Seizures

What are the seizure medication guidelines?

1/3 of patients don't become seizure free with monotherapy. Increase dosage before combination therapy.

Describe a complex febrile seizure

25%, >15 minutes, multiple episodes / 24 hours, outside typical ages, focal onset, one side of body, hemiparesis (paralysis of one side of the body).

Describe parietal lobe epilepsy

5% of cases, features sensory symptoms (pains, paresthesia), dyslexia, sensory aphasia

Describe a simple febrile seizure

75%, <15 minutes, 1 seizure / 24 hours, 6 mo - 5 years, generalized, symmetrical.

What is juvenile myoclonic epilepsy?

A genetic epilepsy syndrome characterized by recurrent myoclonic seizures, generalized tonic-clonic seizures, and absence seizures. The onset of seizures occurs between the ages of 8 and 25, and seizures characteristically occur immediately after waking up or following sleep deprivation.

What to do if a child comes in with fever possibly UTI?

A renal and bladder ultrasound (RBUS) should be performed in all febrile children with a confirmed UTI between the ages of 2 and 24 months. RBUS is used to detect anatomical abnormalities and features suggestive of vesicoureteral reflux that may predispose the child to recurrent UTIs.

What are focal / partial seizures?

Abnormal activation of neurons confined to one cerebral hemisphere.

What is a generalized seizure?

Abnormal neuronal activity that quickly spreads to both hemispheres of the brain.

When would you consider doing a lumbar puncture after a seizure?

After a simple febrile seizure if there is a history or findings suggestive of meningitis (e.g., presence of neck stiffness, photophobia, etc). An LP can also be considered if the child is between 6-12 months of age and has not been immunized against Haemophilus influenzae or Streptococcus pneumoniae (meaning they are at increased risk of bacterial meningitis).

Define breath holding spell.

Benign, children 6 months - 6 years. Related to iron deficiency anemia. Prolonged expiratory apnea, loss of consciousness, cyanosis / pallor, stiffness and jerky movements. Triggered by distress, strong emotions, temper tantrums

What ages do you see febrile seizures?

Between 6 months and 5 years.

When do febrile seizures happen the most?

Between the ages of 6 months - 5 years, mostly year 2.

How does ethosuximide work?

Blocks thalamic T-type Ca channels

What are the clinical features of temporal lobe epilepsy?

Clusters of 30 seconds to 2 minutes. 1. Aura: Visceral, olfactory, or auditory aura; feelings of familiarity or unfamiliarity and "dreamy states" 2. Oral alimentary automatisms like lip-smacking; also stretching of the body, or walking in place, tachycardia, urge to void the bladder, mydriasis, sweating, salivating, absent minded but no loss of consciousness 3. Postictal phase with confusion and tiredness is common.

Focal seizure without intact consciousness

Complex partial

What does a Pancoast tumor cause?

Compression of cervical sympathetic chain (stellate ganglion) leads to Horner syndrome (ptosis, miosis, anhidrosis). Compression of the brachial plexus accounts for severe shoulder and arm pain.

How do you diagnose a focal seizure?

EEG and neuroimaging. If an infectious or a metabolic etiology is suspected, laboratory tests can also be helpful.

What do you expect prolactin and CK levels to be after a seizure?

Elevated.

How do you treat absence seizures?

Ethosuximide

What is the first line treatment for absence seizures?

Ethozuximide.

What is the classification of epilepsy?

Focal with or without complications; Generalized including tonic, clonic, tonic-clonic, atonic, absence.

What is the second line treatment for children seizures?

Gabapentin, valproate, pregabalin, topiramate.

What are predisposing factors to develop generalized febrile seizures?

Genetic factors, infections (herpes), recent immunization, high fever.

What are predisposing factors for febrile seizure?

Genetic predisposition, high fevers (104), infection (influenza, HHV-6), immunization (MMR, TDap).

What do you do if a child is having a febrile seizure with really high temperature?

Give NSAIDs and Acetaminophen - Short-term antipyretic treatment is indicated in children with high fever in order to decrease discomfort and insensible water loss

What is the most common cause of generalized epilepsy in children?

Idiopathic - Genetic causes are suspected (Good prognosis)

When to treat febrile seizures?

If they last more than 5 minutes.

How do you recognize a psychological seizure?

If treatment resistant, check for: closed eyes, no or slight increase in CK and prolactin, duration longer

What is the Jacksonian march?

It only occurs on one side of the body; it progresses in a predictable pattern from twitching or a tingling sensation or weakness in a finger, a big toe or the corner of the mouth, then marches over a few seconds to the entire hand, foot or facial muscles.

What is the first line focal seizure therapy?

Lamotrigine, levetiracetam, phenytoin , carbamazepine, oxcarbazepine, phenobarbital (children)

What is the first line treatment for focal seizures?

Lamotrigine.

What are long term complications of status epilepticus?

Life threatening, if not treated, it can lead to cerebral edema, rise in body temperature, rhabdomyolysis, cerebral cardiovascular failure.

What is status epilepticus?

More than 5 minutes of continuous seizures OR More than 2 seizures with consciousness not being fully regained in interictal period

What is the etiology of temporal lobe epilepsy?

Most common form found in about 70% of patients. Due to hippocampal sclerosis or encephalitis, tumors, neurodegenerative disorders.

Describe frontal lobe epilepsy

Motor symptoms like muscle tension, gaze deviation, vocalization, salivation, enuresis, impairment of speech, staring spells, jacksonian march, Todd's paralysis (paralysis of the affected limb / area after the seizure)

What are factors that can lead to epilepsy?

PKU, ABBA withdrawal, metabolic / electrolyte disturbances, genetics, cryptogenic, water intoxication, exercise, loud music, sleep deprivation, drug intoxication and withdrawal.

When should you terminate seizure medications?

Patient has <2 seizures / year, no genetics, good EEG, possible after 2 - 5 seizure free years

In what ages would you expect to find febrile seizures?

Pediatric emergency associated with high fever in children between six months and five years of age

When is nonpharmacological therapy recommended?

Pharmacoresistance, surgery if there's no response to medications.

What is the first line treatment for children seizures?

Phenobarbital.

What tests may be used for complex seizures?

Physical exam, urine culture, urinalysis, CBC, electrolytes, blood glucose, imaging to ID source of infection, EEG, imaging, lumbar puncture.

Describe occipital lobe epilepsy

Rare, features visual hallucinations, gaze deviation, cortical blindness.

Epilepsia partialis continua

Rare, unspecific damage to cortex (scar, tumor, encephalitis), muscle activity of a particular area of the body (finger or mouth) for several days.

What to do if child is in the hospital but febrile seizure has already happened?

Reassurance. High fever, viral infection (especially HHV-6 and influenza), a family history of febrile seizure, and recent immunization (especially DTP and MMR) are all known risk factors.

What is the difference between complex and simple febrile seizures?

Simple last less than 15 minutes and do not recur within 24 hours, whereas complex do the opposite.

Focal seizure with intact consciousness

Simple partial

What to do post-seizure?

Start antifever therapy (NSAIDs and acetaminophen).

Which type of generalized epilepsy in children has the worst prognosis?

Symptomatic forms are associated with metabolic or structural abnormalities. Don't respond to medications.

What are other conditions that may present like seizure?

Syncope and breath holding spell.

What is the definition of a febrile seizure?

Temperature greater than 38 C or 100.4 in the absence of infection, metabolic abnormalities or history of afebrile seizures.

What is the most common form of epilepsy?

Temporal lobe epilepsy.

What is the most common type of focal seizure?

Temporal lobe epilepsy.

Are febrile seizures life-threatening?

There's low risk of death or neurological damage.

What do antiepileptic drugs do?

They raise the lowered seizure threshold.

What do NSAIDs or acetaminophen do to prevent febrile seizure?

They restore the central thermoregulatory set point back to normal.

What are the primary generalized seizures?

Tonic clonic, clonic, tonic, myoclonic, atonic, absence.

How do you treat focal seizures?

Treat infection, underlying etiology. If unknown, treat with anti-epileptic drugs like lamotrigine (1st), levetiracetam or phenytoin.

What is the abortive therapy for febrile seizures?

Treatment of choice is lorazepam. Other options: IV diazepam, buccal / intranasal midazolam.

What is a pancoast tumor?

Tumor at apex of lung with brachial plexus involvement (C8, T1, T2) which leads to shoulder pain, upper extremity weakness, atrophy of hand muscles, and Horner's syndrome

Describe the post-ictal phase of simple and complex seizures

Typically a quick return to normal. Confusion and drowsiness for a short period of time

What medical conditions are associated to febrile seizures?

UTI, URI, roseola infantum.

What is anisocoria?

Unequal pupil size

What medication is recommended for absence epilepsy?

Valproate (increases the GABA levels).

What is the first line treatment for generalized seizures?

Valproate.

What does VITAMINS stand for?

Vascular, Infections, Trauma, Autoimmune, Metabolic, Ingestion / Withdrawal, Neoplasm, Psychiatric.

How do NSAIDs and acetaminophen work?

-- They interfere with the conversion of arachidonic acid to COX-1/COX-2, therefore prostaglandins E2 and thromboxane A2 are not produced. -- Restore the central thermoregulatory set-point back to normal.