoplastic) S(tructural): cortical malformation, prior stroke, other causes of CP S(yndrome): genetic disorder

Classification of Seizures By Onset

Generalized Begins simultaneously in both hemispheres Generalized-tonic-clonic = grand-mal Absence = petit-mal Myoclonic Tonic Atonic

Classification by Onset, continued

Partial (=Focal) Onset in a focal region of the brain Simple partial Complex partial Secondarily generalized

Classification of Seizures By Cause

Acute Symptomatic Shortly after an acute insult Infection Hypoglycemia, low sodium, low calcium Head trauma Toxic ingestion

Classification by Etiology, continued

Remote Symptomatic Pre-existing brain abnormality or insult
Brain injury (head trauma, low oxygen) Meningitis Stroke Tumor Developmental brain abnormality

Classification by Etiology, continued

Idiopathic No history of preceding insult Likely genetic component

Classification by Syndromes
Definition of a syndrome Cluster of symptoms, signs, and lab findings (EEG) Consistent Implies diagnosis, treatment, or prognosis There are syndromes specific to children

Febrile Seizures
Definition a seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures

Febrile Seizures
Epidemiology 2 to 5 % of children in the US Most common form of childhood seizures Peak at 18 months Simple = isolated, brief, generalized Complex = focal, multiple, or prolonged

Simple Febrile Seizures

< 15 minutes Generalized-tonic-clonic Fever > 100.4 rectal to 101 F (38 to 38.4 C) No recurrence in 24 hours No post-ictal neuro abnormalities (e.g. Todds paresis) Most common 6 months to 5 years Normal development No CNS infection or prior afebrile seizures

Risk Factors for

st 1

Feb Sz

Febrile seizure in 1st/2nd degree relative Day care Neonatal nursery stay of >30 days Developmental delay Height of temperature

Risk Factors for Recurrent FS

1/3 will have a recurrence 10% will have 3 or more
FH of febrile seizures Age <18 months Height of temperature Duration of fever

Risk Factors for Epilepsy

2 to 10% will go on to have epilepsy
Developmental delay Complex FS (possibly > 1 complex feature)
5% > 30 mins => of all childhood status

FH of epilepsy Duration of fever

Evaluation in Febrile Seizures

Exclude acute etiologies HCT, lytes/cbc if history/PE suggests Strongly consider LP < 12 months old Prior antibiotic therapy Suspicious findings on history/PE Not absolutely necessary in > 18 mos

Evaluation in FS (2)
EEG Does NOT predict recurrence or epilepsy More likely to be abnormal in: Older children Neurodevelopmental abnormalities Family history of febrile seizures Complex febrile seizure

Febrile SeizuresTreatment
May reduce short-term recurrence But NO effect on occurrence of epilepsy AND the side effects ! The approach is based on epidemiological data that FS are benign, so Prevent status epilepticus

FSTreatment (2)
Antipyretics
No data that this reduces risk FS at onset of fever => highest recurrence

Benzodiazepines
Rectal diazepam (Valium) 2-5 y/o 0.5 mg/kg 6-11 y/o 0.3 mg/kg (round up to 2.5, 5, 10 mg) Oral diazepam 0.33 mg/kg q8 hrs x 48 hrs during illness

FSTreatment (3)
Daily medications NOT recommended
Phenobarbital Drowsiness, sleep problems, hyperactivity, IQ Valproic acid Hepatotoxicity Phenytoin and carbamazepine Not effective

SeizuresExam
Temp, BP, HC Skin (rash, neurocutaneous lesions), Neck Evidence of dysmorphisms, developmental delay Evidence of increased intracranial pressure Bulging anterior fontanelle Depressed level of consciousness Pupillary asymmetries Downgaze/sunsetting eyes Abducens palsy Papilledema

SeizuresExam (2)
Evidence of focal deficits
Weakness Intracranial lesion versus Todd paresis Tone or reflex asymmetry ? Chronic versus acute

SeizuresEvaluation
Lumbar puncture
Strongly consider in patient <12 mo with first febrile seizure Kernigs, Brudzinskis, nuchal rigidity low sensitivity (Thomas 2002) But usually more than isolated seizure History of irritability/lethargy Complex febrile seizure Slow postictal clearing of mentation

SeizuresEvaluation (2)
Neuroimaging
Emergent HCT Concern of acute focal lesion, mass effect I.e. persistent paresis or change in MS MRI (nonurgent) Focal sz Cognitive/motor impairment Focal EEG findings

EEG
Not if simple febrile seizure

Location, Location, Location

Overview of the Neuro Exam

Mental Status Cranial Nerves Motor Gait Coordination Reflexes Sensory General

General
Growth parameters (HC) Vital signs (temp, BP) Anterior fontanelle Flattening of the occiput Dysmorphic features Cardiac abnormalities Hepatosplenomegaly Cutaneous lesions

Mental Status
Change in mental status = brain is not working correctly Level of consciousness
Lethargy Stupor Coma

Attentive/interactive Language (receptive, expressive)

Cranial Nerves
= Brain stem or nerve CN2 = optic nerve
Funduscopic exam Visual fields/blink to threat Visual acuity/color vision

CN3, 4, 6 = oculomotor, trochlear, abducens

Eyelids Pupils Extraocular movements

Cranial Nerves (2)

CN5 = trigeminal
Sensation Masseter function Corneal reflex (comatose or focal brain stem)

CN7 = facial
Wide palpebral fissure and flat nasolabial fold Both upper and lower face = LMN Only lower face weak = UMN

Cranial Nerves (3)

CN8 = vestibulocochlear nerve
Finger rub Weberslouder ear = conduction deafness Rinneconfirms above ear (air < bone)

CN9, 10 = glossopharyngeal and vagus

Palate elevation, gag

CN11 = spinal accessory

L SCM turns head to R, ear to ipsi clavicle

CN12 = hypoglossal
Tongue in cheek

Motor
Hypotonia = LMN or UMN, cerebellum Hypertonia = UMN lesion, basal ganglia Bulk/Fasciculations Tone
Resistance to passive ROM Traction response, horizontal/vertical suspension

Power
0 to 5 grading scale Techniques to bring out asymmetry
Pronator drift, finger tapping, gait

Gait
Motor cortex, corticospinal tracts, basal ganglia, cerebellum, vestibular system, nerves, muscles, vision, proprioception

Good screening test Natural gait Toe walk, heel walk, tandem walk Romberg (proprioception, vestibular) Sit to stand

Coordination
Limb ataxia = cerebellar hemispheres Gait ataxia = midline cerebellum
Finger-to-nose testing/reaching for toys Rapid rhythmic alternating movements Titubation (truncal ataxia)

Reflexes
Hyperreflexia = UMN lesion Hyporeflexia = LMN lesion
0 to 5+ grading scale Babinskis sign = UMN lesion Correspond to spinal roots Primitive reflexes

Sensation
Stocking-glove = nerve Vibration/proprioception = dorsal columns Pain/temp = spinothalamic tracts Extinction = cortex

Localization of stim Purposeful withdrawal to painful stim Spinal level

Questions re:Neuro Exam?

http://medstat.med.utah.edu/pedineurologicexam/home_exam.html

Bibliography
Baumann RJ and Duffner PK. Treatment of children with simple febrile seizures: The AAP practice parameter. Pediatr Neurol 2000;23:11-17. Hirtz D et al. Practice parameter:evaluating a first nonfebrile seizure in children. Neurology 2000;55:616. Knudsen FU. Febrile seizures: Treatment and prognosis. Epilepsia 2000;41:2-9. Prensky AL. An approach to the child with paroxysmal phenomena with emphasis on nonepileptic disorders. In: Pellock JM, ed. Pediatric epilepsy diagnosis and therapy. New York: Demos Medical Publishing, 2001:97.

Bibliography
Provisional committee on quality improvement, subcommittee on febrile seizures. Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. Pediatrics 1996;97:769. Shinnar S and Glauser TA. Febrile seizures. J Child Neurol 2002;17:S44-52. Thomas KE et al. The diagnostic accuracy of Kernigs sign, Brudzinskis sign, and nuchal rigidity in adults with suspected meningitis. Clin Inf Dis 2002;35:46. Warden CR et al. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med 2003;41:215.