Febrile Seizure and Epilepsy

7/29/2019 Febrile Seizure and Epilepsy

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Prepared by: Nurul Syazwani Ramli


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SEIZURE

A sudden disruption of the brain's

normal electrical activity accompanied

by altered consciousness and/or other

neurological and behavioralmanifestations.


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FEBRILE SEIZURE

Febrile fits, febrile seizure and febrile

convulsions are synonymous terms.

Febrile fits (F.C.) are defined as fits

occurring in association with fever inchildren between 6 months and 6 years

of age, in whom there is no evidence of

intracranial pathology or metabolicderangement that could be the cause of

the fit.


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Epidemiology

There is no comprehensive local

epidemiological data.

3-4% of children < 5 years experiencing

febrile fits (Western Europe)

Higher figures of up to 8% in Japan.

The single most common problem in

paediatric neurology


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Types of Febrile Fits

Duration short (< 15 minutes)

Generalised fits

do not recur during febrileepisode

Simple

FebrileFits

Duration prolonged (> 15 minutes) Focal features

> 1 seizure during the febrile episode

Residual neurological deficit post-ictally, such as Todds paralysis

ComplexFebrile

Fits


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Diagnosis

Diagnosis of febrile seizures is based on

history.

Also ask about possible ingestions of drug or

toxins

Physical examination to rule out of

meningitis or encephalitis


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Investigation

Blood counts, blood glucose, lumbar puncture,urinalysis, chest x-ray, blood culture etc dependon clinical assessment of the individual case.

Lumbar punctare must be done (unlesscontraindicated)

Measurement of serum calcium and electrolytesare rarely necessary.

EEG is not indicated even if multiplerecurrences or complex febrile convulsions.


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Management

Need for admission.

Not all children with febrile fits need to be

admitted. The main reasons for admission are:-

To exclude intracranial pathology especially infection

Fear of recurrent fits

To investigate and treat the cause of fever besides

meningitis or encephalitis.

To allay parental anxiety, especially if they are staying

far from the hospital.


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Management

if in a convulsive state:

Loosen clothing around neck

Wipe off vomitus

Diazepham (0.5mg/kg)

If not in a convulsive state (control fever): Tepid sponging

Anti-pyretic (PCM rectal or syrup- 15mg/kg/6hourly)

Look for cause if initial infection


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Prognosis

Benign events with excellent prognosis

3-4% of population have FC

30% recurrence after 1st attack

48% recurrence after 2nd attack

2-7% develop afebrile seizure orepilepsy

No evidence of permanent neurologicaldeficit.

No deaths reported from simple FC


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Epilepsy

* A neurological condition characterised by

recurrent unprovoked epileptic seizures.

An epileptic seizure is the clinical

manifestation of an abnormal andexcessive discharge of a set of neurons

in the brain

An epileptic syndrome are complexsigns and symptoms that define a

unique epilepsy condition.

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Epidemiology

5 per 1000 school aged children

10% are severely affected.

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Causes

Perinatal Conditions:

Cerebral

malformation

Intrauterine infection

Hypoxic-ischemic

Trauma

Hemorrhage

Infections:

Encephalitis

Meningitis

Brain abscess

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Causes

Metabolic Conditions Hypoglycemia

Hypocalcaemia

Hypomagnesaemia

Hyponatremia

Hypernatremia Storage diseases

Reye syndrome

Degenerative disorders

Porphyria

Pyridoxine dependencyand deficiency

Poisoning Lead

Cocaine

Drug toxicity

Drug withdrawal

NeurocutaneousSyndromes Tuberous sclerosis

Neurofibromatosis

Sturge-Weber syndrome

Klippel-Trenaunay-Weber syndrome

Linear sebaceous nevus

Incontinentia pigmenti

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Causes

Systemic Disorders

Vasculitis (CNS or

systemic)

SLE

Hypertensive

encephalopathy

Renal failure

Hepatic

encephalopathy

Other

Trauma

Tumor

Febrile

Idiopathic

Familial

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Classification of Seizures

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Tonic Clonicgrand-mal or convulsion

Loss of consciousness,

stiffening of body then

jerking of limbs

Absencepetit mal or starting fit or

trance like state

Tonic or Atonicdrop attack

Abrupt fall, either with

stiffening (tonic) or with

loss of muscle tone (atonic

or astatic attacks)

MyoclonicSudden muscle jerks

Seizure Classification

Partialseizure activity starts in one area of the

brain

Generalizedseizure involves whole brain &

consciousness is affected

SimpleRetains awareness

ComplexAltered awareness and behavior

Secondary generalization(spreading from one area to the whole brain)

"jacksonian" seizure


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Generalized vs. Partial

Generalized Seizures- Always loss of consciousness

No warning

Symmetrical seizure

Bilateral synchronous seizure discharge on EEG

Partial Seizure- Begins in a relatively small group of

dysfunctional neurons in one of the cerebral

hemispheres. May have an aura which reflects site of origin

May/not- change in consciousness or more

generalized motor jerking

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Partial Seizures

Simple Partial Seizures The child will retain awareness with

consciousness unimpaired

Complex Partial Seizures Altered conscious state or confusion due to the

abnormal electrical discharge spreading from theoriginating site

Partial Seizures with SecondaryGeneralisation Focal seizure manifests clinically or on an ictal

EEG followed by a generalized Tonic-ClonicSeizure

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Generalised Epilepsies

Absence seizures Transient loss of consciousness, with an abrupt

onset and termination, unaccompanied by motorphenomena except for some flickering of the

eyelids and minor alteration in muscle tone. Onset 4-12 years old.

Absences may be typical (petit mal) or atypical

can often be precepitated by hyperventilation.

Occurs for a few seconds (< 30s) Child does not recall seizure.

EEG would not a 3Hz Spike and wave activity withfrontal accentuation.

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Absence Seizure.flv
http://localhost/var/www/apps/conversion/tmp/scratch_2/Absence%20Seizure.flv


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EEG

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Myoclonic epilepsy (Juvenile Myoclonic

Epilepsy)

Brief often repeatitive, jerking movement of

the limbs, neck and trunk. 10-20years old, (Females: Males = 2:1)

Myoclonic predominates but absences and

tonic-clonic seizures also occur

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Tonic-Clonic Seizure Rhythmical contraction of muscle groups following

the tonic phase

In the rigid tonic phase, children may fall to theground, sometimes injuring themselves.

Do not breath and become cyanosed. Followed by the clonic phase, with jerking of the

limbs.

Breathing is irregular, cyanosis persists and salivamay accumulate in the mouth

May be biting of the tongue and incontinence ofurine.

Lasts a few seconds to minutes, followed byunconscious or deep sleep for several hours.

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Tonic Clonic Seizure.flv


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Atonic Seizures

Often combined with a myoclonic jerk

followed by a transient loss of muscle tone

causing a sudden fall to the floor or drop ofthe head.

1-2 years old, last 1-4seconds

Most frequent during awakening of falling

asleep.

Often have Mental Retardation or underlying

brain abnormalities

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Infantile Spasms (West Syndrome) 4-6months

Violent flexor spasms of head, trunk and limbs,followed by extension of the arms (Salaam Spasms)

Last 1-2s, bursts of 20-30spasms, usually on waking 2/3 children are neurologically abnormal before onset

of seizures- development process further arrested

EEG- hypsarrthymia, a chaotic background of highvoltage dysrhymic slow-wave activity with sharp

components. 30-40% respond well to treatment

Loss of skills and later learning disability or epilepsy.

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Infantile spasms.flv


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Other epilepsies

Lennox-Gaustaut

1-3 years old

Multiple seizure types:

Myoclonic single jerk,

atonic drop attacks oratypical absences.

Developmental arrest

or regression &

behaviour disorder.

Poor prognosis

Benign rolandic

epilepsy of childhood

Common (5-10 yo)

Sleep: generalized

tonic-clonic

Day: distortion of face

and arm on one side +

abnormal feeling of

tounge Seizure stop by mid-

teens & may not

require treatment

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Differential Diagnosis

Neonates and

infants

Jitteriness

Benign myoclonus

Apnoea

Gastro-Oespophageal

reflux

Shuddering attacks

Benign paroxymaltorticollis

Hyperekplexia

Young children

Breath holding spells

Reflex anoxic seizures

Parasomnia

Benign paroxysmal

vertigo

Paroxysmal

choreoathertosis

Tics and ritualisticmovements

Rage attacks

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Differential Diagnosis

Childhood andAdolescents

Vasovagal syncope

Migraine

Narcolepsy

Panic attacks

pseudoseizures

Any Age

Drug-Induced

dystonia

Cardiac Dysrhythmias

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Investigations

EEG

- if normal, try barbiturate induced sleep,

sleep deprivation recording or 24 hour

monitoring. CT or MRI of brain indicated (< 5 years)

Blood electrolyte analysis

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Treatment for epilepsy

Medications

Surgery

Ketogenic Diet

Vagus Nerve Stimulation

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Medication

>2 episode

Attempt to classify the seizure type(s),monotheraphy is recommended. Increase dosegradually until the desired effect is achieved

Add 2nd drug if 1st has failed, optimize seconddrug and try to withdraw 1st drug.

Rational combination (2/3 with differentmechanisms)

Monitor drug levels to check compliance

Withdrawal after 2 years of being seizure free

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Surgical

Lobectomy and Cortical Resection

Hemispherectomy

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Ketogenic Diet

Primarily used in childhood epilepsy.

Mechanism- unknown.

The high-fat, low-protein, no-

carbohydrate diet mimics some effectsof starvation that seem to inhibitseizures.

The diet is very rigid and carefullycontrolled and must be supervised by aphysician -- sometimes in a hospitalsetting.

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Vagus Nerve Stimulation

Approved to treat partial seizures inpatients 12 years of age or older

stimulator is surgically implanted under theskin in the chest. The device is attached to awire that is tunneled under the skin andattached to the vagus nerve, which islocated in the left side of the neck

adjusted to automatically stimulate thevagus nerve from every few seconds toevery few minutes.

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Status Epilepticus

Prolonged episode of seizure activity

(>30 minutes) or an extended period of

recurrent seizures between which the

patient does not return toconsciousness.

Its a medical emergency !!

Can lead to hypoxia, brain damage anddeath

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Management of Status

EpilepticusABCs

ECG monitoring

Oxygen and pulse oximetry

IV access Immediate laboratory tests (electrolytes,

glucose..)

a rapid infusion of 5 mL/kg of 10% dextrose

Antiepileptic drug levels

Toxicologies

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Documents

Febrile Seizure and Epilepsy