epilepsy in childhood-indroduction epilepsy.convulsion.seizure.fit.פרכוסהתכווצות...

Epilepsy in childhood-Epilepsy in childhood-indroductionindroduction

Epilepsy.Epilepsy.Convulsion.Convulsion.Seizure.Seizure.Fit.Fit.פרכוספרכוסהתכווצותהתכווצותכפיון, מחלה כיפיוניתכפיון, מחלה כיפיונית


Very common .Very common .Approx 1% .Approx 1% .From first minute until last minute.From first minute until last minute.

A result of abnormal electrical activity of A result of abnormal electrical activity of the brain ( cortex) .the brain ( cortex) .which cause acute change in function.which cause acute change in function.Usually of motor nature.Usually of motor nature.


Epileptic episode.Epileptic episode.Epileptic disorder ( disease).Epileptic disorder ( disease).

Diagnosis is a clinical one.Diagnosis is a clinical one.History,sometimes with hysteriaHistory,sometimes with hysteriaObservation ( duration ,LOC and Observation ( duration ,LOC and Description of the motor phenomena)Description of the motor phenomena)


Clinical presentation:Clinical presentation:

Motor ( 80%-90%)Motor ( 80%-90%)Sensory.(skin, vision, hearing, Sensory.(skin, vision, hearing, taste, smell)taste, smell)Behavioral .Behavioral .Autonomic.Autonomic.


Neurophysiologic basis.Neurophysiologic basis.

Neuron, dendrites, axon.Neuron, dendrites, axon.Action potentials.Action potentials.Synaptic neurotransmitors Synaptic neurotransmitors Excitators (glutamic , aspartic ac)Excitators (glutamic , aspartic ac)Inhibitors (GABA )Inhibitors (GABA )


Classification of epilepsy:Classification of epilepsy:

Nature of episode.Nature of episode.Origin.Origin.Electrical Abnormality.Electrical Abnormality.Name of Physician who Name of Physician who describedescribe


Current classification ofCurrent classification of epilepsy epilepsy since 1989:since 1989:

Partial ( focal ).Partial ( focal ).Generalized .Generalized .Partial with generalizationPartial with generalization

Status Epilepctus . Status Epilepctus .


Clinical description of motorClinical description of motor seizures :seizures :

Clonic.Clonic.Myoclonic.Myoclonic.Tonic Tonic Atonic ( Akinetic).Atonic ( Akinetic).


Epileptic episode may include:Epileptic episode may include:

Aura.Aura.

Ictal phase ( ictus).Ictal phase ( ictus).

Post ictal phase. Post ictal phase.


Epileptic episode may be Epileptic episode may be primary or secondary due to…primary or secondary due to…

Primary – genetic or Primary – genetic or idiopathic.idiopathic.


Secondary epileptic episode :Secondary epileptic episode :

C.N.S malformationsC.N.S malformationsMetabolic.( metabolic , primary )Metabolic.( metabolic , primary )Infectious.Infectious.S.O.L.S.O.L.TraumaTraumaToxic ( medications, abuse)Toxic ( medications, abuse)


Clinical Approach to a child Clinical Approach to a child with with first seizure:first seizure:

In the E.R.:In the E.R.:Treatment , stabilization.Treatment , stabilization.Physical /neuro examination.Physical /neuro examination.Work -upWork -up


Observation ( patient , Observation ( patient , watch ).watch ).

Position , Oxygen mask.Position , Oxygen mask.

I.V. line. (other 3 options )I.V. line. (other 3 options )

Medications Medications ( Benzodiazepines-( Benzodiazepines-

Diazepam , midazolam)Diazepam , midazolam)


Heart rate , BP.Heart rate , BP.

Temperature ( c.n.s inf vs Temperature ( c.n.s inf vs febrile seizures )febrile seizures )

Dex .Dex .

Physical exam.( trauma, signs Physical exam.( trauma, signs of recent epileptic episode – of recent epileptic episode – tonge biting,urine tonge biting,urine incontinenceincontinence


Neurological ExaminationNeurological Examination

Usually not helpful.Usually not helpful.

State of conciseness.State of conciseness.

Cranial nerves ( eye position)Cranial nerves ( eye position)

Muscle tone.Muscle tone.

Reflexes.Reflexes.

Sensory response.Sensory response.

Influenced by : ictus type, Influenced by : ictus type, med’smed’s


Medical History:Medical History:

PastPast : family ( epilepsy ) : family ( epilepsy )

child. ( preg , child. ( preg , deliverydelivery

p.m.h. , p.m.h. , medications,f.s medications,f.s

Development.Development.

PresentPresent : Detailed : Detailed description description

before episodebefore episode

(illness, trauma , (illness, trauma , medsmeds

activity , sleep )activity , sleep )


Medical History:Medical History:

Majority of dx are based on Majority of dx are based on hx.hx.

Not always accurate and Not always accurate and reliablereliable

Sometimes young , old Sometimes young , old observer.observer.

Single episode is not an Single episode is not an epilepsy epilepsy

Usually ( exceptions C.P, T.S, Usually ( exceptions C.P, T.S, N.F )N.F )


Work – up in the E.R.:Work – up in the E.R.:

Two major urgent Two major urgent decisionsdecisions

Neuroimaging.Neuroimaging.

Spinal tap. (open nl fontanella Spinal tap. (open nl fontanella or Neroim. ) or Neroim. )


Neuroimaging :Neuroimaging :

C.N.S bleeding .C.N.S bleeding .

S.O.L.S.O.L.

Acute hydrocephalus.Acute hydrocephalus.

L.P:L.P:

C.N.S. infection ( bac, viral C.N.S. infection ( bac, viral others )others )

Epidural Hemorrhage in ITP Epidural Hemorrhage in ITP

Epidural Hemorrhage in ITPEpidural Hemorrhage in ITP

Space Occupying LesionSpace Occupying Lesion


Hospitalization :Hospitalization :

Observation (recurrent Observation (recurrent seizure).seizure).

Diagnostic evaluation.Diagnostic evaluation.

Parental care and Parental care and explanations . explanations .


Diagnostic Work–up during Diagnostic Work–up during

Hospitalization:Hospitalization:

EEG. EEG.

Neuroimaging. Neuroimaging.

Others. Others.


E.E.G.E.E.G.

Recording of electrical activity Recording of electrical activity of brain.of brain.

Non invasive.Non invasive.

Cheap.Cheap.

Available.Available.

Portable , bedside, ( picu, Portable , bedside, ( picu, nicu).nicu).


E.E.G.E.E.G.

Complete study includes: Complete study includes:

Alert.Alert.

Sleep, drowsy.(Sleep Sleep, drowsy.(Sleep deprived)deprived)

Photic stimulation.Photic stimulation.

Hyperventilation.Hyperventilation.


E.E.G.E.E.G.

Regular study.Regular study.

24h ambulatory study24h ambulatory study

Video EEG Study.Video EEG Study.


E.E.G recording includes:E.E.G recording includes:

Background activity.( alert, Background activity.( alert, sleep, CNS diseases, drugs)sleep, CNS diseases, drugs)

Abnormal overidding activity.Abnormal overidding activity.

Spike , poly spike , slow wave Spike , poly spike , slow wave

Variable complexesVariable complexes


Abnormal E.E.G is not Abnormal E.E.G is not requiredrequired for the diagnosis of for the diagnosis of Epilepsy.Epilepsy.

A rule with several A rule with several exceptions. exceptions.

The diagnosis of Epilepsy is a The diagnosis of Epilepsy is a

Clinical one based on hx and Clinical one based on hx and or or

Observation.Observation.


2 Exceptions :2 Exceptions :

Infantile spasms (West synd)Infantile spasms (West synd)

Simple Absence Seizure.Simple Absence Seizure.

Simple Absence Simple Absence EpilepsyEpilepsy


Abnormal EEG could be Abnormal EEG could be seen inseen in

CNS infection.CNS infection.

Head trauma.Head trauma.

S.O.L.S.O.L.

Toxic metabolic conditions.Toxic metabolic conditions.

Headache , Migraine.Headache , Migraine.

ADHD , LD.ADHD , LD.


Are all epileptic episodes Are all epileptic episodes required neuroimaging ?required neuroimaging ?

Neuroimaging Modalities:Neuroimaging Modalities:

Ultrasound.Ultrasound.

CT Scan.CT Scan.

MRI.MRI.

SPECT SPECT

PETPET


Ultrasound of brain.Ultrasound of brain.

Non invasive.( no radiation)Non invasive.( no radiation)

Cheap and available.Cheap and available.

Portable Portable

No need for sedationNo need for sedation


CT Scan.CT Scan.

Relatively cheap.Relatively cheap.

Available. Available.

Radiation.Radiation.

Sedation.Sedation.


MRI.MRI.Expensive.Expensive.Non available.Non available.Sedation. Sedation. No radiationNo radiation

fMRIfMRI


The study of choice in The study of choice in the the

work up of a child with work up of a child with

Epilepsy is MRI.Epilepsy is MRI.

In cases of Emergency in In cases of Emergency in

ER , CT Scan is ER , CT Scan is

reliable toolreliable tool


SPECT ( single photon SPECT ( single photon

emission computed emission computed tomography)tomography)

Epileptic focus.Epileptic focus.

Focal blood perfusion.Focal blood perfusion.

Not available.Not available.

Only after epileptic episode.Only after epileptic episode.


PET ( position emission PET ( position emission tomography)tomography)

Demonstrate the content of Demonstrate the content of 0202

And glucose .And glucose .

Epileptic hypermetabolic Epileptic hypermetabolic focus.focus.

Expencsive.Expencsive.

Non available.Non available.


Epileptic Syndromes:Epileptic Syndromes:

Age/sex.Age/sex.

Common clinical expression.Common clinical expression.

Common frequency and Common frequency and durationduration

Family history /genetic .Family history /genetic .

Similar EEG abnormalities.Similar EEG abnormalities.

Common natural hx and Common natural hx and outcome.outcome.


Treatment of Epilepsy.Treatment of Epilepsy.

-Anti epileptic medications.-Anti epileptic medications.

-Other medications( steroids , -Other medications( steroids , vitamines (B complex), vitamines (B complex), diamox)diamox)

-IV IG.-IV IG.

-Ketogenic diet.-Ketogenic diet.

-VNS.-VNS.

-Epileptic surgery.-Epileptic surgery.



How to select an anti epileptic How to select an anti epileptic drug?drug?

Type of seizure/ syndrome.Type of seizure/ syndrome.

Medical history ( liver , kidney Medical history ( liver , kidney ))

Allergies.Allergies.

Side effects.Side effects.



Duration of treatment.Duration of treatment.

Side effects.Side effects.

Follow up (clinical , Follow up (clinical , laboratory)laboratory)

Drug levels. Drug levels.

Recurrent seizures. Recurrent seizures.

Compliance.Compliance.


Outcome Outcome

Type of epileptic syndrome. Type of epileptic syndrome.

Response to treatment. Response to treatment.

High rate of cure . High rate of cure .

Driving Liecence.Driving Liecence.

Army service.Army service.

epilepsy in childhood-indroduction epilepsy.convulsion.seizure.fit.פרכוסהתכווצות...

Documents

f slide

sleep slide

midazolam slide

abuse slide

family epilepsy child

urine incontinence slide

episode illness

nature of episode